1.

2 Gynaecological Cancers
The cancers which can occur in any part of the female reproductive system—the
vulva, vagina, cervix, uterus, fallopian tubes, or ovaries are called gynaecological cancer.
Gynaecological cancers are sex specific cancers i.e. it occurs in females only. As they
occur in female reproductive parts they contribute to maternal morbidity and mortality.
Female reproductive organ cancers affect fewer women than breast, lung and colorectal
cancers worldwide. Following are six parts of female reproductive system categorized
according to ICD-10 classification. It is necessary to mention that the coding used against
each type cancer for six parts is internationally used coding schemes. These are just codes
and they have nothing to do with scales or arithmetic operations for data analyses
1.2.1 C55-Uterus

1.2.2 C53-Cervix uteri

1.2.3 C58-Placenta

1.2.4 C54-Corpus uteri

1.2.5 C56-C57-Ovary & Uterine Adnexa

1.2.6 C51-C52-Vulva & Vagina

1.2.1 C55-Uterus

‘The small, hollow, pear-shaped organ in a woman's pelvis. This is the organ in
which a baby grows. Also called womb (National Cancer Institute).
Definition of endometrial cancer: Cancer that forms in the tissue lining the uterus
(the small, hollow, pear-shaped organ in a woman's pelvis in which a baby grows). Most
endometrial cancers are adenocarcinomas (cancers that begin in cells that make and
release mucus and other fluids) (National Cancer Institute).

1.2.2 C53-Cervix uteri

The cervix is part of a woman's reproductive system. It's in the pelvis. The cervix
is the lower, narrow part of the uterus (womb)
 Definition of cervical cancer: Cancer that forms in tissues of the cervix (the organ
connecting the uterus and vagina). It is usually a slow-growing cancer that may not have
symptoms but can be found with regular Pap tests (a procedure in which cells are scraped
from the cervix and looked at under a microscope) (National Cancer Institute).

1.2.3 C58-Placenta
Placenta is the vascular organ that connects the fetus and the mother's uterus. The
technical term given to the abnormal growth of trophoblastic cells is gestational
trophoblastic neoplasia (Surveillance Epidemiology and End Results).
Definition of gestational trophoblastic tumor: Any of a group of tumors that
develops from trophoblastic cells (cells that help an embryo attach to the uterus and help
form the placenta) after fertilization of an egg by a sperm. The two main types of
gestational trophoblastic tumors are hydatidiform mole and choriocarcinoma also called
gestational trophoblastic disease (National Cancer Institute).

1.2.4 C54-Corpus uteri

The uterus is the sac in a woman's pelvis which allows a baby to develop from a
fertilized egg and protects it until birth (Surveillance Epidemiology and end Results).

3.5 C56-C57-Ovary & Uterine Adnexa

Ovary is the part of female reproductive system where eggs are formed.
Definition of ovarian cancer: Cancer that forms in tissues of the ovary (one of a pair of
female reproductive glands in which the ova, or eggs, are formed). Most ovarian cancers
are either ovarian epithelial carcinomas (cancer that begins in the cells on the surface of
the ovary) or malignant germ cell tumours (cancer that begins in egg cells) (National
Cancer Institute).

1.2.6 C51-C52-Vulva & Vagina

Vagina is birth canal of female reproductive system whereas vulva comprises of
external female genital organs. Definition of vaginal cancer: Cancer that forms in the
tissues of the vagina (birth canal). The vagina leads from the cervix (the opening of the
uterus) to the outside of the body. The most common type of vaginal cancer is squamous
cell carcinoma, which starts in the thin, flat cells lining the vagina. Another type of
vaginal cancer is adenocarcinomas, cancer that begins in glandular cells in the lining of
the vagina.
Definition of vulvar cancer: Cancer of the vulva (the external female genital organs,
including the clitoris, vaginal lips, and the opening to the vagina) (National Cancer
Institute).

