Screening c cervix slideshare 2015 (1)

Screening for Premalignant cervical Screening for Premalignant cervical Lesions In EgyptLesions In Egypt

BYBY

Prof.Prof.

Mohammad EmamMohammad EmamDirector Of Early Cancer Detection UnitDirector Of Early Cancer Detection Unit

OB & GYN Dept.OB & GYN Dept.

Mansoura Faculty of Medicine-Egypt.Mansoura Faculty of Medicine-Egypt.

20152015

Screening GenerallyScreening Generally

• Is to seek about Is to seek about certain problem certain problem in certain high in certain high risk gp.risk gp.

Who is at riskWho is at risk??Women who have had more than one partnerWomen who have had more than one partner

Women whoWomen who’’s partner (s) has had more than s partner (s) has had more than one sexual partner.one sexual partner.

Women with other STDsWomen with other STDs

Who is at riskWho is at risk??Women with immune problems:Women with immune problems:– Steroid medicationsSteroid medications– Transplanted organsTransplanted organs– ChemotherapyChemotherapy– HIVHIV

Women who smokeWomen who smoke

11stst intercourse before Age 18 intercourse before Age 18

Ideal Screening MethodIdeal Screening Method

Adequate sensitivity and specificity.Adequate sensitivity and specificity.

yield reproducible results. yield reproducible results.

Cheap, simple and easy to apply. Cheap, simple and easy to apply. Without side effects or complications.Without side effects or complications.

Painless .Painless .

Socioculturally acceptable.Socioculturally acceptable.

Infrastructures are easily available.Infrastructures are easily available.

RationaleRationale1.1. Prevention is better than cure.Prevention is better than cure.

2.2. Most Cancers Develop In The Unscreened Most Cancers Develop In The Unscreened And The Under screened populationsAnd The Under screened populations

Cervical Cancer Cervical Cancer WorldwideWorldwide

230,000 230,000 womenwomen die die of cervical cancer of cervical cancer every yearevery year

– 80 % occur in 80 % occur in developing developing countries.countries.““WHO , Cervical Cancer Screening in Developing WHO , Cervical Cancer Screening in Developing Countries. Report of a WHO Consultation. 2001”Countries. Report of a WHO Consultation. 2001”

Incidence of Cancers in Incidence of Cancers in Egyptian WomenEgyptian Women

00

55

1010

1515

2020

2525

Breast Breast CancerCancer

Cervical Cervical CancerCancer

Ovarian Ovarian CancerCancer

UterineUterineCancerCancer

PercentPercent

Source: GLOBOCAN 2000.Source: GLOBOCAN 2000.

RationaleRationaleIn developed countriesIn developed countries::– Cervical cytology is considered to be the only test known to Cervical cytology is considered to be the only test known to

reduce cervical cancer .reduce cervical cancer .

In developing countries ( Low resources ):In developing countries ( Low resources ):– An organized screening program is difficult to An organized screening program is difficult to

implement ( some counteris like Pakistan , Indonesia implement ( some counteris like Pakistan , Indonesia have started)have started)

RationaleRationaleIn Egypt:In Egypt: No national screening program for cancer No national screening program for cancer

cervix although in developed countries the cervix although in developed countries the screening is in adulthood ,screening is in adulthood ,

Only sporadic reports regarding the prevalence Only sporadic reports regarding the prevalence in some governorates ( Dakahlia, sharkia , in some governorates ( Dakahlia, sharkia , Assuit, and minia ), utilizing VIA .Assuit, and minia ), utilizing VIA .

WHO guidelines for screening and WHO guidelines for screening and ttt :ttt :developing countries :developing countries :((of CIN ( 2013of CIN ( 2013

– where screening with an HPV test is where screening with an HPV test is not feasible: screen with VIA and treat.not feasible: screen with VIA and treat.

– Screen-and-treat strategies involve ttt with Screen-and-treat strategies involve ttt with cryotherapy, or LEEP when the patient is cryotherapy, or LEEP when the patient is not eligible for cryotherapy.not eligible for cryotherapy.

SeriousSeriousWidespread Widespread DiagnosableDiagnosable in early stages. in early stages.TreatableTreatable

Cancer cx. Screening programs are in Cancer cx. Screening programs are in adulthood.adulthood.ButBut ov. cancer programs are still in relative ov. cancer programs are still in relative infancy,infancy, why?why?

Cancer Cervix Is an Ideal Cancer Cervix Is an Ideal Disease For ScreeningDisease For Screening

Screening Of Cervical Cancer Screening Of Cervical Cancer is in adulthood.. Whyis in adulthood.. Why? ?

