DIP Episode 467 - The Clutch Cervical Cancer Podcast (for Step 1-3)

All right, welcome. My name is Divine. This is episode 467 of the Divine Intervention Podcast. Into these podcasts, we're going to be talking about a mystery topic that I'll reveal after I talk about a vignette. Okay, what if they give you a question about a 32-year-old female? They tell you that she comes to the office because she has not been feeling well for the last two weeks. She has been having headaches, she has been having bleeding from her nose, she has been having, she even tell you that you notice PT here and prepare on the skin. And in the tell you that you get some labs and you know, how I blow sell Countess Momo, right sale Countess Momo, pletly Countess Momo, how creatinine is like five, her BUN is extremely high, some crazy high number. And then they tell you that ultrasound orography of the abdomen shows like a right or a left-sided hydronophrosis. And Lady tells you that she has been having pain with sexual intercourse and she has noticed a few drips of blood with sexual intercourse. What's your diagnosis? No, I hope you're seeing cervical cancer. This first is cervical cancer. So let's kind of explain some of these things from this vignette before we then jump into our discussion. So the first thing is you see this woman with post-quietal spot in, post-quietal bleeding and all these things. Those are all things that are consistent with cervical cancer.

And honestly, it's not, you may wonder what's this who keep me as a physician that you spend so much time talking about. Well the thing is when people have cervical cancer, the most common cause of death is renal failure. Because it can spread and involve the irriters. When you involve the irriters, you'll basically get an obstructive neuropathy. When you obstruct the flow of urine through said irriters, then you're going to have like an obstructive kidney disease basically. That's going to cause that hydronal process. So cervical cancer obviously is not good and you may wonder, okay, divine. Why all this bleeding and all that? Well the bleeding is because of the uremia. Remember uremia makes it hard for your platelets to degranolite. So when you have uremia, it's not a quantitative platelet defect. It's more of a qualitative platelet defect. Your platelets are around. They're just not very useful. So people that have uremia, they can have a qualitative platelet defect. So they'll have a lot of issues. In fact, they'll have issues with like releasing from renal factor for example. So that comes from clearly making these people hypercognizable. They can make them bleed, bleed, bleed, bleed. So they can have all these antithesis of renal failure like hypercalemia and whatnot. So again, those are just always the contested stuff on exams. And remember when a person has cervical cancer, typically it's going to be some kind of squamous cancer or adenocarcinoma.

But usually the most common kind of cervical cancer is going to be squamous cell cancer of the cervix. So when could people get cervical adenocarcinoma? Well, I mean if you're a human being and when you're in the womb, your mom too de-yes, die still still best from. Then that can certainly increase your risk of a clear cell adenocarcinoma of the vagina. That's usually going to be the classic situation where you test adenocarcinoma of the cervix. So the person has like cervical adenocarcinoma. That can certainly happen in the setting of a person exposed to de-yes. But not just that, but de-yes can also cause clear cell adenocarcinoma of. So think of clear cell adenocarcinoma with de-yes. Okay, de-yes doesn't just cause clear cell adenocarcinoma of the cervix. It can also cause that with the vagina. Okay, it can also cause that with the vagina. It can cause clear cell adenocarcinoma. So you see adenocarcinoma of like the cervix or vagina or anything along those lines. You want to think about a person that has been exposed to de-yes still best from. That's going to be the biggest factor you're going to see on your exam. So when a person has cervical cancer, you know, typically you're going to do some kind of, you know, hysterectomy. It's going to be a smart thing to do. Many times they're going to require a utheropie. Remember that a utheropie can increase your risk of having other problems as well, right? A utheropie can induce genetic mutations and cause problems.

