Ca cervix screening: Emphasison LBC.pptx

Overview of screening tests for cancer of the cervix with emphasis on LCB and HPV contesting

1. CERVICAL CANCER SCREENING: EMPHASIS ON LIQUID BASED CYTOLOGY (LBC) Dr Nuhu Teri James MBBS, MSc., FWACS-(OBGYN)

2. O utline Introduction Epidemiology of ca cervix WHO global strategies to prevent ca cervix Conditions/preparation for cervical smear Screening tests Screening schedule Liquid Based Cytology (LBC) Advantages of LBC Procedure for LBC Conclusion References

3. Introduction Cervical cancer is a leading cause of cancer mortality among women 604,000 women were diagnosed with cervical cancer globally in 2020 (WHO) 660,000 new cases and 350,000 mortalities were reported in 2022 (WHO) A bout 94% of the deaths due to cervical cancer in 2022 occurred in low and middle income countries The majority ( 99.9%) of cervical precancers and cancers are caused by a persistent infection with a high-risk genotype of human papillomavirus ( hrHPV )

4. Introduction.. Pre-malignant lesions arise following high-risk HPV infections within 10-15 years in immunocompetent individuals Cervical pre-cancers rarely cause symptoms Screening tests detects pre-malignant lesions Countries with organised cervical cancer screening record lower incidence of the disease

5. WHO Global Strategy to Eliminate Ca Cervix The WHO Global strategy defines elimination as reducing the number of new cases annually to 4 or fewer per 100,000 women T hree targets to be achieved by the year 2030 90% of girls vaccinated with the HPV vaccine by age 15 70% of women screened with a high-quality test by ages 35 and 45 90% of women with cervical disease receiving treatment

6. Patient preparation for cervical smear Best between 7th and 15th day of the menstrual cycle C an be taken at a different time of the cycle except during menses Treat pre-existing infections Avoid vaginal sex for at least 48 hour (two days) prior to test Avoid using tampons, vaginal creams, birth control foams or jellies, lubricants or douches for at least 48 hours prior to test

7. Cervical C ancer S creening Tests Visual (naked eye or magnified) Cytologic Molecular Visual inspection with acetic acid (VIA) Conventional Pap smear Nucleic acid amplification tests (NAAT) -high-risk HPV DNA/NAAT -mRNA Visual inspection with Lugol’s iodine (VILI) LIQUID BASED CYTOLOGY DNA methylation Automated visual evaluation of digital images Dual staining to identify p16 and Ki-67 Protein biomarkers -HPV antibodies -oncoproteins

8. U.S. Preventive Services Task Force (USPSTF )/ACOG/SGO-screening schedule Population Recommendation Less than 21 years No screening 21-29 Cytology alone every 3 years 30-65 years Cytology alone every 3 years hrHPV alone every 5 years Co-testing every 5 years More than 65 years No screening after prior negative test result

9. HIV positive/DES Exposure Initiate cervix screening with an HPV test starting at age 25 in HIV patients Screen HIV patients every 3 years with an HPV test HIV Patients who are positive for HPV, regardless of genotype or cytology results, should be directly referred to colposcopy Discontinue screening at age 74 years in HIV patients DES in utero should have annual cotest with colposcopic examination of both the cervix and vagina until the age 69 years.

10. HPV Screening

11. Cytology Primary screening NILM: re-screening 3 years ASCUS and LSIL will have HPV testing performed (Negative HPV, repeat smear in 5 years, positive HPV, refer for colposcopy) High grade lesions (ASC-H, HSIL, AGC etc )-Refer for colposcopy

12. Normal cervix

13. Normal cervix

14. Liquid Based Cytology (LBC) A collection method used to collect cervical smear using a cytobrush , which are then transferred into a container containing an alcohol-based fixative The aim is improve the transfer of cells from the collection device to a microscope slide and ensure uniformity of the cell population in each sample Designed to overcome the pitfalls of conventional Papanicolaou (Pap) smears in cervical cancer screening

15. Advantages/Benefits of LBC Higher sensitivity compared to convention pap smear (76-95% vs 53-92%). Satisfactory smears, 99% Improved preservation of the cells in the specimen Interpretation accuracy Interference by artifacts such as air drying, cellular degeneration, etc , is eliminated Reduces obscuring inflammatory cells and blood Less incidence of repeat Pap tests HPV testing can be performed on the same sample within 30 days of collection

16. Cervical broom/ Cervex brush

17. Combi-brush Tighter/small cervical os Do not use in pregnancy Do not use in women with IUCD Do not use in fragile cervix

18. Vial for thin prep

19. Vial for SurePath

20. Procedure for LBC B rief history Set trolley with all necessary equipment Confirm the expiry date on the vial Remove the plastic cover over the vial Speculum insertion: Lubricate with warm water. W ater-soluble carbomer -free lubricant can be used, but do not apply on the tip of the speculum Take STI specimens if required Gently wipe away cervical discharge or mucous

21. Procedure for LBC.. Insert the broom into the endocervix so that the shorter bristles fully contact the ectocervix Rotate the cervix brush 5 times in a clockwise direction For combi-brush rotate twice

22. ThinPrep For ThinPrep : Rinse the broom by pushing it into the bottom of the vial 10 times, forcing the bristles apart. Then , swirl the broom vigorously to release more material. Inspect the brush for material, and if present, repeat the sweep and swirl Finally cover the vial/specimen container and send to the laboratory.

23. SurePath For SurePath : Insert the broom into the larger opening of the vial. Rotate the broom 90° to use the inner edge of the insert to pull off the broom into the vial Benefits: Lower rates of unsatisfactory slide Greater proportion of specimen is retained Adequate volume for HPV- test

24. Conclusion Ca cervix is one of the most common gynaecological malignancy Common cause of cancer mortality It is preventable through organised screening strategy LBC is an important screening test with higher sensitivity and specificity with added benefit for HPV testing on the same specimen Proper cervical sampling method is important in ensuring reliable result

25. References WHO guideline for screening and treatment of cervical pre-cancer lesions for cervical cancer prevention, second edition. Geneva: World Health Organization; 2021. Licence: CC BY-NC-SA 3.0 IGO. Bavikar R, Patel N, Buch A, Kulkarni M. A Comparison of Conventional Pap smear and Liquid Based Cytology for Cervical Cancer Screening. Gynaecol Minim Invasive Ther 2024;13(1):77-82. Zhoa FH, et al. Comparison of ThinPrep and SurePath Liquid-Based Cytology and Subsequent Human Papillomavirus DNA Testing in China. Wiley Online Library 2011. doi 10.1002/cncy.20177. Rebolj M, Rask J, Ballegooijen M, Kirschner B, Rozemeijer K, Bonde J, et al. Cervical histology after routine ThinPrep or SurePath liquid-based cytology and computer-assisted reading in Denmark. British Journal of Cancer (2015) 113, 1259–1274 | doi : 10.1038/bjc.2015.339 Guida , F., Kidman, R., Ferlay , J. et al. Global and regional estimates of orphans attributed to maternal cancer mortality in 2020. Nat Med 28, 2563–2572 (2022). https://doi.org/10.1038/s41591-022-02109-2 Macharia E, Machuri L. A comparative analysis of conventional pap smear, liquid based cytology and colposcopy in Kenyatta National Hospital. Int J Reprod Contracept Obstet Gynecol 2014; 3:58-63. https://youtu.be/- WRQIAi-uCU?si=8TVckPM7fEgxyGfL