1.3 Menopause
Menses is the process of ovulation among females as they enter the reproductive
age. There are three phases of menses. Premenopause is the phase before the cessation of
menstruation. During this phase a female is capable of bearing a child. It usually starts at
the age of 10. Postmenopause phase comes after the cessation of menstrual cycle it
usually occurs after 51.The third phase is Perimenopause. It includes the year following
the last menses as well as 3 - 5 years before the last menses (Hilliard, p 292).
Menopause is a permanent cessation of menses resulting from markedly decrease
function of the ovaries or the removal of the ovaries.
- Spontaneous: Naturally occurring and defines as 1 year of no menses.
- Induced: The result of bilateral salpingo-oophrectomy or noxious exposure (e.g.
chemotherapy, radiation) (Hilliard, p 292).
The human ovaries become unresponsive to gonadotropins with advancing age,
and their function declines, so that the sexual cycles disappear. This unresponsiveness is
associated with, and probably caused by a decline in the number of primordial follicles,
which becomes precipitous at the time of menopause. The menses become irregular and
usually cease between the ages of 45 and 55 years, thus marking the end of a woman’s
reproductive life (Adhi 2004).
Premature menopause is defined as menopause that occurs at an age more than two
standard deviations below the mean estimated for the reference population. In practice, in
the absence of reliable estimates of the distribution of age at natural menopause in
populations in developing countries, the age of 40 years is frequently used as an arbitrary
cut-off point, below which menopause is said to be premature (Adhi 2004). The normal
age range for menopause is 41 to 55. The mean age is 51.4 years. POF is characterized by
amenorrhea, hypoestroginism and elevated gonadotropins in women less than 40.
Approximately 1 percent of women have pre mature menopause. Smokers have an earlier
menopause by approximately 1.5 years. Women living at high altitudes may have an
earlier menopause. Women with severe malnutrition may have an earlier menopause
(Hillard, p 292).

1.4 Linkage between Reproductive Morbidity, Medical Demography and Cancer

Epidemiology
Gynaecological cancer epidemiology in relation to health demographics falls
under surveillance research. It helps to quantify the disease by identifying cases as
frequency of that disease. Then the demographic measures can be applied on these
frequencies. These demographic measures give disease pattern within a geographically
defined population in a specified time frame. Cancer statistics are categorized as period
or the year, population, cancer site, sex and the age. These statistics are presented as
tables and graphs.
The health status of any nation is determined by morbidity and mortality within
that nation. Thus morbidity and mortality are two main indicators of health status of a
nation. The epidemiological approach to the determination of community health
problems rests on comparison of mortality and morbidity rates in the population of
concern to some other standard or target (Dever 1991). Morbidity and mortality measures
gives health impact of a specific disease within a population but does not gives any
causal relationships.
Of all the demographic factors, morbidity and mortality represents the clearest
linkage between demography and health care. The morbidity and mortality characteristics
of a population reflect both the level of health services needed and the effects of the
functioning of health care system (Pol and Thomas 2000). Mortality and morbidity are
two indicators of health status of a population. Morbidity is a disease or the incidence of
disease within a population. Two main measures used for measuring morbidity are
incidence and prevalence. Few mortality measures are taken in terms of Mother Mortality
Rate (MMR), Crude Mortality Rate (CMR) and Age & Sex specific Death Rate etc.
Medical Demography is the application of demographic concepts, models, and techniques
to the analysis of the dynamics of morbidity, disability, and mortality. It is concerned
with the consequences of health, sickness, accidents, disability, and death for the size,
composition, and structure of the population; and with the economic, social, and policy
impacts of those dynamics. It is concerned with factors that explain variations in health
and functional transitions across populations; and with the development of methods that
reflect the influence of those factors on the health and longevity of individuals. It is
concerned with the link between the risk factors observed for individuals and the
aggregate effects of those risk factors on population-level outcomes. This concern differs
from epidemiology which has as its primary focus on the control of disease and health
problems in defined populations.
Medical Demography can be used by Epidemiologists as part of their population
surveillance methods. Conversely, epidemiological data and methods can be used by
Medical Demographers as part of their population modeling methods. The different
focuses of the two disciplines, however, means that the results of epidemiological
analyses often are not directly applicable in medical demographic models.
Medical Demography is concerned with the multiplicity of consequences
attributable to diseases singly, and in interaction with one another and the elimination or
control of each. This latter concern directly overlaps with Epidemiology if control is
feasible, and not merely hypothetical. Medical Demography is concerned with changes in
the incidence and prevalence of specific medical conditions, and with the resulting
impacts of those changes on the patterns of other co-morbid conditions and disabilities
(Stallard 2007).
So far the researchers have tried explaining the linkage between medical
demography and epidemiology. Thus morbidity and mortality are the two measures
where the link between medical demography and epidemiology exists. Keeping in view
the morbidity measure, gynaecological cancers fall under the following criteria.
1.4.1 Reproductive Morbidity
As Gynaecological cancers occur in female reproductive parts of female, it hinders
the reproductive activities among females which may even lead to death if not diagnosed
in time. It thus causes maternal morbidity as well as mortality among females.
The World Health Organization (1992) has defined reproductive morbidity as
consisting of three types of morbidity: obstetric, gynecologic, and contraceptive.
(Obstetric morbidity is the equivalent of maternal morbidity.)

