Plenary Discussion Family Medicine (Tutorial 5)

Scenario A Concerned Daughter A 33-years-old woman consults a family doctor on how to care for her ill mother at home. Her mother, a 58-years-old housewife, was diagnosed to have a cancer of the cervix in inoperable stadium four months ago. She was advised to get radiotherapy and chemotherapy, but she refused the treatment. She would prefer to get alternative therapy. Her condition is getting worse. The daughter said that her mother is in pain, significance weight loss and appetite changes. The patient has 3 children. Her husband, 66 years old, retired state university professor, is not really involved in the treatment if his wife, because he is busy working in a private university in another city and comes home every 1-2 weeks. Her eldest daughter, 34 years old is married. Has three children and lives with her family in another island. Her second daughter, 33 years old. Who is married and has adopted 4 years old son, together with his husband live in the same house but does not really care with her mother condition. All this time, the second daughter has been in conflict relationship with the mother since she perceives that the mother has spoilt and cared more to her eldest and youngest siblings. However, because she is very worried of her mothers worse condition and because of her familys circumstances, she is forced to take a more active role in taking care of her mother. Therefore she consults the family doctor for the care of her mother. She also thinks of hiring a nurse to provide daily care for her mother. Unfamiliar Terms Radiotherapy : Radiotherapy, also called radiation therapy, is the treatment of cancer and other diseases with ionizing radiation. Ionizing radiation deposits energy that injures or destroys cells in the area being treated (the "target tissue") by damaging their genetic material, making it impossible for these cells to continue to grow. Chemotherapy : Treatment of cancer with an anti-neoplastic drug or with a combination of such drugs into a standardized treatment regimen. Alternative therapy : Term for medical products and practices that are not part of standard care. Standard care is what medical doctors, doctors of osteopathy and allied health professionals, such as registered nurses and physical therapists, practice. Alternative medicine means treatments that you use instead of standard ones. Complementary medicine means nonstandard treatments that you use along with standard ones. The the doctor decide to go to see the patient. The patient visibly upset and angry, she says I dont belive in any doctor anymore

Analyzing Problems Angry, defensive, frightened or resistant patients. Clenched fists, furrowed brows, wringing of the hands, restricted breathing patterns and warnings from office staff that something is wrong can help to identify these patients. When you see these signs, try to uncover the source of difficulty for the patient and pay attention to the way his or her emotions relate to the medical issues at hand. Don't get drawn into a conflict. Instead, define your boundaries and recognize when your triggers are invoked, as this will help you to modulate your response to the situation and allow you to empathize with the patient. Use reflective statements such as, I can understand why you might feel that way, and follow with a discussion about what it might take to resolve the situation2,3 For example, a patient who is in pain and has been waiting for an hour because you have been tending to a hospital emergency might be quite angry when you finally get to the room. He may say, My time is as valuable as yours. I don't understand why I had to wait. Your own sense of being harried and running late may trigger an angry reaction from you, but simply taking a deep breath and offering a sincere apology would be a more constructive response than having your own meltdown. A statement such as, I can understand why you are upset, and I appreciate your waiting for me, would go a long way toward easing the patient's frustration. If you can say with confidence that you'll handle the situation differently next time, for instance, by instructing your office staff to tell your patients that you are running late and to offer alternatives to waiting, such as rescheduling, then tell the patient what you intend to do. If you sense that a patient is fearful about a diagnosis or treatment, encourage the patient to talk about it, and assess whether the fear is appropriate in proportion to the situation. This may help to establish a context for the fear, allowing the patient to deal with it more constructively. Of course, if at any point during an encounter with an angry patient you sense a potential for harm to you or your staff, ask for assistance from law enforcement and remove those you can from harm's way. The family physician finally able to gain cooperation from the patient History of Presenting Condition Lower back pain which has worsened over the last two months. Pain is a dull, dragging ache in the lower back and pelvis, not related to any particular activity. Associated with some right loin pain Pain is like period pain but continuous throughout the cycle not helped by usual painkillers. Pain on passing urine Urine looks cloudy Not on any regular medication. Systemic symptoms (+) Gynecological assessment (by specialist) four months ago revealed the cervical cancer at inoperable stage (FIGO stage 4A). The process that she through were as follow: Coloscopically there was obvious evidence of invasive carcinoma of the cervix A cervical biopsy was taken at the time of examination under anaesthesia. Vaginal swas for microscopy and culture

Past Medical History Patient was previously well. No major medical problem

Personal History Lives in Yogyakarta. A devoted housewife, actively involved in local community A non-smoker. Non-drinker

Family History No family history of any malignancy. Her father died of a heart attack at age 71. Her mother is alive and well, aged 78 years.