1.1. Screening detects Premalignancy.Screening detects Premalignancy.

2.2. PremalignancyPremalignancy can be detected by can be detected by noninvasive means. noninvasive means.

3.3. Good prognosis of early stage. Good prognosis of early stage.

4.4. Premalignant Course is slowPremalignant Course is slow..

Screening Of Cervical Cancer is in Screening Of Cervical Cancer is in adulthood.. Why ? adulthood.. Why ? ContCont……

5.5. Effective treatment modalities for Effective treatment modalities for premalignant lesions .premalignant lesions .

6. C6. Cervical cancer incidence is reduced by ervical cancer incidence is reduced by about 90% in about 90% in developed countries developed countries with -with -organized screening programs.organized screening programs.

Gold standard Gold standard Screening test For Screening test For

Cancer CervixCancer Cervix☼ PAP smear test is considered to be the gold standard .

☼ Has limitations ?

•CollectionCollection

•Reading Reading

•ReportingReporting

Limitations Associated with Limitations Associated with Pap SmearPap Smear

Pap Smear PreparationPap Smear Preparation

Ayres’ spatula & endocervical Ayres’ spatula & endocervical brushbrush

Broom type samplerBroom type sampler

Differences between the Bethesda & Papanicolaou Differences between the Bethesda & Papanicolaou SystemSystem

Includes the diagnosis of HPV infections and Includes the diagnosis of HPV infections and limits use of the term limits use of the term “atypia”.“atypia”.

squamous intraepithelial lesion = squamous intraepithelial lesion = SIL:SIL:– low-grade SIL = HPV change and CIN Ilow-grade SIL = HPV change and CIN I

– high-grade SIL = CIN II and CIN III lesionshigh-grade SIL = CIN II and CIN III lesions

PAP Smear NormalPAP Smear Normal::

LSILLSIL

Dysplastic nuclear changes, binucleationDysplastic nuclear changes, binucleation

HSILHSIL

Enlarged nucleus, less cytoplasm (increased N:C ratio). Enlarged nucleus, less cytoplasm (increased N:C ratio). Irregular nuclear membraneIrregular nuclear membrane

objectiveobjectiveTo highlight :To highlight :–Alternative methods for Alternative methods for

screening of premalignant screening of premalignant cervical lesions suitable in Egypt cervical lesions suitable in Egypt

–Mansoura Experience.Mansoura Experience.

What are What are Alternatives to Alternatives to

Pap SmearPap Smear??

Alternatives to Pap Alternatives to Pap smearsmear

– Automated pap screening.Automated pap screening.– Visual inspection with acetic acid Visual inspection with acetic acid

(VIA), with magnification (VIAM) (VIA), with magnification (VIAM) &&iodine iodine (VILI).(VILI).

– HPV testing.HPV testing.– Polar probe.Polar probe.

– cervicographycervicography

HPV testingHPV testing

Detect High Risk HPV.Detect High Risk HPV.

Sample from cervix- Sample from cervix- similar to PAP.similar to PAP.

Special transport Special transport medium medium

Processed in the labProcessed in the lab

HPVHPV

Objective testsObjective testsNot suitable for Egypt)Not suitable for Egypt)) )

ExpensiveExpensive

VILI: VILI: test-positivetest-positive– Well-defined area.Well-defined area.– Canary yellow .Canary yellow .– Transformation zoneTransformation zone

VILI negativeVILI negative– Mahogany brown Mahogany brown

VILI & VIAVILI & VIASensitivitySpecificity

VIA76.885.5

VILI91.785.4

Limitations of VILILimitations of VILI

Stains underwear .Stains underwear .Lugol’s iodine is more expensive than acetic acid.Lugol’s iodine is more expensive than acetic acid.

Moderate specificity may result in over-referral Moderate specificity may result in over-referral and over-treatment in a single-visit approachand over-treatment in a single-visit approach

What Infrastructure For What Infrastructure For VIA?VIA?

Examination table.

Sterile speculum ( Cusco's)

Sterile gloves

Source of light, a lamp or a torch

Cotton swabs

Forceps

Syringe for acetic acid lavage

Acetic acid in dilutions of 3%

Recording data

Via Is An Ideal Alternative to Pap smearVia Is An Ideal Alternative to Pap smear

Keep a bottle Keep a bottle of vinegar in of vinegar in your office.your office.

inexpensiveinexpensive& & 1.1. Simple & quickSimple & quick2. Immediate results 2. Immediate results 3. Not need cytopathologist .3. Not need cytopathologist .4. 4. One step diagnosis and tttOne step diagnosis and ttt..

55 . .SensitiveSensitive66 . .SpecificSpecific????????????

Advantages of VIA over Advantages of VIA over PAPPAP

Disadvantages Of VIADisadvantages Of VIA

Lower specificity than the smear test. (May be Lower specificity than the smear test. (May be an advantage for women, through over refferal).an advantage for women, through over refferal).

