CERVICAL CANCER SREENING

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Slide 1 : Screening of Cancer Cervix in Low Resource Settings DR RAJEEV IGMC SHIMLA
Slide 2 : Cancer Cervix Jawahar Lal Nehru in 1949 “We cannot allow tomorrow to slip out of our hands, because of petty problems of today” Hence in 21st century our emphasis should be on Public education and awareness about cancer Screening and early detection HPV testing and vaccines to be introduced Introduce new strategies and concepts
Slide 3 : 50% of patients visiting Surgery, Medicine, Eye, E.N.T, Ortho, Skin O.P.D are females. All females must be educated -- About PREVENTABLE carcinoma-- CA. CERVIX Cancer Cervix
Slide 4 : Cervical cancer is the most common malignancy 3,70,000 cases diagnosed annually, 78% of the cases in developing countries. It ranks the first carcinoma and breast carcinoma ranks second. Ratio between cervix and breast cancer is 3:1. But in developed countries the ratio between and cervical CA and breast CA is 1:3 where cervical CA ranks the second. Cancer Cervix
Slide 5 : Predicted Cervical Cancer by 2020 2002 2020 World 4,93,000 7,02,500 Developed Countries 83,000 92,500 Developing Countries 4,09,000 6.39,000 Ref : BOSCH GLOBOCAN 2002
Slide 6 : Cervical Cancer 1,20,000 women suffer in India 80,000 die of it “Preventable but not prevented” The reality today
Slide 7 : Invasive cancer of the cervix is considered a preventable disease because it has a long preinvasive state. Cervical cytology screening program and effective treatment of preinvasive lesion. Cervical Cancer
Slide 8 : The cervix is composed of columnar epithelium which lines the endocervical canal and squamous epithelium covers the exocervix. The point at which they meet is called the squamocolumnar junction or original squamo -columnar junction. This remains stable at the alkaline pH in prepubertal girls. Cervical Cancer
Slide 9 : Cervical Cancer But at menarche or after the first pregnancy the production of estrogen causes the vaginal epithelium to fill with glycogen. Lactobacillus act on the glycogen to make vaginal pH acidic ? elicits the protective response of replacing the columnar epithelium with the squamous epithelium .
Slide 10 : Transformation Zone The zone of metaplasia extending from the original squamo-columnar junction to the new squamo-columnar junction is recognized colposcopically as the transformation zone. It is important because it is the site of precancerous lesions of the cervix.
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Slide 13 : Transformation zone
Slide 14 : Mature metaplastic epithelium is called the healed transformation zone and are resistant to oncogenic stimuli. The SCJ with immature metaplastic epithelium is susceptible to oncogenic factors. Cervical intraepithelium neoplasia (CIN) is most likely to begin at immature metaplastic epithelium of the SCJ mostly after pregnancy or during menarche when metaplasia is most active. After menopause women undergo little metaplasia and are at lower risk to develop CIN. Transformation zone
Slide 15 : Natural history of Cervical cancer Normal smear Inflammatory Mild dysplasia Mod. dysplasia Severe dysplasia CIS invasive cancer
Slide 16 : Natural history of Cervical cancer Cofactors High- Risk HPV Types (16, 18 33, etc.) HPV Infection Normal Cervix About 60% regress within 2-3 years HPV- Related Changes Low – Grade SIL (Atypia, CIN1) High- Grade SIL (CIN 2,3/ CIS) Invasive Cancer About 15% progress within 3-4 years 30-70% progress within 10 years
Slide 17 : Cervical Cancer Screening Five years survival rate for cervical cancer Stage IV : 7% Stage I : 79% Precancerous lesion :100% Hence, incentive for screening. Sasieni P. Lancet 1991; 338 : 818-19
Slide 18 : Screening NEW CONCEPT which was introduced in 20th Century PRESUMPTIVE IDENTIFICATION of unrecognised disease, by the application of diagnostic procedures which are reliable, safe & rapidly applied
Slide 19 : Types Of Screening Mass Screening For whole population difficult and expensive. Selective screening for high risk only age specific. Cervical Cancer 35-64 years. Multiphasic Screening Breast, Genital Tract, Anaemia, Diabetes. Opportunistic Those attending Hospitals, Family Planning Clinics Feasible, Less expensive.
Slide 20 : Methods Of Cervical Cancer Screening Pap smear (traditional) Liquid based cytology reduces false negative rates of conventional cytology Colposcopy Visual Inspection of Cervix. Education Awareness Campaign (Barshi experience) HPV – DNA testing.