Gynaecological History Three normal pregnancies, all delivered by normal vaginal delivery Three children, all very healthy aged from 23 to 34 years Only one sexual partner in her life and is currently are not sexually active. Never had Pap smears in her life. Used the oral contraceptive pill during her fertile age Periods are regular, with 28 day cycles. Irregular vaginal bleeding. Intermestrual or poscoital bleeding, few times in the last few years before diagnosed by cancer

Physical examination Very unwell looking, weight 50kg (used to be 67kg), 163 cm tall. Respiration rate = 18 per minute. Pulse rate = 76 per min. Blood pressure = 130/70 mm Hg Temperature = 36.8 oC No lymphadenopathy. Chest and heart examination normal. Breast both normal to palpation Urine test shows microscopic haematuria Abnormal examination o No fullness in flanks. Liver and spleen not palpable o No other palpable masses. No shifting dullness and ausculataion was normal o Pain in lower region, especially suprapubic area

Gynaecologist Examination (performed by specialist) Normal vulva. The cervix is replaced by an irregular mass of tumour measuring approximately 6 cm in diameter The tumour appears to extend onto the anterior and posterior vaginal fornicles Rectal examination is normal but there appears to be early parametrial involvement

Further Investigation (Result of investigations performed by specialist) Full blood count: normal with Haemoglobin 10.1 g/dl Plasma biochemistry profile: normal Liver function: normal

Chest Xray: normal CT scan Of abdomen and pelvis confirm six cm diameter tumour arising from cervix and hazing of tissue plaints adjacent to the tumour mass. Clear evidence of retroperitoneal lymphadenopathy. Liver and upper abdomen normal. Clear evidence of tumour mass metastatic to the bladder. Biopsy of cervix: Large cell, non-keratinising squamous cell carcinoma of the cervix

Family APGAR

A=2 P=2 G=2 A=2 R=2 Total = 8 Nilai 0-3 = disfungsi keluarga berat Nilai 4-7 = disfungsi keluarga moderat Nilai 8-10 = fungsi keluarga baik Family SCREEM Aspek Social Sumber daya Patologi Interaksi social dalam keluarga berpotensi sebagai paologi oleh karena adanya konflik antara anggota keluarga, terutama antara anak kedua dengan ibu Keluarga ini kurang taat beribadah dan sering pergi ke dukun/paranormal Masalah financial tidak terlalu bermasalah karena suami pasien masih aktif bekerja di universitas swasta setelah pension dari universitas negeri Hampir semua anggota keluarga berpendidikan sarjana. Tidak ada masalah

Cultural Religious

Tidak ada masalah budaya

Economic

Education

dalam memahami pengetahuan tentang penyakit Akses ke pelayanan kesehatan cukup baik, Medical (accessibility) selalu pergi ke RS swasta terbaik di Yogyakarta adik pasien adalah dokter yang bekerja di RS tersebut

