Screening for premalignant cervical lesions in Egypt is important given the high incidence of cervical cancer. Visual inspection with acetic acid (VIA) is recommended for screening in developing countries due to its low cost, simplicity, and ability to provide immediate results and treatment. Mansoura University experience found VIA to be a sensitive screening method, detecting cervical lesions. While a positive VIA does not always indicate cancer, it allows for low-cost screening and identification of suspicious lesions requiring further evaluation or treatment.

1. Screening for Premalignant cervicalScreening for Premalignant cervical
Lesions In EgyptLesions In Egypt
BYBY
Prof.Prof.
Mohammad EmamMohammad Emam
Director Of Early Cancer Detection UnitDirector Of Early Cancer Detection Unit
OB & GYN Dept.OB & GYN Dept.
Mansoura Faculty of Medicine-Egypt.Mansoura Faculty of Medicine-Egypt.
20152015

2. Screening GenerallyScreening Generally
• Is to seek aboutIs to seek about
certain problemcertain problem
in certain highin certain high
risk gp.risk gp.

3. Who is at riskWho is at risk??
Women who have had more than one partnerWomen who have had more than one partner
Women whoWomen who’’s partner (s) has had more thans partner (s) has had more than
one sexual partner.one sexual partner.
Women with other STDsWomen with other STDs

4. Who is at riskWho is at risk??
Women with immune problems:Women with immune problems:
– Steroid medicationsSteroid medications
– Transplanted organsTransplanted organs
– ChemotherapyChemotherapy
– HIVHIV
Women who smokeWomen who smoke
11stst
intercourse before Age 18intercourse before Age 18

5. Ideal Screening MethodIdeal Screening Method
Adequate sensitivity and specificity.Adequate sensitivity and specificity.
yield reproducible results.yield reproducible results.
Cheap, simple and easy to apply.Cheap, simple and easy to apply.
Without side effects or complications.Without side effects or complications.
Painless .Painless .
Socioculturally acceptable.Socioculturally acceptable.
Infrastructures are easily available.Infrastructures are easily available.

6. RationaleRationale
1.1. Prevention is better than cure.Prevention is better than cure.
2.2. Most Cancers Develop In The UnscreenedMost Cancers Develop In The Unscreened
And The Under screened populationsAnd The Under screened populations

7. Cervical CancerCervical Cancer WorldwideWorldwide
230,000230,000 womenwomen diedie
of cervical cancerof cervical cancer
every yearevery year
– 80 % occur in80 % occur in
developingdeveloping
countries.countries.
““WHO , Cervical Cancer Screening in DevelopingWHO , Cervical Cancer Screening in Developing
Countries. Report of a WHO Consultation. 2001”Countries. Report of a WHO Consultation. 2001”

8. Incidence of Cancers inIncidence of Cancers in
Egyptian WomenEgyptian Women
00
55
1010
1515
2020
2525
BreastBreast
CancerCancer
CervicalCervical
CancerCancer
OvarianOvarian
CancerCancer
UterineUterine
CancerCancer
PercentPercent
Source: GLOBOCAN 2000.Source: GLOBOCAN 2000.

9. RationaleRationale
In developed countriesIn developed countries::
– Cervical cytology is considered to be the only test known toCervical cytology is considered to be the only test known to
reduce cervical cancer .reduce cervical cancer .
In developing countries ( Low resources ):In developing countries ( Low resources ):
– An organized screening program is difficult toAn organized screening program is difficult to
implement ( some counteris like Pakistan , Indonesiaimplement ( some counteris like Pakistan , Indonesia
have started)have started)

10. RationaleRationale
In Egypt:In Egypt:
 No national screening program for cancerNo national screening program for cancer
cervix although in developed countries thecervix although in developed countries the
screening is in adulthood ,screening is in adulthood ,
Only sporadic reports regarding the prevalenceOnly sporadic reports regarding the prevalence
in some governorates ( Dakahlia, sharkia ,in some governorates ( Dakahlia, sharkia ,
Assuit, and minia ), utilizing VIA .Assuit, and minia ), utilizing VIA .

11. WHO guidelines for screening and tttWHO guidelines for screening and ttt
::developing countries :developing countries :((of CIN ( 2013of CIN ( 2013
– where screening with an HPV test iswhere screening with an HPV test is
not feasible: screen with VIA and treat.not feasible: screen with VIA and treat.
– Screen-and-treat strategies involve ttt withScreen-and-treat strategies involve ttt with
cryotherapy, or LEEP when the patient iscryotherapy, or LEEP when the patient is
not eligible for cryotherapy.not eligible for cryotherapy.

12. SeriousSerious
WidespreadWidespread
Diagnosable in early stages.Diagnosable in early stages.
TreatableTreatable
Cancer cx. Screening programs are inCancer cx. Screening programs are in
adulthood.adulthood.
ButBut ov. cancer programs are still in relativeov. cancer programs are still in relative
infancy,infancy, why?why?
Cancer Cervix Is an IdealCancer Cervix Is an Ideal
Disease For ScreeningDisease For Screening

13. Screening Of Cervical CancerScreening Of Cervical Cancer
is in adulthood.. Whyis in adulthood.. Why??
1.1. Screening detects Premalignancy.Screening detects Premalignancy.
2.2. PremalignancyPremalignancy can be detected bycan be detected by
noninvasive means.noninvasive means.
3.3. Good prognosis of early stage.Good prognosis of early stage.
4.4. Premalignant Course is slowPremalignant Course is slow..