They can also require a chemo. And then, you know, friends at the USML is one thing they can ask is, what could have been done to prevent this? Well, the thing that could have been done is getting the HPV vaccine, right? Remember there's vaccines for HPV. Typically, it's indicated between the ages of 9 to 26. You know, in the vaccine, you're going to be in good, in good state, right? Because the biggest risk factor for cervical cancer are those higher is HP Vs. Basically, the 16 to 18 and those in the 30s. So the thing is, you may wonder why is it that HPV has this really bad ability to cause cancer? Well, the reason it has that ability is because of two key proteins known as E6 and E7. The thing is E6 and E7 are ubiquitin ligases. So the question is, what are ubiquitin ligases? Are ubiquitin ligases something? It's a protein, actually, that sticks a ton of ubiquitin on stuff. And when you stick a ton of ubiquitin on stuff, that targets it to the proteins or for degradation. Targetes it to the predisone for degradation. So, HPV has these two proteins, E6, E6 polyubiquitynates. Is ubiquitin ligase for P53. And then E7 is a ubiquitin ligase for RB. These things, as you probably know from cell biology for studying for step one, is that these are both tumor suppressor genes. So if you pull ubiquitinid, they are gene products. You will not get that tumor suppressor effect. You're going to become more prone to developing malignancy. So that's pretty high yield to know, for example.

And one other thing with regards to, so if they give you a question and say, which of the following could have been used for primary prevention of this press-in-strural cancer? Again, the vaccine is going to be the answer. Getting the vaccine is very good for primary prevention. But then, you can see, which of the following secondary preventive strategies could have helped? If you're asking about secondary prevention, then they're not asking about the vaccine. They're asking about screening. So how in the world do we screen for certain causes? Well, there's a bunch of ways we can do that. But the two big ones to know is, basically, you start at 21. If you're less than 21, you don't get screened. You're going to start at 21, all the way to 65. Okay? 21, all the way to 65. And they're basically, how do you do that? From 21 to 65, you can just do Pub smears every three years. That's it. But if you want from ages 30 to 65, you can do Pub smears and HPV-quotesque testing and kind of stretch that out to every five years. But remember, put a half HIV completely different story. People that have HIV, the first year of life, they're going to get the first year after HIV discovered. They're going to get Pub smears twice within that year. But after that, they're going to get Pub smears every single year afterwards. They're going to get Pub smears every single year afterwards.

And one thing I guess I would also say is if you're over age 65, you can actually continue Pub smears in a person that is high risk. So say, for example, a person has a history of HIV. Because again, remember, your immune system has anti-cancer properties. So if you have HIV or you have some kind of immunodeficiency disease, another thing that can also kind of polyopen that high risk category is exposure to diethyl steel best role. People that have feed that bill, you know, after age 65, they can certainly keep getting Pub smears. Now, one other thing I want to say is you can stop Pub smears after a person's uterus has been removed. Although you need to be careful. You need to ask yourself, why was the uterus removed? Was there a removal for a benign reason or from a legnut reason? If it was removed for a benign reason, like Lyoma, Lyoma, for example, you can stop Pub smears right after the person has delivered, you know, after the person gets the history right to me. But if their history of tumor was done for malignant reasons, like a pre malignant lesion or malignant lesion, then those people need to keep having Pub smears of the vaginal cough. You need to keep having Pub smears of the vaginal cough. Now, one thing I want to say about the pathway for, because I think one big thing that many people always worry about is, what are the risk factors for getting cervical cancer? Well, the big thing is just riskier, risky lifestyle, right? Early sexual intercourse, right?

You start having sex early in life, multiple sex partners. If you're immunocompromised, if you've been exposed to DS. Remember DS can also cause some other problems like anatomical issues with the uterus, like a T shape of the uterus. But I think the thing I want to maybe really focus on here is Pub smears. But one thing I want to make clear is, what is the progression of how these things should go? So the thing is you get a Pub smear first. Typically a Pub smear afterwards. Again, I'm going to go into specifics, but I just want to discuss like a general pathway. You start off with a Pub. After the Pub, if you see something bad, typically you do some kind of coposcopy. Again, we're going to go into some more details here. Just chill out, right? You do some kind of coposcopy. And after you do that coposcopy, a coposcop is like a microscope. You'll see something there. If you see something I want to resect it, the resection is done with a bunch of different procedures. You can do it with a lip procedure. That's like the loop electricization procedure. You can do it with a colonization procedure. It can do like cryotherapy, for example. The thing is pretty high to know that the lip and the colonization procedures, they can increase your risk of cervical incompotence, cervical insufficiency. So you see these people, they have this painless pregnancy loss in their second trimester. Basically the baby essentially falls through the cervix out into the outside world.