Slide 21 : Cervical Cancer Screening Hence, the Pap smear and Colposcopy are the preferred screening methods for cervical cancer precursor. Shankaraman R et al : Cancer Nov 15; 1998; 83 (10) : 2150-56. In 1969, WHO – Cancer cervix preventable disease – Preventable if diagnosed at precancerous stage
Slide 22 : Cervical Cancer Screening by Pap Smear The meta-analysis of 84 appropriately designed and conducted studies reported that conventional cytology has a sensitivity of 51% and specificity of 98%. The accuracy is increased when the goal is detection of higher grade lesions. Johnson C. Textbook & Atlas, USA WB, Saunders Company 2002 : 52-56.
Slide 23 : Cervical Cancer Screening by Pap Smear Advantages High specificity Low costs Decades of experience to use Disadvantages Requiring repetitive smears Loss to follow up Need for laboratory Need for colposcopy with colposcopist Incompatibility with some women’s belief to abolish the disease by screening World Health Organization (Geneva) 2002.
Slide 24 : Screening Policy First screening 3 yrs after 1st intercourse < 30 yrs ? Annually due to high risk type of HPV ? 30 yrs ? Annually for 3 yrs Negative Once in 3 yrs Cervical cancer screening July 31, 2003 New ACOG Recommendation
Slide 25 : Discontinue Age 70 years if 3 consecutive normal in 10 years Screening after hystrectomy for benign diseases not necessary.
Slide 26 : Factors necessary to improve effectiveness of cervical screening Spread screening evenly across a wide age range Ensure a high participation rate of the target population by making the service acceptable to women Repeat the tests at a suitable interval not exceeding five years Ensure adequate facilities and quality control for taking and interpreting smears Ensure a reliable safe methods for the prompt follow up of abnormal results Ensure adequate facilities for appropriate treatment Ensure systemic evaluation and monitoring Reduction in mortality by 70% expected in long term
Slide 27 : Barriers to Screening Little understanding of cervical cancer Limited understanding of female reproductive organs and associated diseases. Lack of access to services Shame and fear of a vaginal exam Fear of death from cancer Lack of trust in Health care system Lack of community and family support Concept of “Preventive care” is foreign
Slide 28 : High Risk Groups for CIN Genital HPV infection Positive HIV status Multiple sexual partners Early age of intercourse High parity Cigarette smoking Low socioeconomic status H/o prior STD High risk groups require frequent screening
Slide 29 : British Columbia (Canada) Screening Program B.C. Cancer Registry, April,2007 Shift from late cases Stage I Preclinical Ref. www.bccancer.bc.Ca
Slide 30 : Cervical Cancer Screening by Colposcopy : Indications Abnormal PAP smear Visible or palpable abnormality of the cervix Persistent leucorrhoea, not responding to treatment Contact bleeding Intermenstrual bleeding Postmenopausal bleeding Follow up following treatment
Slide 31 : Cervical Cancer Screening by Colposcopy Used in conjunction for early diagnosis and prevention of cancer cervix Used for biopsies from abnormal areas Used for loop excision of transformation zone An integrated approach for screening cervical cancer using cytology, colposcopy and biopsy is the best.
Slide 32 : Cervical Cancer Screening : Indian Scenario There are no organized screening programmes for cancer cervix in India. Low intensity cytology (Once in lifetime >35 yrs or at 10 yrs interval) has been suggested as a possible alternative to organized cytology for control of cancer cervix in India. Shantitri SJ et al, India Bull; WHO, 2005; 83 (3) : 186-94 - Shankaranarayan R et al : Cancer Nov1998; 83 (10) : 2150-56
Slide 33 : It is estimated that India even with a major effort expands cytology services still not more than 25 percent of women at high risk could be screened annually. - Parkin DM et al. Eur J Cancer 2001; 37 : 54-66. Cervical Cancer Screening : Indian Scenario
Slide 34 : Cervical Cancer Screening in Low Resource Setting Visual inspection of cervix by simple speculum examination Visual inspection of cervix, VIA, VILI Use of megnascope instead of colposcopy Single visit approach Treatment with cryosurgery for VIA +ve women Education and counseling Increasing coverage by camp approach Low cost HPV tests HPV vaccine
Slide 35 : Sensitivity – 60 to 90% Specificity – 40 to 90% Both are on lower side But very useful in prevalent areas of cancer cervix. Cervical Cancer Screening in Low Resource Setting - Nene BM et al Int J Cancer 1996 Dec 11 : 68 (6) : 770-73.