14. Screening Of Cervical Cancer is inScreening Of Cervical Cancer is in
adulthood.. Why ?adulthood.. Why ? ContCont……
5.5. Effective treatment modalities forEffective treatment modalities for
premalignant lesions .premalignant lesions .
6. C6. Cervical cancer incidence is reduced byervical cancer incidence is reduced by
about 90% inabout 90% in developed countriesdeveloped countries withwith
-organized screening programs.-organized screening programs.

15. Gold standard ScreeningGold standard Screening
test For Cancer Cervixtest For Cancer Cervix
☼
PAP smear test is
considered to be the
gold standard .
☼ Has limitations ?

16. •CollectionCollection
•ReadingReading
•ReportingReporting
Limitations Associated withLimitations Associated with
Pap SmearPap Smear

17. Pap Smear PreparationPap Smear Preparation

18. Ayres’ spatula & endocervicalAyres’ spatula & endocervical
brushbrush

19. Broom type samplerBroom type sampler

20. Differences between the Bethesda & PapanicolaouDifferences between the Bethesda & Papanicolaou
SystemSystem
Includes the diagnosis of HPV infections andIncludes the diagnosis of HPV infections and
limits use of the termlimits use of the term “atypia”.“atypia”.
squamous intraepithelial lesion =squamous intraepithelial lesion = SIL:SIL:
– low-grade SIL = HPV change and CIN Ilow-grade SIL = HPV change and CIN I
– high-grade SIL = CIN II and CIN III lesionshigh-grade SIL = CIN II and CIN III lesions

21. PAP Smear NormalPAP Smear Normal::

22. LSILLSIL
Dysplastic nuclear changes, binucleationDysplastic nuclear changes, binucleation

23. HSILHSIL
Enlarged nucleus, less cytoplasm (increased N:C ratio).Enlarged nucleus, less cytoplasm (increased N:C ratio).
Irregular nuclear membraneIrregular nuclear membrane

24. objectiveobjective
To highlight :To highlight :
–Alternative methods forAlternative methods for
screening of premalignantscreening of premalignant
cervical lesions suitable in Egyptcervical lesions suitable in Egypt
–Mansoura Experience.Mansoura Experience.

25. What areWhat are
Alternatives toAlternatives to
Pap SmearPap Smear??

26. Alternatives to Pap smearAlternatives to Pap smear
– Automated pap screening.Automated pap screening.
– Visual inspection with acetic acidVisual inspection with acetic acid
(VIA), with magnification (VIAM)(VIA), with magnification (VIAM)
&&iodineiodine (VILI).(VILI).
– HPV testing.HPV testing.
– Polar probe.Polar probe.
– cervicographycervicography

27. HPV testingHPV testing
Detect High Risk HPV.Detect High Risk HPV.
Sample from cervix-Sample from cervix-
similar to PAP.similar to PAP.
Special transportSpecial transport
mediummedium
Processed in the labProcessed in the lab
HPVHPV
Objective testsObjective tests
Not suitable for Egypt)Not suitable for Egypt)))
ExpensiveExpensive

28. VILI:VILI: test-positivetest-positive
– Well-defined area.Well-defined area.
– Canary yellow .Canary yellow .
– Transformation zoneTransformation zone
VILI negativeVILI negative
– Mahogany brownMahogany brown

29. VILI & VIAVILI & VIA
Sensitivity Specificity
VIA 76.8 85.5
VILI 91.7 85.4

30. Limitations of VILILimitations of VILI
Stains underwear .Stains underwear .
Lugol’s iodine is more expensive than acetic acid.Lugol’s iodine is more expensive than acetic acid.
Moderate specificity may result in over-referralModerate specificity may result in over-referral
and over-treatment in a single-visit approachand over-treatment in a single-visit approach

31. What Infrastructure For VIA?What Infrastructure For VIA?
Examination table.
Sterile speculum ( Cusco's)
Sterile gloves
Source of light, a lamp or a torch
Cotton swabs
Forceps
Syringe for acetic acid lavage
Acetic acid in dilutions of 3%
Recording data

32. Via Is An Ideal Alternative to Pap smearVia Is An Ideal Alternative to Pap smear
Keep a bottleKeep a bottle
of vinegar inof vinegar in
your office.your office.

33. inexpensiveinexpensive&& 1.1. Simple & quickSimple & quick
2. Immediate results2. Immediate results
3. Not need cytopathologist .3. Not need cytopathologist .
4.4. One step diagnosis and tttOne step diagnosis and ttt..
55..SensitiveSensitive
66..SpecificSpecific????????????
Advantages of VIA overAdvantages of VIA over
PAPPAP

34. Disadvantages Of VIADisadvantages Of VIA
Lower specificity than the smear test. (May beLower specificity than the smear test. (May be
an advantage for women, through over refferal).an advantage for women, through over refferal).
Not suitable for endocervicalNot suitable for endocervical
glandular disease.glandular disease.

