Presentation on theme: "Guidelines for Cervical Cancer Screening 26th and 27th January 2010"— Presentation transcript:
1Guidelines for Cervical Cancer Screening 26th and 27th January 2010 Presented byDr. Nadia Sarhan
2Cervical cancer Incidence Cervical cancer the second most common cancer worldwide after breast cancerHalf a million new cases each year. Approximately 80% occurred in developing countries. .Cervical cancer account to about 10% of all cancers and 9% 0f all cancer death in women.
3Cervical cancer is the 11th most common cancer in the GCC (1998-2005). There were 1, 314 cervical cases reported from all GCC states accounted to 1.8% from all cancer and 3.6% from cancers among females. The ASR for all GCC 3.0 per 100,000( GCC cancer incidence, 2009).
4Cervical cancer ranked sixth in the GCC States women, however its incidence in the lowest rank worldwide.( )Qatar /100,000OmanBahrainUAEKuwaitKSAGCC cancer incidence, 2009).
7Age Standardized Incidence Rates (per 100,000) of cancer among Bahraini female(1998-2005) Breast cancerTrachea, bronchus, lungThyroidColorectalOvaryCervix uteri
8Since the Papanicolaou (Pap) smear screening test for cervical cancer was introduced in the United States in 1941, its use has significantly reduced the number of deaths related to the disease.incidence and mortality of cervical cancer occur in 50% women who had never screened, and over 60% in women had not screened last 5 yearsDespite these statistics, cervical cancer is one of the most successfully treated cancers if detected early, with a 73% 5-year survival rate in 2000 compared to a 59% 5-year survival rate in Mortality rates generally increase with age with the highest number of deaths occurring in the age groups
9Etiology of Cervical Cancer The primary underlying cause of cervical cancer is infection with human papilloma virus (HPV).It usually takes 10 to 20 years for precursor lesion caused by HPV (or dysplasia) to develop into invasive cancer (WHO, 2006).The spectrum of HPV- related genital disease ranges fromexternal genital warts to cervical dysplasia and malignancy
10Etiology of Cervical Cancer Cervical lesions, particularly CIN I and CIN II, may regress to normal; rates of regression for low grade lesions are as high as 75 percent at five years for adults and up to 91 percent at three years in adolescents .The cervical transformation zone is the area where great majority of pre-cancers and cancers arise. The transformation zone is larger during puberty and pregnancy and (OCPs) for a long time
11Main Objectives:1. Early detection of cervical cancer thus allowing early intervention and treatment.2. Reduce cervical cancer mortality and morbidity.3. Reduce the financial burden of cervical cancer on the long run.4. Promote women health by increasing awareness.
12Cervical Cancer Screening in Ministry of Health Bahrain The periodic women screening services was initiated in December It aims at early detection of cervical cancer through screening of women at the age of years.If two smears three years apart, were negative, it should be followed by one smear every five years. Women screening committee issued a protocol for women screening services in 1995 and updated it in 1997 and 2006.Cervical screening were opportunistic not population based, usually for women attending health centers.
13A study done in 2003 to evaluate the occurrence of HPV infection and HPV types present among women in Kingdom of Bahrain. In addition the possible role of risk factors for HPV infection and oncogenesis.The study showed HPV DNA was detected in 11% of women and they were HPV types 16,18,45,62 and 53 with normal cytology.
14The risk factors found in the study The first sexual contact was not significant in both groups.Both groups were monogamous marriagesOver 90% of both groups non smokersThe trend of had 5 children or more not significant in positive groupThe proportion of women with OCP usage was similar in both group (Hajji. A. A., 2005)
15Relative Risks for Cervical Cancer HIV infection Very highModerate dysplasia on Pap smear within past 5 yr Very highIntercourse within 1 yr of menarche 16No prior screeningHPV infection (depending on subtype)Six or more lifetime sexual partnersLow socioeconomic classBlack race (compared with white race)SmokingOral contraceptive useBarrier contraceptive use
16Risks Factor for Cervical Cancer Women having a child at age less than 20 yearsWomen who have had a high number of live births are more likely to develop cervical cancer.Having other sexually transmitted infectionshaving sexual partners who themselves have had multiple sexual partners.Intrauterine devices are not linked to any increase in cervical cancer risk .