Apa itu Kanker Serviks Kanker serviks adalah keganasan yang terjadi pada leher rahim. Kanker serviks disebut juga kanker leher rahim atau kanker mulut rahim dimulai pada lapisan serviks. Kanker serviks terbentuk sangat perlahan. Pertama, beberapa sel berubah dari normal menjadi sel-sel prakanker dan kemudian menjadi sel kanker. Ini dapat terjadi bertahun-tahun, tapi kadang-kadang terjadi lebih cepat. Perubahan ini sering disebut displasia. Mereka dapat ditemukan dengan tes Pap Smear dan dapat diobati untuk mencegah terjadinya kanker. Untuk dapat memahami kanker serviks, ada baiknya kita memahami terlebih dahulu anatomi rahim wanita. Anatomi Rahim wanita Leher rahim (serviks) adalah bagian bawah uterus (rahim). Rahim memiliki 2 bagian. Bagian atas, disebut tubuh rahim, adalah tempat di mana bayi tumbuh. Leher rahim, di bagian bawah, menghubungkan tubuh rahim ke vagina, atau disebut juga jalan lahir. Ada 2 jenis utama kanker serviks. Sekitar 8-9 dari 10 jenis yang ada adalah karsinoma sel skuamosa. Di bawah mikroskop, kanker jenis ini terbentuk dari sel-sel seperti sel-sel skuamosa yang menutupi permukaan serviks. Sebagian besar sisanya adalah adenokarsinoma. Kanker ini dimulai pada sel-sel kelenjar yang membuat lendir. Jarang terjadi, kanker serviks memiliki kedua jenis fitur diatas dan disebut karsinoma campuran. Jenis lainnya (seperti melanoma, sarkoma, dan limfoma) yang paling sering terjadi di bagian lain dari tubuh. Jika Anda memiliki kanker serviks, mintalah dokter Anda untuk menjelaskan jenis kanker apa yang Anda miliki. Berapa banyak wanita terkena kanker serviks ? Jumlah prevalensi wanita pengidap kanker serviks di Indonesia terbilang cukup besar. Setiap hari, ditemukan 40-45 kasus baru dengan jumlah kematian mencapai 20-25 orang. Sementara jumlah wanita yang berisiko mengidapnya mencapai 48 juta orang. Beberapa peneliti berpikir bahwa kanker serviks non-invasif (yang hanya terjadi di leher rahim ketika ditemukan) adalah sekitar 4 kali lebih umum daripada jenis kanker serviks yang invasif. Ketika ditemukan dan diobati secara dini, kanker serviks seringkali dapat disembuhkan. Kanker serviks cenderung terjadi pada wanita paruh baya. Kebanyakan kasus ditemukan pada wanita yang dibawah 50 tahun. Ini jarang terjadi pada wanita muda (usia 20 tahunan). Banyak wanita tidak tahu

bahwa ketika menjadi tua, mereka masih beresiko terkena kanker serviks. Itulah sebabnya penting bagi wanita lebih tua untuk tetap menjalani tes Pap Smear secara teratur Faktor Resiko Kanker Serviks Faktor-faktor resiko dibawah ini dapat meningkatkan peluang seorang wanita terkena kanker serviks: Infeksi Virus Human Papilloma (HPV) Pada kanker serviks, faktor risiko yang terpenting adalah infeksi HPV (human papilloma virus). HPV adalah sekelompok lebih dari 100 virus yang berhubungan yang dapat menginfeksi sel-sel pada permukaan kulit, ditularkan melalui kontak kulit seperti vaginal, anal, atau oral seks. Virus HPV berisiko rendah dapat menimbulkan genital warts (penyakit kutil kelamin) yang dapat sembuh dengan sendirinya dengan kekebalan tubuh. Namun pada Virus HPV berisiko tinggi tipe (tipe 16, 18, 31, 33 and 45), virus ini dapat mengubah permukaan sel-sel vagina. Bila tidak segera terdeteksi dan diobati, infeksi Virus HPV ini dalam jangka panjang dapat menyebabkan terbentuknya sel-sel pra kanker serviks. Melakukan hubungan seks tidak aman terutama pada usia muda atau memiliki banyak pasangan seks, memungkinkan terjadinya infeksi HPV. Tiga dari empat kasus baru infeksi virus HPV menyerang wanita muda (usia 15-24 tahun). Infeksi Virus HPV dapat terjadi dalam 2-3 tahun pertama mereka aktif secara seksual. Pada usia remaja (12-20 tahun) organ reproduksi wanita sedang aktif berkembang. Rangsangan penis/sperma dapat memicu perubahan sifat sel menjadi tidak normal, apalagi bila terjadi luka saat berhubungan seksual dan kemudian infeksi Virus HPV. Sel abnormal inilah yang berpotensi tinggi menyebabkan kanker serviks. Saat ini sudah ada beberapa vaksin yang mencegah terjadinya infeksi dari beberapa jenis HPV. Faktor Resiko Lainnya Merokok: Wanita yang merokok berada dua kali lebih mungkin mendapat kanker serviks dibandingkan mereka yang tidak. Rokok mengandung banyak zat racun/kimia yang dapat menyebabkan kanker paru. Zat-zat berbahaya ini dibawa ke dalam aliran darah ke seluruh tubuh ke organ lain juga. Produk sampingan (by-products) rokok seringkali ditemukan pada mukosa serviks dari para wanita perokok. Infeksi HIV: HIV (human immunodeficiency virus) adalah virus yang menyebabkan penyakit AIDStidak sama dengan HPV. Ini dapat juga menjadi faktor resiko kanker serviks. Memiliki HIV agaknya membuat sistem kekebalan tubuh seorang wanita kurang dapat memerangi baik infeksi HPV maupun kanker-kanker pada stadium awal. Infeksi Klamidia : Ini adalah bakteri yang umum menyerang organ wanita, tersebar melalui hubungan seksual. Seorang wanita mungkin tidak tahu bahwa ia terinfeksi kecuali dilakukan tes untuk klamidia

