Cervical cancer screening 14.02.24.....pptx

cancer awareness program

1. CERVICAL CANCER SCREENING PROCEDURE Dr. Anjalatchi Muthukumaran Vice principal Professor cum vice principal Era college of nursing Era university

2. Content Cervical Cancer Screening Enumerate the methods to prevent Cancer Cervix VILII VIA Pap smear & Colposcopy

3. Introduction Cervical cancer second most common cancer in women in India & other developing countries Most common cause of cancer death in women –India Prevention of cervical cancer is possible by screening It is a public health problem Primary etiological factor - Human Papilloma virus(HPV) Preinvasive cancer cervix---- Invasive cancer Prevention of Invasive cancer is by screening, diagnosis & treatment of preinvasive diseases and by vaccination against HPV

4. Definition Cervical intraepithelial neoplasia (CIN)is the premalignant condition involving the uterine cervix. The cellular abnormalities are limited to surface epithelium & do not extend beyond basement membrane

5. Prevalence Infection by highrisk HPV occurs in 36% women Prevalence is high in younger women The incidence decreases with age Prevalence of CIN I - 3%, regress 1% progress to Invasive cancer CIN II &CIN III is 0.6 &0.4 % respectively Caused due to persistent HPV infection

6. Terminology Previously Dysplasia – Mild, Moderate & Severe CIN I- Mild dysplasia CIN II- Moderate Dysplasia CIN III- Severe Dysplasia

7. Bethesda System CIN I – LSIL CIN II & III –HSIL Immunostaining of P16 is diagnostic for CIN II CIN P16 negative – CIN I CIN P16positive CIN III

8. ACP & ASCCP New terminology by ACP & ASCCP CIN I CIN II P16 negative LSIL CIN II P16 positive CIN P16 positive - HSIL

9. Etiopathogenesis –Transformation zone Most cervical malignancies occur at transformation zone(TZ ) Squamocolumnar junction (SCJ) Dynamic area –metaplastic activity – oncogenic activity

10. HPV Low risk- genital warts-6 & 11 40,42,43,44,54,61,72 &81 High risk-60% of CIN2&CIN3- 16 & 18; cervical cancer 50%- HPV 16; HPV 18 20 % -31,33,35,45,52,56,58,59,68,69,82 – rest 19% Ca Cervix

11. Prevention of intraepithelial neoplasia (IENP)& Cervical cancer Awareness Safe sex Use of barrier method to prevent STD Lifestyle modification HPV Vaccine WHO 2020-Triple intervention Vaccination by age of 15 – 90% 70%of women screened at least twice in the lifetime Appropriate management of 90% of women foe prwcancerous /cancerous lesion

12. Secondary Prevention Prevention of progression of Intraepithelial lesions to invasive cancers Diagnosis, appropriate ,management of precancerous lesion & follow up

13. Screening for Intraepithelial / invasive cervical cancer Screening asymptomatic women Easy to do as cervix can be easily visualized, long course 10-20 years precancerous lesion –cancer cervix

14. Cervical Cytology The exfoliated cervical cells can be collected by scaping – staining the smear The cells –abnormality seen –premalignant lesions/ malignant lesions Papanicolaou stain – Pap test Cervical cancer screening by Pap smear – decrease the incidence of cervical cancer by 60-70%

15. Methods used for cervical cancer Screening Universal Screening methods Cytology Conventional LBC Manual interpretation Automated screening HPV testing Methods for resource setting VIA VIAM VILI Point of care HPV testing

16. Cytological screening Conventional cytology (Pap smear) Bivalve speculum Ayre’s spatula Scaping done from ectocervix Endocervix scraping – cyto brush Smear made – fixed in 95% alcohol or ether/ fixative spray Stain –examine under ME Low sensitivity -, High specificity Metanalysis – sensitivity 51%; false negative 49%; Specificity – 98%

17. LBC Cells are scraped using special broom Cells are collected in liquid medium & transported to lab Processed , smear of monolayer of cells made & fixed No drying, blood and debris are removed The residual sample used for HPV Detection rate of CC & LBC are same no difference was found