17Summary of Recommendation AGE TO START CERVICAL SCREENING According to most reference cervical screening should be initiated on all women beginning at age 21 years or within three years of onset of sexual activity. (NHS 2003, Postgraduate 2003, USPSTF 2006,ACS(2002), ACOG 2003, Michigan Cancer Consortium 2003).
18WHO RecommendationIt recommends that the priority age group to be screened should be defined by the age-related incidence of invasive cancer of the cervix in the country.it is recommended screening for women aged years or more, and include younger age group only when the highest-risk group been covered
19The following groups of women should be offered screening 1. Women ages between years who never been screened.2. Women whose previous Pap smear was reported as inadequate or showed mild abnormality.3.Women who have abnormal bleeding after intercourse or after the menopause, or other abnormal symptoms.4.Women who have been found abnormalities on their cervix
20Screening frequency two Pap smears one year a part, followed by one every three years (CAPRE, 2004).The USPSTF recommends screening at least every three years; ACS and ACOG advocate annual screening for women under age 30. every two to three years for women aged 30 and older who have had three consecutive normal Pap tests, or every three years if they also are tested for HPV DNA.
21Absence of a cervical smear over the five years prior to the cancer diagnosis almost tripled the risk for invasive cervical cancer (odds ratio 2.7). (Sirovich.B.E,2009)
22Adequate screening is defined as, within the last 5 years the patient has had:Two or three consecutive normal,technically satisfactory Pap smearsAND no Pap smear indicating possible dysplasia.
23Discountuation of cervical cancer screening in older women is appropriate, provided women have had adequate recent screening with normal Pap results.Cervical cancer is no more aggressive in older women than in younger and high grade lesions are rare among older women who have been previously screenedIncorporating age as one component but also possibly including life expectancy, results of prior screening, HPV status, and current sexual activity.
24RecommendationPeriodic cervical screening for women to be started three years after the onset of sexual activity or at age of 21 years whichever comes first.If the results were normal in the last two consecutive years, repeat the test every three years.Those women with high risk of cervical cancer should have Pap smear annually.Discontinuation of cervical cancer screening in older women is appropriate at age 65, provided women have adequate recent screening with normal Pap smear result.
25In Primary CareBecause of shortage of the resources and lake of studies about the cervical cancer in the region we recommended the following:screening of women start at the age of , if they having two or three consecutive normal,technically satisfactory Pap smears AND no Pap smear indicating possible dysplasia to repeat test after three years.
26Signs and symptomsEarly cervical cancer generally produces no signs or symptoms. As the cancer progresses, these signs and symptoms may appear:Bleeding from vagina after intercourse, between periods or after menopauseWatery, bloody discharge from vagina that may be heavy and have a foul odorPelvic pain or pain during sexual intercourse
27Methods for cervical screening Screening is performed usingcervical cytology (Pap test), or a human papillomavirus (HPV) test, or a combination of the two tests.cervical cytology (Pap test) the conventional Pap smear and the liquid-based, thin layer preparation (ThinPrep in BDF SurePath in SMC. Another liquid-based system, MonoPrep®, is no longer available.Both used to check for any cervical cell changes, for detecting infectious, pre-malignant, and malignant processes in the transformation zone, the junction of the ecto- and endo-cervix, where cervical dysplasia and cancers arise.
28Preparing for Pap smear The test must be done when women not menstruating and does not have vaginal infection.To improve the accuracy of the test results:Schedule Pap smear appointment about 2 weeks (10-18 days) after the first day of her last menstrual periodDo not douche within 48 hours before the test.Do not use tampons, birth control foams, jellies or other vaginal creams or vaginal medications for 48 hours before test.Refrain from intercourse for 48 hours before the test
29Procedure for taking Pap smear Position the patientInspect the vulva, vagina and cervixAfter lubricated the speculum with warm water only, separate with hand labia. insert the speculum 45 degrees and then back to normal position.