selama pemeriksaan panggul. Beberapa riset menemukan bahwa wanita yang memiliki sejarah atau infeksi saat ini berada dalam resiko kanker serviks lebih tinggi. Infeksi dalam jangka panjang juga dapat menyebabkan masalah serius lainnya. Diet : Apa yang Anda makan juga dapat berperan. Diet rendah sayuran dan buah-buahan dapat dikaitkan dengan meningkatnya resiko kanker seviks. Juga, wanita yang obes/gemuk berada pada tingkat resiko lebih tinggi. Pil KB: Penggunaan pil KB dalam jangka panjang dapat meningkatkan resiko terjadinya kanker serviks. Riset menemukan bahwa resiko kanker serviks meningkat sejalan dengan semakin lama wanita tersebut menggunakan pil kontrasepsi tersebut dan cenderung menurun pada saat pil di-stop. Anda harus membicarakan dengan dokter Anda tentang pro kontra penggunaan pil KB dalam kasus Anda. Memiliki Banyak Kehamilan: Wanita yang menjalani 3 atau lebih kehamilan utuh memiliki peningkatan resiko kanker serviks. Tidak ada yang tahu mengapa ini dapat terjadi. Hamil pertama di usia muda: Wanita yang hamil pertama pada usia dibawah 17 tahun hampir selalu 2x lebih mungkin terkena kanker serviks di usia tuanya, daripada wanita yang menunda kehamilan hingga usia 25 tahun atau lebih tua Penghasilan rendah: Wanita miskin berada pada tingkat resiko kanker serviks yang lebih tinggi. Ini mungkin karena mereka tidak mampu untuk memperoleh perawatan kesehatan yang memadai, seperti tes Pap Smear secara rutin. DES (diethylstilbestrol): DES adalah obat hormon yang pernah digunakan antara tahun 1940-1971 untuk beberapa wanita yang berada dalam bahaya keguguran. Anak-anak wanita dari para wanita yang menggunakan obat ini, ketika mereka hamil berada dalam resiko terkena kanker serviks dan vagina sedikit lebih tinggi. Riwayat Keluarga: Kanker serviks dapat berjalan dalam beberapa keluarga. Bila Ibu atau kakak perempuan Anda memiliki kanker serviks, resiko Anda terkena kanker ini bisa 2 atau 3x lipat dari orang lain yang bukan. Ini mungkin karena wanita-wanita ini kurang dapat memerangi infeksi HPV daripada wanita lain pada umumnya. Dampak kanker serviks terhadap keluarga pasien mencakup : Ekonomi Biaya pengobatan pasien akan mempengaruhi keuangan keluarga karena biaya yang dikeluarkan tidak sedikit sehingga keuangan akan berkurang. Semakin tinggi derajat kanker, maka biaya terapi akan semakin besar. Untuk mencegah pengeluaran biaya yang lebih, dapat dilakukan dengan mendeteksi sejak dini yang dapat dilakukan dengan screening dan pemeriksaan periodik. Sosial Keharmonisan dalam keluarga dapat terpengaruh, keluarga pasien bisa menjadi perhatian terhadap pasien atau terjadi keretakan karena kondisi pasien yang terdiagnosis kanker pasien. Hubungan terhadap suami dapat terpengaruh. Psikologis

Kondisi kanker serviks yang diderita oleh pasien, selain berdampak pada psikologis pasien dapat berdamapak psikologis keluarganya, keluarga pasien dapat terjadi kekhawatiran akan kondisi pasien, kesedihan, depresi. Religi pada kondisi di mana pasien terdiagnosis kanker serviks, maka ada kemungkinan orang terdekat akan memberikan dukungan yang berupa doa sehingga pada konsdisi ini kemungkinan dapat terjadi peningkatan ibadah pada keluarga pasien untuk berdoa mengharapkan yang terbaik. Edukasi Keluarga akan mulai mencari info-info tentang kanker serviks, sehingga pemahaman keluarga terhadap kanker serviks ada kemungkinan akan lebih meningkat. Kultural Stage IVA: The management of patients with stage IVA disease (invasion of bladder and or rectum) has to be individualized, taking into account the extent of bladder / rectal involvement, parametrial infiltration, renal function and patients performance status. The treatment options include: Neoadjuvant chemotherapy or concurrent chemoradiotherapy Palliative Radiotherapy / Chemotherapy Pelvic Exenteration Best Supportive Care / Palliative Care

Neoadjuvant chemotherapy or concurrent chemoradiotherapy: Selected patients with good general and re nal status and not suitable for surgical exenteration can be treated with this approach with radical intent.