35. ``
ColposcopyColposcopy
How to do VIAHow to do VIA??

36. Reporting VisualReporting Visual
Inspection FindingsInspection Findings
Acetic Acid Test-
Negative
Aceto-white area(s) not
present
Acetic Acid Test-
Positive
Aceto-white area(s)
present
1)Density of whiteness
2)Time needed for whiteness to
appear and disappear
3)Sharpness of demarcation

37. ACETO-WHITEACETO-WHITE
VIA imagesVIA images

38. Positive VIAPositive VIA

39. Significance Of Positive VIASignificance Of Positive VIA
MinorityMinority ::
– may bemay be suspicious ofsuspicious of cancer or CINcancer or CIN..
Majority :Majority :
– occur in conditions other than cancer :occur in conditions other than cancer :
– Healing orHealing or regenerating epithelium.regenerating epithelium.
– Inflammation.Inflammation.
– Immature squamous Metaplasia.Immature squamous Metaplasia.
– HPV infection.HPV infection.

40. Positive VIA Suspicious OfPositive VIA Suspicious Of
CancerCancer
Rapid uptake of acetic acid (Rapid uptake of acetic acid (less than 20less than 20
seconds).seconds).
Slow release of acetic acid(Slow release of acetic acid( more than 2more than 2
minutes)minutes)
Sharp raised edges.Sharp raised edges.
Irregular surface.Irregular surface.

41. Categorize YourselfCategorize Yourself::
Has no ColposcopyHas no Colposcopy
VIAVIA ± biopsy± biopsy
Has ColposcopyHas Colposcopy
One step :( see and treat ).One step :( see and treat ).
Two stepsTwo steps
What To Do if VIA is Positive &What To Do if VIA is Positive &
suspicioussuspicious??

42. VIA DISCOVERSVIA DISCOVERS
THE CRIMETHE CRIME
LOCATES THELOCATES THE
CULPRIT +/-CULPRIT +/-
COLPOSCOPYCOLPOSCOPY
And canAnd can
CytologyCytology
discoversdiscovers
the crimethe crime
And needAnd need
ColposcopyColposcopy
for locatingfor locating
the culprit.the culprit.

43. Age to
initiate
screening
Age to discontinue
screening
Screening interval for
cervical cytology
Post
hysterectomy
for benign
disease
ACS
(2002(
3years after
onset of sexual
intercourse, or
by age 21
Women may choose, if
70 years and 3
negative tests and no
positive tests within
last 10 years
Annual for conventional
cytology: every 2 years for
liquid-based cytology; for age
>30, every 2 to 3 years after 3
normal consecutive smears and
no increased risk
Not Indicated
ACOG
(2003(
3years after
onset of sexual
intercourse, or
by age 21
Inconclusive evidence Annual for age <30; for age >30,
every 2 to 3 years after 3 normal
consecutive smears, no history
CIN 2 or 3, and no increased risk
Women may
decline testing
USPSTF
(2003(
3years after
onset of sexual
intercourse, or
by age 21
Age 65, if not at high
risk
At least every 3 years Not indicated

44. Mansoura ExperienceMansoura Experience
Int J Gynaecol Obstet.Int J Gynaecol Obstet. 20062006
May;93(2):118-22. Epub 2006 Mar 20.May;93(2):118-22. Epub 2006 Mar 20.
 Screening for cervical carcinoma using visualScreening for cervical carcinoma using visual
inspection with acetic acid.inspection with acetic acid.
 Abdel-Hady ESAbdel-Hady ES11
,, Emam MEmam M,, Al-Gohary AAl-Gohary A,,
Hassan MHassan M, Farag MK, Abo-Elkheir M, Farag MK, Abo-Elkheir M

45. Mansoura ExperienceMansoura Experience
J Exp Ther Oncol.J Exp Ther Oncol. 2014;10(4):247-53.2014;10(4):247-53.
Human papillomavirus (HPV) is not theHuman papillomavirus (HPV) is not the
main cause of preinvasive and invasivemain cause of preinvasive and invasive
cervical cancer among patients in Deltacervical cancer among patients in Delta
Region, Egypt.Region, Egypt.
Thabet M, HemidaThabet M, Hemida R, Hasan M, ElshamyR, Hasan M, Elshamy
M, Elfaraash M, Emam M.M, Elfaraash M, Emam M.

46. ConclusionsConclusions
The easiest female cancer to preventThe easiest female cancer to prevent
through screening is cancer cervix.through screening is cancer cervix.
Regular ( VIA ) are the best way toRegular ( VIA ) are the best way to
prevent cervical cancer in developingprevent cervical cancer in developing
counteriescounteries
An abnormal Pap testAn abnormal Pap test
or ( VIA ) does not mean cancer.or ( VIA ) does not mean cancer.

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