30HOW TO OBTAIN A SAMPLE For both methods, cells are obtained from the external surface of the cervix (ectocervix) and the cervical canal (endocervix) to evaluate the transformation zone (squamocolumnar junction), the area at greatest risk for neoplastic.Conventional pap:The slide is then rapidly fixed to avoid air-drying; the usual fixatives are either ethyl ether plus 95 percent ethyl alcohol or 95 percent ethyl alcohol alone
32Liquid based cytology (LBC) Insert the cervical broom (spatula) into the cervical os which brushes cell from the neck of the womb and rotate 5 times.The head of the spatula where cells are lodged is broken off into a small glass vial containing preservative fluid and tightly cap the vial.The sample is sent to the laboratory where it is spun and treated to remove obscuring material, such as mucus, blood, or pus. A thin layer of the cells is deposited onto slide. The slide is examined by a cytologist.
34Collection device Cotton tipped swabs should be avoided because they collect fewer endocervical cells and do not detect CIN as well as other devices
35In women at high risk for vaginal cancer because of in utero diethyl stilbestrol exposure, additional samples from the anterior and posterior fornices should be obtained.
36any lesion that is raised, friable, or has the appearance of condyloma should be biopsied, regardless of previous cytology results or other risk factors for cervical cancer. the only exception is a diagnosis of Nabothian cyst by an experienced examiner
39Liquid-based cytology advantages over conventional cytology lower incidence of inappropriate fixation and drying artifact, and less cellular obscuration on the slide resulting in fewer unsatisfactory tests.Liquid-based and conventional cytology equally well for detection of HSIL, but liquid-based methods perform better for detection of glandular abnormalities, ASCUS, and LSIL .opportunity to re-test the liquid preparation HPV
40FACTORS THAT INTERFERE WITH SAMPLING Menses or other genital tract bleedingInterval between Pap tests Gel lubricants and other contaminantsVaginal intercourse, douching, and tampon use
41Screening Women with special circumstances Immune-compromisedHIVWomen who have sex with womenIf women never sexually active, her chance to develop cervical is very low.Prior hysterectomy
42Indication for screening frequency for pregnant women should be same as for women who are not pregnant. Interpretation of Pap smear result during pregnancy is more difficult, so the pregnant woman should be advised to retain for screening 12 weeks after giving birthacute infection, appropriate treatment should be given and cervical cancer screening should be deferred until the infection has resolved.
43Risk from screeningdiscomfort and inconvenience, psychosocial consequences.costs Annual spending on cervical cancer screening is estimated to exceed $7.5 billion.adverse health outcomes; Some studies found an association between cold knife conization and preterm delivery (RR 2.59, 95% CI ) and low birth weight (RR 2.53,
44HPV can be accurately detected using DNA–based testing. HPV testing plays a vital role in cervical cancer screening programs. HPV testing, either alone or in combination with cervical cytology, has been shown in multiple studies to be more sensitive than cervical cytology alone in detecting high or low grade cervical. HPV testing has better specificity in women over age 30 than in younger women
45Risk of cervical cancer with HPV High-risk (oncogenic or cancer-associated)types Common types: 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68, 69, 82Low-risk (non-oncogenic) types Common types: 6, 11, 40, 42, 43, 44, 54, 61, 72, 81Data from: at:
46The external cervical os is round and small in a nulliparous woman.
47Cervicitis is an inflammation of the uterine cervix.
48Cervicitis is suspected if the cervix is erythematous, edematous, or easily friable. Classic mucopurulent cervicitis (thick yellow-green pus) in the cervical os
55Treatment options for HPV infection Although there is currently no medical cure for HPV infection the lesions and warts these viruses cause can be treated. Methods commonly used to treat lesions include:Cryosurgery (freezing that destroys tissue).LEEP (loop electrosurgical excision procedure, the removal of tissue with hot wire loop).Conventional surgery
58SPECIEMEN ADEQUACYAbsence of an endocervical cell/transformation zone (EC/TZ) component to repeat Pap test in 12 months and not to wait longer.A specimen is considered "partially obscured" when 50 to 75 percent of the epithelial cells cannot be visualized. Specimens in which more than 75 percent of the cells are obscured are designated unsatisfactory. Women with partially obscuring blood or inflammation should have a repeat test in six months.