Palliative Radiotherapy / Chemotherapy: The majority of stage IVA patients has poor general condition a nd extensive local disease in our setting and are best treated with palliative radiation therapy / chemothera py. The major symptoms which can be palliated are vaginal bleeding, profuse discharge, low backache du e to local disease etc. A short palliative regime of 30 Gy in 10 fractions over two weeks or 30 Gy / 3# / 60 days (10 Gy / every month x 3#) is generally used and in few patients who respond very well, this is follo wed by intracavitary application. Palliative chemotherapy has been dealt in detail later.

Surgical Exenteration: Selected patients of stage IV, with no or minimal parametrial invasion may be treat ed with primary exenterative surgery, the extent of which (anterior, posterior or total) would depend on th e extent of the lesion.

Best Supportive Care / Palliative Care : Patients with poor general condition, extensive local disease like f istulae, symptoms of uremia etc. can be offered best supportive care / palliative care only.

ParaAortic nodes: Extended field radiation therapy has been reported to produce long term disease contr ol in women with microscopic or small volume (<2cm) lower paraaortic nodes (below L3) with acceptab le complications rates when radiation dose was not exceeded beyond 50 Gy and the lymphadenectomy wa s performed by extraperitoneal rather than transperitoneal route . In the RTOG randomized trial reported r ecently , the 10 year overall survival was improved from 44% with pelvic radiation to 55% with pelvic plus prophylactic paraaortic radiation in 367 women with stage IB1 and IIA disease. Grade 4 and 5 radiation toxicities at 10 years however increased from 4% to 8% with paraaortic irradiation. Patients with positive common iliac or para aortic nodes may be treated by extended field Radiation with or without chemotherapy. Grade C Recommendations.

Management of patients who relapse after primary treatment: Treatment decisions should be based on the performance status of the patient, the site of recurrence and/or metastases, the extent of metastatic disease and the prior treatment.

Therapeutic options for local relapse after Primary Surgery Relapse in the pelvis following primary surgery may be treated by either radical radiation or pelvic exente ration. Radical irradiation (+/concurrent chemotherapy) may cure a substantial proportion of those with is olated pelvic failure after primary surgery. Radiation dose and volume should be tailored to the extent of disease. Fifty Gray in 25# @ 1.8 Gy per day should be delivered to microscopic disease and using field reductions 64 to 66 Gy should be delivered to the gross tumour volume. Where disease is metastatic or recurrent in the pelvis after failure of primary therapy and not curable, a trial of chemotherapy with palliative intent or symptomatic care is indicated. Cisplatin is the single most active agent for the treatment of cervical cancer. The expected median time to progression or death is three to seven months

Local Recurrence after Primary Radiotherapy: Selected patients with resectable recurrences should be con sidered for pelvic exenteration. The only potentially curative treatment after primary irradiation is pelvic e xenteration. Patients should be selected carefully; those with resectable central recurrences that involve th e bladder and/or rectum without evidence of intraperitoneal or extra pelvic spread and who have a dissect

able tumourfree space along the pelvic sidewall are potentially suitable. The triad of unilateral leg edema , sciatic pain and ureteral obstruction almost always indicates unresectable disease on the pelvic sidewall, and palliative measures are indicated. This surgery should be undertaken only in centres with facilities an d expertise for this surgery available and only by teams who have the experience and commitment to look after the longterm rehabilitation of these patients. The prognosis is better for patients with a diseasefree interval greater than six months, a recurrence 3 cm or less in diameter, and no sidewall fixation. The five year survival for patients selected for treatment with pelvic exenteration is in the order of 30 60% and the operative mortality should be < 10%. In carefully selected patients, a radical hysterectomy may be performed. Suitable patients are mainly those whose central tumour is not more than 2 cm in diam eter. Grade C Recommendations.

