Prof. Farhat HussainDept. of Obs & GynaePabna Medical College

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Projections assume rates estimated for 2002 hold into the future.

20022020(% change)2020% burdenWorld493,000702,500 (42%)100%Women aged

Early Age of MarriageMultiple Sexual Partners

High ParitySmoker

Oral Contraceptive PillLess Aware About Reproductive Health (Low SES)

Any age of women can develop cervical cancer but women at or above 40 years of age have more risk of developing cancer Less Risk

High Risk

Illiteracy and lack of empowerment of women Lack of awareness of women & family regarding the disease.Less use of cancer preventive toolsLess availability & accessibility for diagnosis & treatment of cancer in early stage.

Post Menopausal BleedingFrequent Irregular PV BleedingPost Coital Bleeding

Foul Smelling vaginal DischargeBlood Mixed with UrineSevere Pain in Lower Abdomen, Back & Bone

The effort to eleminate cervical cancer began 50 years ago with the introduction of pap test which has reduced the incidence of cervical cancer by 75% in countries that have implemented quality control screening programs.

The next significant milestone in cervical cancer prevention came in 1980s with the discovery of a link between cervical cancer and HPV.

In the following 20 years, the basis of sensitive molecular methods for detecting HPV i.e. HPV DNA test and cancer prevention vaccine i.e. HPV vaccine was established.

In 2006, HPV vaccine was incorporated into cervical cancer prevention efforts

Cytological testing involves collection of exfoliated cells from cervix & microscopic examination of these cells after staining. The specimen is obtained using Ayres spatula & Conical Cervical brush & spread on labeled glass slide.Ayres spatula & Conical Cervical brush Paps smear collection from cervix

Cytology-based screening have been implemented for secondary prevention of Cervical cancer since the mid 20th century,Recent review of impact is highly variable with efficacy ranging from 20 % to 90%,In US, the incidence rates of cervical cancer have fallen by 75% or more since 1960In England, the incidencc rates of cervical cancer was relatively constant, despite the presence of Pap smear screening until 1988, following which there was precipitous drops in rates in subsequent years.

Organized screening program with wide coverage and quality assurance has led to a concomitant reduction in cervical cancer incidence and mortality due to detection and treatment of precancerous lesions and earlier stage treatable cancers respectively.

Cytology has limited sensitivity (51%) for detection of precancerous lesions and treatable cancer. Thus repeated cytology over short intervals (Annual, biennial and triennial) has been used to achieve program efficacy.Cytology is a subjective test and poorly reproducible. Without quality control it is impossible to achieve and maintain the clinical performance. Cytology is labour intensive and has been refractory to high throughput automated screening.Despite the low cost of consumables, high quality cytology is expensiveThree visit approach (cytology, colposcopy and Rx) is needed for an intervention cycleThe rate of loss to follow up associated with multiple visits is high.

A multidisciplinary approach involving gynaecologists, family practitioners, nurses & cytopathologists are essentialTraining of involved manpower adhering to clinical practice guideline & their accreditation system of call/ recall program where every woman in the screening age range receive regular invitation.Establishment of quality assurance in every stage of process smear collection, laboratory reading, colposcopic management Presence of administrative infrastructure support to track women in the process Provision of political support which ensures adequate funding, including evidence based advances

For successful implementation of cytology based screening program the key considerations are

Screening, diagnosis & treatment provided in site or in clinics accessible to majority of at risk womenLow cost, low technology screening test that allows immediate treatment of abnormalitiesWide coverage of at risk womenEducational programs for health workers & women to ensure high participation & correct implementationBuilt in mechanism for evaluation of screening program

VIA involves naked eye inspection of the cervix one minute after application of 3-5% dilute acetic acid. VIA has been widely investigated as screening test & is now an acceptable test in low resource setting.VIA PositiveVIA Negative

The sensitivity of VIA in detecting high grade precancerous lessons & invasive cervical cancer is similar to that of cytology.The test results are immediately available & thus is a screen-andtreat or single visit approach. Therefore treatment compliance among screen in positive women is high.The test involves minimum expenditure & is safe.The test can be performed by nurses or paramedics with short training and thus the test is feasible in low resource settings.

HPV Test ToolsSpecimen is collected for HPV TestHPV test involves looking for HPV DNA in the cervix. The kit contains special conical brush and a vial with Specimen Transport Medium (STM).

Colposcopy allows magnified viewing of cervix & vagina with colposcope. Morphological features of transformation zone of cervix like aceto whiteness, margins, blood vessels & iodine uptake is noted with colposcope.ColposcopyColposcopy guided biopsy

Positive screening test results like Paps smear positive, VIA positive, VILI positive. Suspicious looking cervixPost coital bleedingClinically apparent leukoplakia

HPV infection leading to cervical cancer can be prevented through vaccination. Vaccination offers primary prevention against cervical cancer. There are both bivalent & quadrivalent vaccine against cervical cancer.The bivalent vaccine (Cervarix from Glaxo Smithkline) is composed of HPV 16 &18 antigens in the form of VLPs combined with a novel adjuvant system called ASO4Cervarix

In order to obtain maximum effectiveness, vaccination need to be given before the onset of sexual activity, which means vaccinating young girls between 9-13 years. Since all sexually active women continue to remain at risk of acquiring an HPV infection throughout their lives, therefore women between 10 to 45 years can be benefited from vaccination.Cervarix is administered in three doses (0,1 & 6 months) via intra muscular injection into the deltoid area.

Cervarix provides protection against HPV 16 & 18 for 8.4 years till date.The antibody level remains 10-11 fold higher than natural infection.

Cervarix provides cross protection against HPV 31 & 45.

Vaccination along with regular screening offers the best possible protection against cervical cancer. Screening is done to ensure that an infection caused by a non vaccine HPV type does not progress to invasive cancer.

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Careful integration of primary and secondary prevention programs would lead to greater reduction in cervical cancer making it a disease of the past.

Victim of cervical cancer who has been treated and now is leading a normal life

Thank You

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