Visual Screening

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Screening for Cancer Cervix

by Visual Technique

Professor .Surendra Nath Panda,M.S.of Obstetrics and Gynecology

M.K.C.G.Medical College

Berhampur, 760004, Orissa, India


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205 November 2012 Screenig For Cancer Cervix by Visual Technique

Cervical Cancer

500,000 new cases identified each year

80% of the new cases occur in developing

countries

At least 200,000 women die of cervical cancer

each yearCervical cancer is the third most common

cancer worldwide

Magnitude of the Problem: -


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Natural History of Cervical Cancer:

Source: PATH 1997.

HPV-related Changes

Normal Cervix

Low-Grade SIL (Atypia, CIN I)

High-Grade SIL (CIN II, III/CIS)

Invasive Cancer

HPV Infection

CofactorsHigh-Risk HPV

(Types 16, 18, etc.)

About 60%regresswithin2-3 yrs

About 15% progress within 3-4 yrs

30% - 70% progress within 10 yrs

Current Understanding


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Prevention of Cervical Cancer

Cervical cancer is a preventable disease

Primary prevention:

Education to reduce high risk sexual behaviour

Measures to reduce/avoid exposure to HPV andother STIs

Secondary prevention:

Treatment of precancerous lesions before theyprogress to cervical cancer (implies practicalscreening test)


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Secondary Prevention of Ca.Cx.

Key Point is to detect precancerous lesionsDown staging

Answer: - A good screening method

PAP smear test is considered to be the goldstandard Has limitations ?

Alternatives to Pap Smear What are they?


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Qualities of a Good Screening Test?

Safe

Practical

AffordableAvailable

Effective



Limitations of Pap Smears for NationalScreening Programs

Pap smear-based programs require complex logistics,advanced training, and well managed program

implementation for adequate testing to occur.

These elements are not available outside large cities

in many low-resource settings.

Even in large cities, quality pap smears are possible

but ongoing supervision, refresher training and

continued supplies are necessary.

Cytology is not viable as a nationally accessible

screening method in many developing countries in

Low Resource Settings.



Alternatives to Pap Smear Screening

Cervical cancer is a significant public health problem

in many countries.

Cervical cancer is a sexually transmitted disease.

Cervical cancer is preventable (i.e., Methods of

screening and treatment for precancerous lesions

exist).

Pap Smear as a screening methods may not be

appropriate or adequate for many low-resource

settings.

Why?



Cervical Cancer Screening

Visual inspection with acetic acid (VIA)

Visual inspection with acetic acid and

magnification (VIAM): Gynescope or Aviscope

Colposcopy

Cervicography

Automated pap smears

Molecular (HPV/DNA) tests

Other Options: -



Approaches to Cervical CancerPrevention in Low-resource Settings

Source-Program for Appropriate Technology in Health [PATH] 1997.

Effective Safe Practical Affordable Available

VisualInspection:AA

Yes Yes Yes Yes Yes

VisualScreening:Unaided

No Yes Yes Yes Yes

AutomatedPap Screening

Yes? Yes ? No No

HPVScreening

Yes Yes ? ? Yes

Cervicography Yes? Yes ? ? Yes

HPV Vaccine ? ? Yes ? No



What Is VIA / Cervicoscopy ?

Looking at the cervix to detect abnormalities after

applying acetic acid

Acetic acid is used to enhance and mark the

acetowhite change of a precancerous lesion or actual

cancer

Sensitivity and specificity of VIA - 70-92%

Positive Predictive Value - 15-20%

Visual Inspection after Acetic Acid Also known as Aided Visual Inspection of Cervix, or

Acid Acetic Test



History of Research on Visual Inspection

Historically, before the advent of Pap smears andprogrammatic screening, healthcare providers relied

on looking at the cervix to detect abnormalities.

Schiller test has been used for many years(to aid in

differentiating "mature" normal from "immature" abnormalepithelium).

After the 1950s, when the Pap smear became the

standard for cervical cancer screening-.

Increasing numbers of women undergoing this test led toincreased utilization of the colposcope (initially developed inthe 1930s) to confirm screening findings.




Years later, given the expense and inconvenience ofcolposcopy services, clinicians began to explore

whether unmagnified visualization of the cervix (with

acetic acid) could be used as an adjunct to cytology

so that patients in need of colposcopy could beidentified more effectively and efficiently.

However few studies were conducted, that examined

the value of unmagnified inspection of the cervix after

the application of acetic acid (VIA) for purposes ofidentifying a normal "transformation zone" or

detecting precancerous lesions of the cervix (i.e.,

primary screening).




Then, in 1982, Ottaviano and La Torre published animportant study involving 2,400 women who were

examined visually and colposcopically after a cervical

wash with acetic acid.

"naked-eye" (unmagnified) inspection detected abnormalitiesin 98.4% of the cases (i.e., in 307 of 312 patients assessedcolposcopically as having an abnormal transformation zone).

These authors concluded that "colposcopic magnification isnot essential in clinical practice for the identification of thecervix at risk."




In 1990, Abrams published his experience with the"Gynoscope," a monocular telescope with a

magnifying power of 2.5,

high correlation between the (visual) Gynoscope examination

and cytology. should be considered as a practical adjunct that willencourage better sampling by the clinician.

World Health Organization (WHO) supported a study

in India between 1988 and 1991 in which unmagnified

visual inspection with acetic acid washing wasevaluated as a "down staging" technique.

VIA was found to be effective in identifying women withcancer at an earlier, more treatable stage.




Several other comparative studies in Kenya,Zimbabwe and South Africa suggest that visual

inspection with acetic acid performs comparably to

the Pap smear and/or other screening tests.