Think about those lip colonization procedures as increasing your risk. And in general cryotherapy is something you can use. But we generally don't like that because cryotherapy, I believe, destroys the biopsy specimen. So it's kind of hard to do any kind of pathological analysis on a destroyed specimen. So lip colonization procedures are probably what you want to do on an example. Now, one other thing I want to define here are some terms. I think some of these terms may be helpful. So many times you see these terms like LSL, HSIL, what in the world does that mean? Basically, if you see the work LSL, it just means low rate squamous inter-apithelial lesion. These are basically pre-counselous lesions. LSL includes CIN1 and 2. CIN1 and 2. So what in the world do these CI Ns even mean? CIN just means that you're kind of worried about malignancy for the BISO-3rd of the cervical epithelium. CIN2, right? 2, number 2. It means two-thirds of the epithelial line you're worried about, you know, something that may be pretty malignant. And then CIN3 is what is called HSIL. Basically, another thing for CIN3 is HSIL. High-grade squamous inter-apithelial lesion. CIN3 means the entire epithelial layer is just filled with stuff that's really worrisome. So like for example, you're worried about like, you're seeing a ton of mytotic figures, you're seeing a normal, like nuclei, just weird stuff. Or you're seeing like dysplasia kind of makes you worried, right? So again, LSL is CIN1 and 2.

HSIL, another name for it literally is CIN3. Or you can see it referred to as carcinoma inside 2. Literally, CIN3 is carcinoma inside 2. So HSIL, CIN3, carcinoma inside 2, all the same thing. When you have CIN3, the cancer cells have literally not broken through the basement membrane just yet. Now, one other thing I want to say here is, let's go over how you manage pap smear results. This is something that is a big, big, big, boggable for many medical students. But I'm going to give you a simplified approach. That should help you get the vast majority of the questions you see on your exam. Correct. The vast majority, correct. The vast majority, correct. Okay. So basically, here's what I'm going to tell you. The first one I'm going to talk about is who gets coposcopy. Who? Who is the person where you see them on your USMD exams and the next step free is like OG. We're going to get a coposcopy. Number one, are people that have HSIL. People that have HSIL, you have CIN3, you're going to get coposcopy. Number two, if pap smear shows a typical glandular cells, a typical glandular cells, you need to get a coposcopy. Number three, if you have pap smears that show ask H. What does ask H mean? What does ask H mean? What it means, a typical squamous cells cannot rule out high grade, blah, blah, blah, blah, blah. You need to worry about all those terms. But ask H. If you have ask H, you're going to get a coposcopy.

Another person that gets a coposcopy is people that tell you in the question that somewhere, they test that possible for higher-risk HPV. Like HPV 16, HPV 18, they're going to get coposcopy. The fifth group that's going to fall into this, you're going to get a coposcopy, are people that get multiple positive askuses, multiple positive askuses. What does ask us mean? It just means literally ASEUS, a typical squamous cells of undetermined significance. If you have multiple spread across time that are positive, you should probably go ahead and get a coposcopy. So again, I'm going to repeat what the five people that get a coposcopy. Number one, H.S.IL. Number two, ATP-google-landular cells. Number three, ask H. Number four, positive higher-risk HPV, like HPV 16 or 18. Number five, repeated positive askuses. A typical squamous cells of undetermined significance. Now let me tell you this. If you don't fall into any of these categories on your exams, but you have an abnormal pap smear. So these five categories I mentioned, if you don't fall into any of them on your exams, but you have an abnormal pap smear, your next step on exams should be to get higher-risk HPV testing. Your next step on exams should be to get higher-risk HPV testing done. Another option that you may see is, oh, repeat the pap smear in six to twelve months. But let me tell you this.

If you get one of these options of, oh, get higher-risk HPV testing done, or get a pap smear in six to twelve months, get the higher-risk HPV testing. If you have an abnormal pap smear, and you don't fall into these five categories I've mentioned, literally get higher-risk HPV testing. Get tested for HPV 16 or 18. That's a much, much better answer. That's something we actually prefer to saying, oh, let's repeat pap smear in six to twelve months. Now, the final thing I'm going to say here is, again, let's talk about etypical glandular cells. It's kind of a unique pap smear result. And it's one of, they love to test it on a lot of the exams. The thing is when you have etypical glandular cells, there are three things you need to do, because it's associated with people having like malignancy beyond the cervix, having malignancy in like the endosurvix on the uterus, for example. So when you see etypical glandular cells, you have to check out the entire productive tract. How in the world do you do that? Well, number one, you're going to do an endometrial biopsy. Remember, sometimes we call that endometrial sampling on exams. Check out the uterus. Number two, you're going to do an endosurvicocaureatech. You're going to do an endosurvicocaureatech. It's a beautiful way to check out the endosurvix. And then number three, check out the ectosurvix by doing a colposcopy. Okay? By doing a colposcopy. So really, again, I want to keep this short and sweet.

