Presentation on theme: "CERVICAL CANCER SCREENING AND TREATMENT STRATEGIES"— Presentation transcript:
1CERVICAL CANCER SCREENING AND TREATMENT STRATEGIES Z.M. CHIRENJE, MD, FRCOGUNIVERSITY OF ZIMBABWEDept. of Obstetrics and Gynaecology
2Cancer Burden in WomenIn 1985 it was estimated that there were approximately 7.6 million new cases of cancer diagnosed throughout the world (Parkin DM et al., Int. J. Cancer, 1993) .Half of the cases occurred in women
3Cancer Burden in Women (continued) Cervical cancer is second most common cancer worldwide with an estimated 471,000 new cases a year and 223,000 deaths in year 2000 (Parking et al, Cancer burden in year 2000: The global picture. Eur.J.Cancer(2001); 37 Suppl. 8: 54 – 566.Eighty [80%] of these estimates] occur in low resource contries like Zimbabwe.
4Six leading cancers in Women (FIGO 1999) BreastCervix (80% of cases are from developing countries)ColorectalStomachLung (compared to in men)Ovary
5The highest age standardized incidence rates are in Southern Africa,Central America,South America and parts of Asia with >40 cases/100,000.In 1997 Harare recorded the highest ASR of 54/100,000.
6PROFILE OF FEMALE RECORDED CANCERS: (Zimbabwe Cancer Registry) Cervical cancer 30%Kaposi sarcoma 18%Breast 7%Ovary 3%Corpus uteri 2%
7Profile of Gynaecological Cancers among Zimbabwean women Cervical carcinoma 80% of casesOvarian carcinomaEndometrial carcinomaChoriocarcinomaVulvaVaginal/fallopian tube
8Magnitude of ProblemCancer of the cervix is the second most common cancer among women worldwide after breast cancer.In developing countries it is the most common cancer constituting 20% to 30% of female cancers compared to 4% to 6% in developing countries, a reflection of impact mass screening using cervical cytology.
9Natural History of Cervical Cancer Proposal that ICC arises through progression of pre-invasive lesion as opposed to a de novo event was proposed in 1908 by Schanenstein.Carcinoma in “situ” was used to describe cancerous changes confined to the epithelium.
10One of the earliest observations in cancer epidemiology was that cancer of the uterine cervix rarely occurred among celibate nuns (Rigoni-Stern, 1842). Rigoni-Stern D.A, Fatti statistici relativi alle mallattie cancrose. Giovnali per servire ai progressi della Patologia e della Terapeutica (1842); 2: 507 – 517.
11The term “dysplasia” was introduced by Reagan in 1956 as a “less anaplastic” lesion than “carcinoma in situ”. Dysplasia was divided into mild, moderate, severe meaning part of epithelium was replaced by cells showing varying degrees in atypia.In 1966 Richart proposed term CIN to describe biological spectrum of cervical pre-invasive squamous disease. Three grades were described.
12Remarkable reduction in ICC through discovery of exfoliative cytology by Papanicolaou and Traut 63 years ago (90% reduction in ICC cases where national programme coverage is up to 80% of women at risk).
13Screening for Cervical Cancer The aim is to detect pre-cancerous lesions which should be treated effectively and prevent development of invasive cancer.Cervical cancer develops over years through a well recognised pre-cancerous phase allowing screening programmes to detect these charges.
14The long latency period of cervical cancer precursor lesions permits early detection and cure often with retention of fertility!!Screening for cervical cancer is therefore of proven benefit in cervical cancer prevention and control.
15Most squamous cell cancers of the. cervix develop from CIN over a long Most squamous cell cancers of the cervix develop from CIN over a long latency period [estimated to be 10 to 15 years in immunocompetent individuals].
1628 years ago Meisel of Fortin observed koilocytosis in cervical cytology and this was the 1st clue for HPV demonstration using immunohistochemistry.Within 10 years of description of koilocytosis Zur Haunsen’s group cloned and characterised new HPV types particularly 16 and 18 which were found in cervical cancer.