More recent studies have also demonstrated that "VIA

is a safe, simple and effective adjunct to the

Papanicolaou smear for cervical cancer screening

and can be helpful in reducing referrals forcolposcopy without compromising quality of care.


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Needed Equipment andSupplies for VIA

VIA can be performed in any clinical settingwhen the following are available:

Examination table, preferably with stirrups or legsupports

Sterile speculum, preferably Cusco'sSterile glovesSource of light, a lamp or a torchCotton swabs

ForcepsSyringe for acetic acid lavageAcetic acid in dilutions of 3-5%Stationary, to record examination findings


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The Examination

The procedure and the reason for it should be carefullyexplained to the woman to be examined and she should be made

as comfortable as possible. Take into consideration the privacy

of the patient.

Put patient in lithotomy position (if possible) or suppine with

legs bent at knees.

Good visualization is essential. Direct the light source to the

genital area.

Observe and record any abnormal findings in the external

genitalia.

Lubricate the speculum with warm water and insert into the

vagina with the speculum closed.


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The Examination

Open the speculum and adjust the light source so as to get aclear view of the cervix.

If there is excess mucus or discharge, clean it with a cotton

swab soaked in boiled water or normal saline solution.

Observe any abnormal findings.

Wash the cervix with the acetic acid (3-5%) with the help of the

syringe. Alternatively can be applied with a cotton swab.

Wait for approximately 1 minute.

Inspect the cervix for acetowhite areas.


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The Examination

Do not perform the examination if the woman

is having menstrual period or is using

intravaginal medication. Advise her to comeback when the mensus or the treatment is

over.

Do not apply acetic acid if there is a grosslesion suspicious of malignancy, refer patient

directly to oncology / tertiary care facility.

Important


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Objectives Of Acetic Acid Examination

Locate the squamocolumnar junction

Identify any lesion & its limits

Decide whether the lesion is CIN

Determine whether invasion is possible

Select a site or sites for biopsy if appropriate


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What does Acetic Acid do?

Acetic acidDissolves mucus

Induces intracellular dehydration

Causes coagulation of protein

As a result cells with increased

Nuclear / Cytoplasmic ratio ratio

Nuclear density

Chromosomal aneuploidy

Become opaqueacetowhite areatest positive


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Abnormalities Seen After Acetic Acid

Aceto-white

Margins and surface

White gland openings

Mosaic & punctation

Abnormal vessels


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What May Be Acetowhite

All acetowhite patches are not cancerAny of these epithelial changes can become

acetowhite

Healing or regenerating epitheliumCongenital transformation zone Inflammation Immature squamous metaplasia

HPV infectionCIN / CGINAdenocarcinoma Invasive squamous cell carcinoma


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Reporting Visual Inspection Findings

Smooth, pink

Clear mucoid secretion

Central hole-'external os'

Nulliparours-roundMultiparous-slit or cruciate

Cervix in postmenopausalwomen is atrophic

BEFORE ACETIC ACID APPLICATION- Unaided visualinspection of Cx Clinical Down staging

Normal Cervix

NORMAL: -


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Hypertrophy

Redness or congestion Irregular surface

Distortion

Simple erosions (do not bleed on touch)

Cervical polyps (with smooth surface)

Abnormal discharge: foul smelling, dirty / greenish, cheesy white,blood stained

Nabothian follicles

Prolapsed uterus


ABNORMAL: -


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Clinical interpretation can be:

Infection

Ectopy (Erythroplasia)

Benign tumour

SUSPICIOUS OF MALIGNANCY: - Erosion that bleeds on touch or friable

Growth, with an irregular surface or friable


ABNORMAL: -


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AFTER ACETIC ACID APPLICATION- Aided visualinspection of Cx Acid Acetic Test

Acetic Acid Test-

Negative

Aceto-white area(s) not

presentAcetic Acid Test-

Positive

Aceto-white area(s)

present

Important: All findings, normal or abnormal, should becarefully recorded in a printed form. The patient should

be informed and explained the follow-up procedure

accordingly.


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Action Plan

VIANegative Positive

Follow-up after 3-5

years according tothe decided policy.

Advise to come

back if develops

symptoms.

Treat / Refer to an

appropriate center-

PHC/ Secondary /

Tertiary / Oncology

Centre


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Action Plan

If infection is suspected /present take a swab

and send for analysis.Treat the patient

accordingly. Re-examine after six weeks. If no signs of infection: - perform Pap-smear

and / or Colposcopy:

I. Pap-smear / Colposcopy negative: re call

for follow-up in 6-12 months.

II. Pap-smear / Colposcopy positive: call the

patient for appropriate treatment

Management of VIA Positive Cases: -


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VIA - The Status To-Day

A randomised trial of early detection of breastand cervical cancers using low cost

technology approaches - Professor I. Mittra,

Tata Memorial Hospital, Mumbai.The study is now in its 3rd year and 110,000 women

have so far been randomised.

VIA appears to be more sensitive but less specific

than the PAP smear.

Why VIA as an Alternative in


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Why VIA as an Alternative inLow-resource Settings?

Non-invasive, easy to perform and inexpensiveCan be performed by all levels of healthcare workers,

in almost any setting

Skills consistent with service delivery tasksperformed by nurses/midwives in MCH/FP clinic

settings

Results are available immediately

Why VIA as an Alternative in


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Why VIA as an Alternative inLow-resource Settings?

Initial treatment can be provided at the time ofthe examination

All system requirements are available locally

Potential for immediate link to treatment

Approach suitable for lowest-resource

settings

***


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A

At the service of women

V I A

Visual Screening

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