But honestly, if you know the stuff we've talked about, you're going to be in pretty good shape with regards to cervical cancer questions on your exams. Okay? You're going to be in pretty, pretty good shape with regards to cervical cancer questions. I know the way I talked about managing post-mary results, maybe a little non-traditional, compared to a lot of stuff that's out there. But here's what I'm going to tell you. If you understand what I just explained, if you literally understand what I just explained, you will probably be able to get like 99% of your post-mary questions right on exams. Okay? It's a pretty accurate, again, it does encapsulate every 100% of your post-mary results. Okay? So, I'm going to go ahead and wrap up here. I do offer review courses for the NV Me Testicking Strategies class that's going to be for Step 1 to Step 3. I have a four-hour biostatistics class that's also for Step 1 to Step 3. I have a five-hour social sciences ethics, quality improvement and communications, and healthcare systems class. That's also for Step 1 to Step 3. I actually have those next week. On Thursday, next week, I have the Testicking Strategies class Friday, the biostat's class Saturday, the social sciences class. And then the week after that, basically I believe from the 10th to the 14th, although we're on the day of the 12th, we have the 20-hour Step 2 review. So, if you're interested in any of those classes, just shoot me an email through the website.

I can give you some more information. I also offer one I wanted to learn for all the USMLA exams. Step 1, Step 2, and Step 3. Preclinical Medical Exam, 30-ish-off exams. And I have these podcasts on the major platforms, Apple, Google, Spotify, podcasts. I actually have a You Tube channel as well known as the Divine Intervention, USMLA Podcasts, and Videos. Divine Intervention, USMLA Podcasts, and Videos. That's where I post the videos that I make. And then many people have said, oh, Divine, I really, really love the life lessons that you put at the end of your podcast. So, I said I'll start a new website. It's called Divine Intervention, Life Lessons.com. There's actually an Apple Podcast associated with that. It's called the Divine Intervention Life Lessons Podcast. Basically, just check that out. Every week I post like two podcasts using a biblical perspective to talk about a life lesson, a problem that's commonly faced by people in this world. So, if you're interested in any of those, just go ahead and check that out. Basically, the life lesson I'm going to live with you today is the importance of thinking long term. Think long term. Don't be an impulsive person. Many people have made so many grave mistakes in life because they've just been very, very impulsive people. Think long term. Don't just look at the shiny stuff that's standing right in front of you. Think long term.

There's some people that have just acted impulsively and they've just caused irreparable damage to their lives. You don't want that, right? You want to think long term. You want to think about the consequences. Count the cost before you jump into certain things. I think there's just a smart way to live life just in general. So, thank you for listening to me today. I will see you in the next podcast. I guess that'll be episode 468. God bless you. Have a wonderful weekend. Bye for now.

E6 and E7.

E6 targets p53; E7 targets RB.

A qualitative platelet defect (due to uremia).

Endometrial biopsy, endocervical curettage, and colposcopy.

Co-testing with Pap smear and HPV testing every five years.

LEEP (Loop Electrosurgical Excision Procedure) or cold snare procedures.

Clear cell adenocarcinoma (of the vagina/cervix).

Atypical squamous cells of undetermined significance, high-risk.

Colposcopy.

HPV vaccination (recommended ages 9-26).

Early sexual intercourse, multiple sex partners, and immunocompromised status/DES exposure.

High-risk HPV testing (testing for types 16 or 18).

Clear cell adenocarcinoma (of the vagina/cervix).

Atypical squamous cells of undetermined significance, high-risk.

Colposcopy.

HPV vaccination (recommended ages 9-26).

Early sexual intercourse, multiple sex partners, and immunocompromised status/DES exposure.

High-risk HPV testing (testing for types 16 or 18).