17Over 80 different HPV types have been identified and only 23 have been shown to infect the cervix with HPV types 6, 11, 42, 43 and 44 associated with CIN I hence “low oncogenic risk”.
18Extensive molecular biology and epidemiologic research confirms HPV 16,18,31,33,35,39,45,51,52,56,58,59,66,68 to be the resultant precursor event in the genesis of ICC. (Womach SD, Chirenje ZM, et al, BJOG 107(1) 33-38, Int.J. Cancer , 206 – 210.
19HPV genome is divided into coding and non-coding region HPV genome is divided into coding and non-coding region. The coding is has the open reading frames which encode “E” early and “L” late proteins.
20The encoding proteins, E6 of high risk HPV types interfere with cell cycle control by reducing the availability of the host’s oncosuppression protein p53 and retinoblastoma (RB) protein.E6 protein binds p53 and E7 binds and inactivates the RB protein and both events result in uncontrolled proliferation.
21HPV infection are transcient in normal women. Prevalence of HPV is age related (woman aged years prevalence of % whereas women > 30 years prevalence is 6%).Progression of: CIN I 1%CIN II 5%CIN III 12%In immunocompressed individuals HPV, CIN prevalences are 2 - 6x higher and progression to ICC is more rapid, treatment outcomes poorer.
22Strategy for control of cervical cancer is now focusing on: Pathogenesis of ICC is now clearly demonstrated to be highly linked to persistence replication on oncogenic HPV infection on the cervix.Strategy for control of cervical cancer is now focusing on:PRIMARY HPV ScreeningHPV vaccine clinical trials for prophylaxis and therapeutic purposes.
23Cervical Cancer Screening Methods Cervical Cytology (Papanicolaou Smear)Has been around for about 55 years and where screening coverage is adequate, 90% mortality reduction in cervical cancer has been demonstrated.Cells must be scrapped from TZ a full 360° first clockwise then anticlockwise.Use spatula, cytobrush as per availabilitySpread (thinly) over glass slide
24Apply fixative immediately (within 30 seconds to avoid air-drying) Send to labpapanicolaou staining done in labCytotechnician to read/ interpret slideCytopathologist to confirm all positive slides and 10% negative slides (internal quality control)
25Problems of Pap smear Expensive to implement on wide scale coverage % False - negative ratesRecall of positive cases difficult in rural communitiesIn developing countries like Zimbabwe Pap Smears have been performed opportunistically in < 2% of eligible women. Most are done in urban centres on younger women of relative low risk, I.e. reducing their impact on prevention of cervical cancer.
262. CERVICOGRAPHY (taking photograph of cervix at fixed magnification) 3. HPV (Human Pappiloma Virus) DNA testing is done by using molecular techniques which amplify the HPV DNA present in the virus.This is done on a specimen taken by a brush from cervix or vagina and presence of viral HPV is detected by Hybrid Capture[HP] Assay or Polymerase chain reaction[PCR] technique.A self collected specimen may also be taken by a swab taken by a swab inserted deep into the vagina and taken to lab via a transport medium.
274. AUTOMATED PAP SCREENING to identify subsets of smears for examination by cytologist. 5. THIN-PREP SCREENING
286. VISUAL INSPECTION WITH ACETIC ACID (VIA) (Chirenje ZM et al, Lancet 1999).Is an affordable, non-invasive, safe, acceptable and readily available test for identifying women with CIN. Has a sensitivity of % specificity of %, therefore must emphasize good training to reduce rates of false positive by identifying inflammation, HPV, ectropion, Polyps.
29COLPOSCOPY for routine cervical cancer screening is unaffordable, therefore only reserved for women with positive Pap/HPV/VIA.
30Regression by Cell-Mediated Immune Functions MutagenicCo-factorsGenomic instabilityHormonesViral/Genome modification integration/mutationMutation of genes affecting differentiation/ angiogenesisModulation of cellular genes regulating viral gene expressionViral PersistenceInfectionSubclinicalLow GradeCINHigh GradeCINInvasiveCancerMetastasisRegression by Cell-Mediated Immune Functions