59A specimen is considered "unsatisfactory" for evaluation to repeat Pap test within two to four months .If the cells are obscured by inflammation and a specific infection is identified, treatment should be given before repeating the Pap test.Findings of endometrial cells are usually benign, but if the finding is not associated with menses or occurs after menopause, it may indicate a risk for an endometrial abnormality
60Infection/ OrganismsTrichomonas: treat if on liquid-based, but Conventional Pap smears, the diagnosis should be confirmed by wet prep.Bacterial vaginosis; cervical cytology is not a reliable diagnostic method for bacterial vaginosis, so it need confirmation with clinical testing before treatment.
61Actinomyces typically in women who have an intrauterine device Reactive changes/inflammation; The cervical cytology sampling does not need to be repeated unless the patient is HIV positive, in which case it should be repeated in four to six months.
62Hyperkeratosis : is negative cervical cytology test ( Hyperkeratosis : is negative cervical cytology test (? related to infection or trauma with inflammation, use of a diaphragm). We repeat the cervical cytology test in 6 to 12 months. If hyperkeratosis persists, treatment with topical estrogen may resolve the finding, but no treatment is necessary.
63InflammatoryMildModerate and sever evaluate for gonorrhea, Chlamydia, KOH if +ve treat and repeat after 3 monthsIf –ve repeat after 6 monthsPersistent refereed to colposcopy
64EPITHELIAL CELL ABNORMALITIES:- SQUAMOUS CELLS Atypical squamous cells Of undetermined Significance (ASC- US) The presence of infection or reactive changes After treatment of the infection, evaluation of ASC-US is performed
65Management of women (pre-menopausal, post-menopausal and immune compromised (HIV) with ASC-US
69-with features suspicious of invasion (if invasion is suspected) High grade squamous Intraepithelial Lesion (HSIL) Encompassing Moderate and sever dysplasia, CIS, CINII,CINIII.-with features suspicious of invasion (if invasion is suspected)Squamous cell carcinoma
70EPITHELIAL CELL ABNORMALITIES:- GLANDULAR CELLS Atypical glandular cells (AGC) Specify endocervical, endometrial or glandular cells not otherwise specified (NOS) Atypical glandular cells, favour neoplastic (specify endocervical or not specified) Endocervical adenocarcinoma in situ (AIS) Adenocarcinoma
72TECHNIQUES FOR FOLLOW-UP OF ABNORMALITIES Colposcopy After application of acetic acid, visual examination of the cervix under magnification using a colposcope allows identification of specific areas with epithelial changes. The most severely abnormal areas are biopsy to determine the histological diagnosis. This is an office procedure that is performed during a pelvic examination without the need for anesthesia
73Endocervical curettage or sampling (ECS) using a brush or curette is performed in patients with ASC-H, HSIL, AGC, adenocarcinoma in situ (AIS), some cases of LSIL, if ablative treatment is contemplated, and in those with an unsatisfactory colposcopic examination.ECC is not performed in pregnancy
74Loop electrosurgical excision procedure The loop electrosurgical excision procedure (LEEP), also called large loop excision of the transformation zone (LLETZ), utilizes a very thin wire in the shape of a loop and modern electrosurgical generators that allow accurate and selective blending of the current. The loops are available in a variety of sizes, allowing individualization and avoidance of excessive excision.
75Cold knife conization 1.Descripency between cytology and histopathology2.+ve Endocervical curettage3.Unsatisfactorycolposcopy.4.Microinvasive discease.
76Prevention of cervical cancer HPV vaccineSexual contactStop smokingOCP
77Vaccine research The HPV vaccine (Gardasil) The vaccine, Gardasil®, protects against four HPV types, (types 6, 11, 16, and 18) which together cause 70% of cervical cancers and 90% of genital warts. given to girls/women, ages 9-26 years. The vaccine is given through a series of three shots over a six-month period.About 30 % of cervical cancer will not be prevented by the vaccine, so it will be important for women to continue getting screened for cervical cancer.Also, the vaccine does not prevent about 10 % of genital warts