18. Causes for failure of screening program Lack of awareness Lack of infrastructure Lack of technical expertise Need for repeated testing Lack of good referral system Poor resources Poor facility of treatment of test positive

19. HPV testing for screening cervical cancer Detects high risk HPV’s DNA based test used often, mRNA tests are available More sensitive than cytology alone Has high negative predictive value Reduces cervical cancer incidence & mortality Can be used for Cotesting with cytology Primary HPV testing Reflex testing Recommended as primary testing for all women >30 years Frequency –every 5 years

20. The overall sensitivity- 98% Specificity- 85% HPV testing identifies those at risk for developing cancer Cytology detects existing diseases Primary HPV testing Cotesting – cytology +HPV Reflex testing- high risk HPV is found cytology is equivocal- colposcopy is required

21. Screening modalities used in low resource setting Cytology & HPV testing is difficult to implement VIA- 3-5%freshly prepared acetic acid is used Low grade lesions –dull white plaque and faint borders High grade lesions- sharp borders Inexpensive Does not require expertise Minimal training required Can be performed by health workers Sensitivity 60%; Specificity- 79%; PPV-10-20%; NPV -92-97 % False positive rate is high –high number of referral

22. VIA Positive Referral for colposcopy & cervical biopsy & treatment Screen –see- treat Immediate treatment depends on VIA report screen & treat Referral for VIA with magnification VIAM followed by biopsy & treatment VIAM-After acetic acid application handheld magnification lens is used for reducing false positive cases

23. Visual inspection after Lugol’s iodine On application of iodine, the normal cervical epithelium which is reach in glycogen stains mahogany brown (Schiller’s test). The abnormal areas, columnar epithelium and areas lined by immature metaplastic epithelium do not contain iodine and appear mustard yellow The test has the same specificity and similar advantage and disadvantage as VIA

24. After application of acetic acid, dense acetowhite areas appear rapidly (within 18 seconds of application of acetic acid), with well-defined margins. The squamo -columnar junction is not seen in this image. This different than thin aceto-whitening seen on the columnar epithelium due to squamous metaplasia Dense acetowhite area (blue arrows) application of acetic acid, dense acetowhite areas appear rapidly (within 18 seconds of application of acetic acid), with well-defined margins. The squamo -columnar junction is not seen in this image. This is different than thin aceto-whitening seen on the columnar epithelium due to squamous metaplasia Dense acetowhite area (blue arrows)

25. Normal cevix Nabothian cysts Strawberry Cervix

26. Point of care ( rapid result) HPV testing Point of care or rapid result HPV test is a rapid test that identifies high risk HPV and is less expensive. The results are available in 2.5 hours The test is superior to VIA, and comparable to standard HPV testing. Self collected sample by using vaginal tampon, cotton swab or cytobrush can be used for HPV testing in low resource sitting No significant difference in self collected /provider collected samples Xpert HPV testing using PCR, similal to Gene Xpert for tuberculosis is also available in some countries Combining VIA & HPV testing performed together or sequentially improves sensitivity & reduces false positive

27. Colposcopy Visualization of Cervix vagina &vulva under magnification to detect premalignant lesions of vulva , vagina and cervix Place the patient in dorso lithotomy position Place colposcopy one foot from vulva Insert bivalve speculum Focus colposcope on the cervix Use low power for overall visualization initially Shift to high power for closer visualization Clean with saline, remove mucus and note findings Apply 3% acetic acid note findings Apply Lugol’s iodine and note findings Document colposcopic findings Biopsy if indicated

28. Use of Colposcope Localization of lesion Making a diagnosis Taking a direct biopsy Guiding ablative procedures

29. Colposcopy finding See for adequacy – no inflammation, bleeding or scarring SCJ is visible type 1,2,3 TZ type 1,2,3, Typical appearance of CIN Mosaic & punctation- abnormal capillary distribution grade 1 or grade 2 Inner border sign – sharp acetowhite demarcation with in a les opaque acetowhite area Ridge sign- thick opaque ridges of acetowhite epithelium growing irregularly in the SCJ,

30. Continued Screening for cervical cancer is hallmark for prevention of cervical cancer