CONCEPTS ON CERVICAL CANCER SCREENING.pptx

General concepts on Cervical cancer screening

1. SCREENING AND PREVENTING REPRODUCTIVE CANCERS CERVICAL CANCERS BY SIMON MUSSA 1

2. Learning objectives Define cervical cancer Describe rationale for screening for cervical cancer Identify individuals at increased risk of developing cervical cancer Describe primary preventive measures against cervical cancer Describe the types, eligibility and schedule of HPV vaccine Describe modalities for screening cervical cancer Perform Pap smear and Visual Inspection with Acetic Acid to screen for cervical cancer Link clients suspected with cervical cancer to continuum of care 2

3. Cervical cancer Cervical cancer refers to malignant or tumor of the cervix. Cancer is a term used for the malignant, autonomous and uncontrolled growth of cells and tissues. Such growth forms tumours , which may invade surrounding and distant parts of the body, destroying normal tissues and competing for nutrients and oxygen . 3

4. Cervical cancer… The primary cause of squamous cervical cancer is persistent or chronic infection with one or more oncogenic types of H uman papillomavirus (HPV) . The most common cancer-causing types are 16 and 18 , which are found in 70% of all cervical cancers reported. 4

5. Rationale for screening for cervical cancer To detect pre-cervical cancerous lesion which is asymptomatic. To initiate early treatment of precancerous lesions to prevent development of cervical cancer . 5

6. Individuals at increased risk of developing cervical cancer Almost all sexually active women/ Women living with HIV i.e . Inmunosuppresion (HIV co-infection ) Women involving in unprotected sexual contact Adolescents i.e. early sexual initiation Multiple sexual partners Uncircumcised male partner High parity (> 5 pregnacies ) Cigarette smokers 6

7. Primary preventive measures against cervical cancer Community sensitization and reproductive health promotion among women of reproductive age. Vaccination against HPV type 16, 18 Screening and early treatment. Delay onset of sexual activity Practice safer sex/use condoms Treatment of sexually transmitted infections (STIs) Do not smoke 7

8. Types of HPV vaccine Two HPV vaccines protect against high-risk HPV types 16 and 18 have been licensed Bivalent vaccine ( protect against types 16 and 18 only) Quadrivalent vaccine (contains additional protection against types 6 and 11, which are responsible for 90% of benign anogenital warts or condyloma ). Both vaccines contain virus-like particles (VLPs), which are pieces shaped like the outside of a human papillomavirus. 8

9. Eligibility for HPV vaccine The recommended target population for HPV vaccination are girls aged 9–14 years , prior to initiation of sexual activity . 9

10. Schedule of HPV vaccine A two-dose schedule with an interval of six months between doses for girls aged < 15 years ( including those girls aged ≥ 15 years at the time of the second dose ). All formulations of HPV vaccine should be kept cold at 2–8˚C. HPV vaccines are freeze-sensitive and lose efficacy if frozen. 10

11. Modalities for screening cervical cancer Cervical cancer screening is the systematic application of a test to identify abnormalities on cervix in an asymptomatic population. Women targeted for screening may actually feel perfectly healthy and see no reason to visit health facilities. 11

12. Modalities for screening cervical cancer Three different types of tests are currently available: Visual inspection methods: Visual Inspection with Acetic Acid (VIA) –National CECAP Program screening strategy. Visual Inspection with Lugol’s Iodine (VILI) Cytology-pap smear; involves taking a sample of cells from the entire transformation zone. HPV DNA testing for high-risk HPV types (e.g., types 16 and 18). 12

13. Modalities for screening cervical cancer Visual inspection with acetic acid (VIA) is a method for detecting early cell changes that are visible when using a speculum to inspect the cervix with the naked eye after applying dilute (3–5%) acetic acid to it. 13

14. Inclusion and exclusion criteria for VIA INCLUSION 30-50 years (HIV-negative /Unknown status) Any age for HIV+ women (sexually active) Women with symptoms of cervical cancer ( PV- bleeding , discharge, post-coital bleeding) Not pregnant No signs of PID EXCLUSION Pregnancy Post- menopausal women ( when SCJ is not visible) Women who have had total hysterectomy ( cervix removed) Cervicitis Menstrual period (heavy) 14

15. Visual inspection with acetic acid (VIA) Visual inspection with acetic acid (VIA) An evidence-based alternative approach Safe, effective, feasible, highly acceptable, and sustainable in low-resource settings Promotes linkage of screening with treatment A simple test that uses vinegar to visualize abnormal changes on the cervix . 15

16. Perform Visual Inspection with Acetic Acid to screen for cervical cancer Basic supplies needed for VIA 5% acetic acid Cotton swabs Light source Speculum Gloves Hand sanitizer 0.5% chlorine Buckets for IPC Examination bed Gall pots/kidney dishes 16

17. How to perform VIA? Conduct counseling Insert the speculum use os as a guide Identify the SCJ Most cervical cancers originate in the SCJ Apply vinegar on the cervix with cotton swab Remove the swab Wait for one minute Read results : either VIA negative , positive or suspicous for cancer Treat on the same day if find VIA positive lesions ( precancer ) Rescreen after 3 years if results are VIA negative (HIV+/HIV-/ Unk ) 17

18. Identify the SCJ Endocervix Ectocervix Squamo-columnar junction (SCJ) Endocervical canal 18

19. Variations of the Normal Cervix Ectropion Nabothian cyst Cervical polyp 19

20. Ectropion Physiological state were columnar epithelium is visible on the ectocervix . 20

21. Nabothian Cysts Mucus glands in the columnar epithelium that are covered over by squamous cells . They collect mucusal secretions 21

22. Cervical Polyp Small growth that starts in the cervical canal and extends to the ectocervix . 22

23. Possible VIA results and descriptions VIA Negative Smooth , pink , uniform and featureless without acetowhite lesion . May include : ectropion , infection , nabothian cysts , squamous metaplasia , and polyps VIA Positive/Pre cancer Raised and thickened acetowhite lesion that starts at the SCJ and persists for more than 1 minute after the acetic acid is removed Suspicious for cancer Very irregular appearing lesions , cauliflower-like growth or ulcer , fungating mass . Bleeds easily on touch . Such an area turns densely aceto-white after application of 3-5% acetic acid Unsatisfactory Unable to visualise the entire SCJ 23

24. Classifications of VIA test results Negative Positive Suspicious for cancer 24

25. Questions before diagnosis Visualize the cervix Suspicious for cancer? SCJ visible? Identify VIA-negative or VIA-positive? If positive, identify the full extent of the acetowhite lesion(s) Good candidate for cryotherapy ? Review eligibility criteria 25

26. VIA Negative 26

27. VIA Positive 27

28. VIA Positive 28

29. Perform Pap smear to screen for cervical cancer Gently insert a sterile, pre-warmed speculum to visualize cervix. Gently cleanse the cervix with cotton pledget if obscured with discharge or secretions. Identify extent of transformation zone and probable squamocolumnar junction. If Squamocolumnar Junction is Visible Rotate a spatula 360° once to obtain a single sample. Smear the sample onto the labeled slide. Fix the sample immediately (before it is air-dried ) using a cytology spray fixative. 29

30. Pap smear procedure 30

31. Pap smear slide 31

32. Link clients suspected with cervical cancer to continuum of care Refer women with abnormalities or suspected cervical cancer for diagnosis . Ensuring adequate treatment of those diagnosed with acetowhite lesion 32