1.4.1.1 Obstetric Morbidity—Morbidity in a woman who has been pregnant (regardless

of the site or duration of the pregnancy) from any cause related to or aggravated by the
pregnancy or its management, but not from accidental or incidental causes.

a. Direct obstetric morbidity results from obstetric complications of the pregnant

state (pregnancy, labor, and the puerperium), from interventions, omissions, incorrect
treatment, or from a chain of events resulting from any of the above. This can include
temporary conditions, mild or severe, which occur during pregnancy or within 42
days of delivery, or permanent/chronic conditions resulting from pregnancy, abortion
or childbirth. Some chronic conditions (such as anemia or hypertension) may be
caused by pregnancy and delivery, but are equally likely to have other causes.
b. Indirect obstetric morbidity results from a previously existing condition or disease,
such as sickle cell disease or tuberculosis, which is aggravated by the physiologic
effects of pregnancy. Such morbidity may occur at any time and continue beyond the
reproductive years.
c. Psychological obstetric morbidity may include puerperal psychosis, at tempted
suicide, strong fear of pregnancy and childbirth, and may be the consequence of
obstetric complications, obstetric interventions, cultural practices (such as isolation
during labor and delivery), or coercion.

1.4.1.2 Gynecologic morbidity—includes any condition, disease, or dysfunction of the

reproductive system which is not related to pregnancy, abortion, or childbirth, but may be
related to sexual behavior.
 a. Direct gynecologic morbidity includes reproductive cancers,
premenstrual syndrome (PMS), endocrine system disorders, bacterial or viral sexually
transmitted diseases (STDs) and their sequelae (cervical cancer, pelvic inflammatory
disease [PID], secondary sterility, AIDS), reproductive tract infections (RTIs), and
coital injuries.
b. Indirect gynecologic morbidity includes primarily traditional practices,
some of which are for treatment of real or perceived gynecologic conditions (such as
female genital mutilation).
c. Psychological morbidity includes psychological disorders associated
with STDs, infertility, traditional practices, dyspareunia, fistulae, and rape.

1.4.1.3 Contraceptive morbidity—includes conditions which result from efforts (other

than abortion) to limit fertility, whether they are traditional or modern methods.
Examples include menorrhagia from IUD use, thromboses from oral contraceptive use,
and wound infections after Norplant insertion (Reed et. al. 2000).

1.5 Cancer Epidemiology

Epidemiology is “The study of the distribution and determinants of health related
states or events in specified populations and the application of this study to control health
problems” (Last 2007). Epidemiological data on the occurrence of cancer, knowledge of
causative factors and how to avoid these factors provide a basis for determining where
emphasis of cancer control efforts should be placed” (Bhurgri 2004). The frequency of
occurrence of disease injury often varies over time and between populations.
Epidemiological principles and methods are used to describe the frequency and
determinants of these events (Bailey et. al. 2005)

1.5.1 Types of Cancer Epidemiology Research

Cancer epidemiology research is of following two types:
a. Analytic research examines factors that influence cancer occurrence
b. Surveillance research tracks population trends in cancer Etiology, incidence, and
mortality. (National Cancer institute)
1.6 Medical Demographic Analysis
Demographic Analysis has typical data requirements whereas medical
demographic analysis has additional data requirements. Demographic analysis includes
the initial size and defining characteristics of each cohort Decrements due to death,
emigration, or other censoring events and Increments due to immigration or other forms
of cohort recruitment. Medical demographic analysis of health related measures, are
specific to the particular model being employed and May have to deal with “missing
data” or unobserved latent health states (Stallard 2007).

1.7 Cancer Registration

"Cancer registration is a process of continuing, systematic collection of data on
the occurrence and characteristics of reportable neoplasms." Following are the types of
cancer registration.
1.7.1 A population-based registry
1.7.2 A hospital, institution or oncology-based registry records
1.7.2 Pathology-based registries records (Bhurgri 2004).
Here we will discuss that what are population-based registry, a hospital,
institution or oncology-based registry records and pathology-based registries record.

1.7.1 Population Based Cancer Registry

A population based cancer registry is a centralized cancer database covering a
known population, usually resident of a defined a defined geographic area, such as
country or state. Because the population denominator can be counted or estimated by a
census, a population-based registry can calculate incidence rates (Gail and Benichou
2000).

1.7.2 A Hospital, Institution or Oncology-Based Registry Records.

A hospital- based cancer registry is a cancer data base maintained in a health care
facility to collect pertinent information on all cancer patients who use the service of that
facility for diagnosis, staging and treatment. A hospital Based cancer registry can
calculate frequency of cases and measure outcomes for the patients it monitors. A
hospital based cancer registry cannot calculate incidence rates because the denominator
population is not known (Gail and Bénichou 2000).

1.7.3 Pathology Based Registries

Pathology based registries record all cases of cancer in a given laboratory with
emphasis on pathological diagnosis, grading and staging of cancers, thus maintaining the
quality control of population registries. Large hospitals or pathology series are sometimes
used for monitoring of cancer control programs in the absence of population data
(Bhurgri 2004).