Slide 36 : To train nurses and paramedical workers to use the speculum for visual inspection of to identify any abnormality visible to naked eye and refer the cases early to centers where facilities exist for treatment of premalignant / malignant lesions. Visual Inspection of Cervix by Simple Speculum Examination - Anaesth R. J. Indian Med, Assoc 2000 Feb, 98 (2) : 41-4.
Slide 37 : New approach – experimental stage Suitable for areas where Labs are not adequate Advance diseases common IARC studies in India indicate Sensitivity 65-98% Specificity 73-91% VIA comparable to that of conventional cytology Paramedical staff involved Visual Inspection of Cervix with Acetic Acid - Sankaranarayanan R et al In J Cancer 2004; 110 : 907-13.
Slide 38 : Visual Inspection of Cervix with Acetic Acid
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Slide 47 : Visual Inspection with Lugol’s Iodize (VILI) A multicentric study conducted in various countries including India has shown that VILI is a more sensitive test (73-98%) than VIA. VILI has specificity and positive predictive value similar to VIA. - Shankaraman R et al. In J. Cancer 2004; 110:907-13.
Slide 48 : Colposcopy VIA VIA Repeat 3-5 Yrs Colposcopy + Biopsy Absent Present Visual Inspection Health Education Women 30-60 Yrs High Risk Signs/Symptoms Positive Negative Positive Negative Cytology or HPV
Slide 49 : Use of Magnascope Instead of Coloposcopy Low cost instrument with magnification of 5x (In the absense of colposcope) Indian study showed 80% sensitivity and 95% specificity compared to PAP smear in a hospital – based setting. - Vimla N et al, AIMS, New Delhi, India 1999.
Slide 50 : Difficult to visit more than once VIA +ve 10 - 15 % Women treated immediately with cryosurgery without confirmation or investigations like colposcopy and histology. Successful in Thailand & South Africa. Where possible atleast 2 visits to plan Rx Single Visit Approach - Royal Thai Cooly of Ob Gyn, Lancet 2003; 361: 814-20.
Slide 51 : Single Visit Approach: Steps Apply Cryoprobe and freeze for 3 minutes Defrost for 5 minutes Re-freeze for 3 minutes Post treatment and follow up instructions Cryotherapy Before and After
Slide 52 : Ghana, Africa Cervicare Program Trained Nurses did screening of 19000 women while doing regular clinical duties. SAFE Project Safety Acceptability Feasibility Program Effort
Slide 53 : Experience with VIA by Nurses No discomfort 85.1% Experience better than expected 83.6% Informed enough about procedure 99.7% Satisfied 79.8% Recommend to others 99.2%
Slide 54 : Coverage By Camp Approach District laboratory conducts rural cytology camps Current aims To create awareness Impart knowledge of cancer Data collection of incidence/prevalence To co-operate with other camp activities Help in comprehensive health care Gynaecological check-up
Slide 55 : District Team
Slide 56 : Camp Picture
Slide 57 : Lecture
Slide 58 : Posters
Slide 59 : Protocols cannot be followed strictly Only guidelines can be given Individualized treatment is finally the answer
Slide 60 : Low cost HPV tests are developed Women get report on the same day HPV vaccines are a new hope as primary prevention. Prophylactic vaccine intramuscularly in 3 doses at 0,1 & 6 months. Recommended to all boys and girls of 10 to 12 yrs of age. Currently recommended girls upto age 26 yrs preferable before starting sexual activity. HPV Testing and HPV Vaccine
Slide 61 : Accuracy of screening test in developing countries: range in senstivity and specificity
Slide 62 : Requires resources and consistent planning on the part of health services managers, public health departments and professional bodies To screen - reach about 80% of the women Screening linked to appropriate treatment Screen positive women for further evaluation Effective follow up of the treated cases and of the low grade abnormalities Conclusion : For effective Cervical Cancer Programme
Slide 63 : Conclusion Periodic monitoring and evaluation of the programme and its impact on incidence and mortality due to Cancer Cervix Call it a “Health Camp” and not a cancer detection camp. The aim is “To enlighten and not to frighten” Camp approach is very suitable to give a good coverage to rural areas.
Slide 64 : Responsibility lies with we Gynaecologist with whole hearted support, we may be able to say “GOOD BYE to invasive cervical cancer” just as we have been able to say that to smallpox and polio. Conclusion
Slide 65 : Thank You

 


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