Systemic CT in Stage IVB or Recurrent Metastatic Disease: Chemotherapy has a palliative role in the pati ents with metastatic or recurrent cervical cancer after failure of surgery or radiotherapy. There are a numb er of chemotherapeutic agents with activity in metastatic or recurrent cervical cancer. Cisplatin, at present , is considered the most active cytotoxic agent, with a response rate of 2030% and a median survival of 7 months. Although the older combination regimens failed to show an impr ovement in survival compared to cisplatin alone, the use of newer combinations has shown promise. In a phase III GOG study, paclitaxel + cisplatin was superior to cisplatin alone in terms of response, PFS and s ustained QOL but not for overall survival. In another GOG study the combination of topotecan + cisplatin was superior to cisplatin alone for response, progression free survival and overall survival. Therefore selected patients with recurrent or metastatic disease in good general condition could be offered one of the newer combination regimens. For others single agent cisplatin and best supportive care contin ue to be appropriate choices.

Distant Metastases: Should be treated with a palliative intent with chemotherapy or radiotherapy or symptomatic & supportive care only. Symptoms of recurrent / metastatic cervical cancer may include pain, leg swelling, anorexia, vaginal bleeding, cachexia and psychological problems among others. The coordinated efforts of a team of professionals are optimal; this may include gynaecologic oncologists, radiation and medical oncologists, palliative care physicians, specialized nursing staff, psychologists,

and possibly stomal therapists. Relief of pain and other symptoms, along with comprehensive support for the patient and her family, are paramount. Local treatment with radiation therapy is indicated to sites of symptomatic involvement in patients with m etastatic disease for alleviation of symptoms including pain arising from skeletal metastases, enlarged par aaortic or supraclavicular nodes, and symptoms associated with cerebral metastases. In view of the shortened life expectancy of patients with metastatic cervical cancer, palliative radiotherapy should be given via larger fractions over shorter periods of time than conventional radical courses of treatment.

Pencegahan Kanker Servik Bila mungkin, hindari faktor resiko yaitu bergati pasangan seksual lebih dari satu dan berhubungan seks dibawah usia 20 karena secara fisik seluruh organ intim dan yang terkait pada wanita baru matang pada usia 21 tahun. Bagi wanita yang aktif secara seksual, atau sudah pernah berhubungan seksual, dianjurkan untuk melakukan tes HPV, Pap Smear, atau tes IVA, untuk mendeteksi keberadaanHuman Papilloma Virus (HPV), yang merupakan penyebab dari tercetusnya penyakit kanker serviks.

Bagi wanita yang belum pernah berhubungan seks, atau anak-anak perempuan dan laki-laki yang ingin terbentengi dari serangan virus HPV, bisa menjalani vaksinasi HPV. Vaksin HPV dapat mencegah infeksi HPV tipe 16 dan 18. Dan dapat diberikan mulaidari usia 9-26 tahun, dalam bentuk suntikan sebanyak 3 kali (0-2-6 bulan). Dan biayanya pun terbilang murah. Menjaga pola makan seimbang dan bergizi, serta menjalani gaya hidup sehat (berolahraga).

Pencegahan Kanker Serviks 1. Jalankan POLA Hidup Sehat (Hindari rokok, alkohol, dan narkoba). 2. SETIA terhadap pasangan (Seks Bebas & Perselingkuhan mempercepat penyebaran Kanker Serviks). 3. VAKSINASI Kanker Serviks Vaksin HPV (Efektif hanya untuk Usia Wanita 9-26 Tahun dan belum melakukan hubungan intim). Efektif mencegah hanya 70% saja. 4. TEST Pap Smear secara berkala (Termasuk Test Peradangan & Infeksi Ringan Lainnya). Test Pap Smear hanya mampu mendeteksi Kanker Stadium dini, tidak bias Untuk Kanker Stadium Lanjut; juga tidak untuk mendeteksi Peradangan, Infeksi,Keputihan atau gejala abnormal lainnya 5. Usahakan daerah Organ Kewanitaan CUKUP OKSIGEN (Aerob) atau ada sirkulasi Udara (Hindari memakai pakaian dalam yang tidak higienis dan yang tidak Memungkinkan sirkulasi udara, serta hindari pemakaian celana ketat). 6. Gunakan pemakaian PEMBALUT yang BERKUALITAS & ALAMI (50% pemicu Kanker Serviks disebabkan karena pembalut kualitas rendah dan bahan baku daur ulang Karena menghasilkan Dioxsin / Zat Beracun hasil dari proses kimiawi daur ulang, Spt. Pemutihan).