Not suitable for endocervical Not suitable for endocervical

glandular disease.glandular disease.

`̀

ColposcopyColposcopy

How to do VIAHow to do VIA??

Reporting Visual Reporting Visual Inspection FindingsInspection Findings

Acetic Acid Test- Negative

Aceto-white area(s) not present

Acetic Acid Test-Positive

Aceto-white area(s) present 1)Density of whiteness2)Time needed for whiteness to appear and disappear3)Sharpness of demarcation

ACETO-WHITEACETO-WHITE

VIA imagesVIA images

Positive VIAPositive VIA

Significance Of Positive Significance Of Positive

VIAVIA Minority Minority ::– may be may be suspicious of suspicious of cancer or CIN cancer or CIN..

Majority :Majority :– occur in conditions other than cancer :occur in conditions other than cancer :

– Healing or Healing or regenerating epithelium.regenerating epithelium.– Inflammation.Inflammation.– Immature squamous Metaplasia.Immature squamous Metaplasia.– HPV infection.HPV infection.

Positive VIA Suspicious Of Positive VIA Suspicious Of CancerCancer

Rapid uptake of acetic acid (Rapid uptake of acetic acid (less than 20 less than 20 seconds).seconds).

Slow release of acetic acid( Slow release of acetic acid( more than 2 more than 2 minutes)minutes)

Sharp raised edges.Sharp raised edges.

Irregular surface.Irregular surface.

Categorize YourselfCategorize Yourself::

Has no ColposcopyHas no ColposcopyVIA VIA ± biopsy± biopsy

Has ColposcopyHas Colposcopy One step :( see and treat ).One step :( see and treat ).

Two steps Two steps

What To Do if VIA is Positive & What To Do if VIA is Positive & suspicioussuspicious ? ?

VIA DISCOVERS VIA DISCOVERS THE CRIMETHE CRIME

LOCATES THE LOCATES THE CULPRIT +/- CULPRIT +/-

COLPOSCOPYCOLPOSCOPY

And canAnd can

Cytology Cytology discovers discovers the crime the crime And need And need

Colposcopy Colposcopy for locating for locating the culprit.the culprit.

Age to initiate

screening

Age to discontinue screening

Screening interval for cervical cytology

Post hysterectomy

for benign disease

ACS (2002)

3 years after onset of sexual intercourse, or

by age 21

Women may choose, if 70 years and 3

negative tests and no positive tests within

last 10 years

Annual for conventional cytology: every 2 years for

liquid-based cytology; for age >30, every 2 to 3 years after 3

normal consecutive smears and no increased risk

Not Indicated

ACOG (2003)


by age 21

Inconclusive evidenceAnnual for age <30; for age >30, every 2 to 3 years after 3 normal

consecutive smears, no history CIN 2 or 3, and no increased risk

Women may decline testing

USPSTF (2003)


by age 21

Age 65, if not at high risk

At least every 3 yearsNot indicated

Mansoura ExperienceMansoura Experience

Int J Gynaecol Obstet. 2006 2006 May;93(2):118-22. Epub 2006 Mar 20.May;93(2):118-22. Epub 2006 Mar 20.

Screening for cervical carcinoma using visual Screening for cervical carcinoma using visual inspection with acetic acid.inspection with acetic acid.

Abdel-Hady ES11, , Emam M, , Al-Gohary A, , Hassan M, Farag MK, Abo-Elkheir M, Farag MK, Abo-Elkheir M

Mansoura ExperienceMansoura Experience

J Exp Ther Oncol. J Exp Ther Oncol. 2014;10(4):247-53.2014;10(4):247-53.

Human papillomavirus (HPV) is not the Human papillomavirus (HPV) is not the main cause of preinvasive and invasive main cause of preinvasive and invasive cervical cancer among patients in Delta cervical cancer among patients in Delta Region, Egypt.Region, Egypt.

Thabet M, Hemida Thabet M, Hemida R, Hasan M, Elshamy R, Hasan M, Elshamy M, Elfaraash M, Emam M.M, Elfaraash M, Emam M.

ConclusionsConclusionsThe easiest female cancer to prevent The easiest female cancer to prevent through screening is cancer cervix.through screening is cancer cervix.Regular ( VIA ) are the best way to Regular ( VIA ) are the best way to prevent cervical cancer in developing prevent cervical cancer in developing counteriescounteries

An abnormal Pap test An abnormal Pap test or ( VIA ) does not mean cancer.or ( VIA ) does not mean cancer.

Telfax 002/050/2319922Telfax 002/050/2319922

Mobile: 002/01223475579Mobile: 002/01223475579

Email. [email protected]. [email protected]

Screening c cervix slideshare 2015 (1)

Documents

Transcript of Screening c cervix slideshare 2015 (1)