Prevention of carcinoma cervix- primary secondary and tertiary prevention
●Cervical cancer
➢Risk factors
➢HPV vaccination and guidelines
➢HPV testing
➢Cytology
➢VIA/ VILI
➢Screening guidelines
➢Colposcopy
➢Ablative and excisional procdures
➢Management of invasive cancer
➢Global strategy to accelerate the elimination of cervical cancer as a public health problem
2. CONTENTS
Cervical cancer
Risk factors
HPV vaccination and guidelines
HPV testing
Cytology
VIA/VILI
Screening guidelines
Colposcopy
Ablative and excisional procdures
Management of invasive cancer
Global strategy to accelerate the elimination of cervical
cancer as a public health problem
Vaginal and vulval cancer
5. RISK
FACTORS
DEMOGRAPHIC
RISK FACTORS
BEHAVIOURAL
RISK FACTORS
MEDICAL
RISK FACTORS
Race
Low
socioeconomic
status
Increasing age
Young age at first
intercourse
Multiple sexual
partners
Cigarette
smoking
Dietary deficiency
Inadequate screening
High parity
Chronic immune
suppression
HPV infection (Herpes
and Chlamydia act as
cofactors)
6. HPVAND
CERVICAL
CANCER
Causative for >95% of the cervical cancers
Low risk types- 6, 11
High risk types- 16, 18, 31, 33, 45, 52, 58
HPV 16 is the most oncogenic- causative for 45% CIN
and 55% of carcinoma cervix
HPV INFECTON
PRECANCEROUS
CHRONIC INVASIVE
SELF RESOLVE
7.
8. COMPREHENSIVE CERVICAL CANCER
CONTROL
Primary prevention (vaccination against HPV)
Secondary prevention (screening and treatment
of precancerous lesions)
Tertiary prevention (diagnosis and treatment of
invasive cancer)
Palliative care
10. HPV
VACCINATION
4WHO prequalified vaccines- against HPV 16 & 18
Safe and effective in preventing HPV infection, high
grade precancerous lesions and invasive cancer as
per clinical trials and post- marketing surveillance
Most effective if administered prior to HPV exposure
TARGET POPULATION- GIRLS AGED 9-14YRS
PRIMARY
PREVENTION
11. ACTIONOF
HPV
VACCINES
COMPONENTS:
Ag- sp component- generates immunity against
HPV
Non- sp component- adjuvant/ delivery system
rDNA technology expresses the L1 protein coat in
HPV in yeasts without genetic material VLPs
(virus-like proteins)
12. HPV
VACCINES
BIVALENTVACCINE (CERVIRIX)(2009)
- HPV 16,18
QUADRIVALENTVACCINE (GARDASIL)(2006)
- HPV 6,11,16,18
- 97-100% effective if administered prior to HPV
infection
- 44% effective if administered after HPV infection
GARDASIL-9 (2014)
- HPV 6,11, 16,18, 31, 33, 45, 52, 58
- 97% effective in the HPV naïve population
16. SINGLE DOSE
VACCINE
Based on the IARC India HPVVaccineTrial & Costa
RicaVaccineTrial
Simpler delivery system
Lower program costs
Might accelerate introduction of HPV vaccines into
National Immunisation Schedules
22. CERVICAL
CYTOLOGY
Identification of atypical cells in the cervix
OPTIMISINGTHE PAPTEST:
- Avoid menstruation
- Abstain from vaginal intercourse/ douching/ vaginal
tampons for 24-48hours
- Optimum cervical visualization using speculums
- Avoid touching the cervix prior to the test to avoid
removing the dysplastic epithelium, if any
- Sampling of the transformation zone at the
squamocolumnar junction
25. LIQUID
BASED
CYTOLOGY
Liquid-based cytology- sample is
collected by a brush deposited into a
small bottle of preservative liquid
- At the laboratory the liquid is treated &
a layer of cells is placed on a slide.
FDA APPROVED :
1. Sure Path : centrifugation and
sedimentation through a pressure
gradient
2.Thin Prep : filtration and collection of
Vaccum packed cells on membrane and
transferring to slide
3. Mono Prep
27. AUTOMATED
CYTOLOGY
Computerized analysis of Pap smear slides.
1.Autocyte (semi automated):
Scans the slides & records images of 128 of the most
abnormal fields found on the slide (most significant
abnormality found in the center).
When the findings of both the reviewer and the computer
match then, a diagnosis of “within normal limits” is given.
Sensitivity: 97.2%
2. AutoPap.:The material on the slide is reviewed and scored
based on an algorithm, as to the likelihood of an abnormality
is given.
97% sensitivity
30. CO-TESTING
Co testing : HPV testing used along with Pap smear.
The combination of both tests together provides
nearly 100% sensitivity, while maintaining the
specificity of cytology.
For women aged 30-65 years, co-testing has been the
preferred method.
The negative predictive value is high when both test
results are negative and there is a very high level of
reassurance.
31. VIA
VISUAL
INSPECTION
UNDERACETIC
ACID
Low cost and effective method of screening in low
resource settings
Offers immediate diagnosis & possibility of
simultaneous treatment
Application of 3-5% acetic acid:-
3-5ml glacial acetic acid added to 95-97 ml distilled
water
Reversible if application of diluted acetic acid(3-5%)
Coagulation of the cellular proteins,
Swelling of the epithelial tissue, columnar cells and
dehydration of the cells
Examined after 1 minute
33. VILI
VISUAL
INSPECTION
WITH LUGOL’S
IODINE
Squamous epithelium contains glycogen, whereas precancerous
lesions and invasive cancer contain little or no glycogen.
Precancerous lesions and invasive cancer do not take up iodine
and appear as well-defined, thick, mustard or saffron yellow areas.
Lugol iodine: Potassium iodide: 10 g added in Distilled water: 100
ml, Iodine crystals: 5 g added while shaking .
VILI Category Clinical Findings
Test-negative:
Squamous epithelium turns mahogany brown
Test-positive:
Well-defined, bright yellow iodine non-uptake areas
Suspicious for cancer:
Clinically visible ulcerative, cauliflower- like growth or ulcer
37. WHO RECOMMENDATION
POPULATION
INITIATION OF
SCREENING
FREQUENCY OF
SCREENING
GENERAL POPULATION 30YR 5-10YEARS
PEOPLE LIVINGWITH
HIV
25YR 3-5YEARS
WHO GUIDELINES FOR FOR SCREENING ANDTREATMENT OF PRECANCEROUS CERVICAL LESIONS CERVICAL CANCER
PREVENTION- 2ND EDITION
46. COLPOSCOPY
Colposcopy is the examination of the lower genital tract under
magnification and is coupled with obtaining directed biopsies of
suspected lesions.
Bright light source with variable magnification using a optical lens
system
PRIMARY GOAL- to identify preinvasive/ invasive lesions for biopsy
47. COLPOSCOPY
SOLUTIONS USED:
• Normal saline: removes discharge and mucous and helps assess
vascular pattern
• 3-5% acetic acid: mucolytic and causes denaturation of cellular
proteins (acetowhitening) transient whitish hue in lesions
• Lugol’s iodine solution:
- Stains mature glycogen rich, mature squamous epithelium dark
purple brown
- Stains dysplastic epithelium yellow due to poor glycogen store
51. ABLATION
-CRYOSURGERY
-CO2ABLATION
-THERMALABLATION
Involves physical destruction of tissue and is
generally effective for non-invasive ectocervical
disease
PRE-REQUISITES:
- Exclude glandular neoplasia or invasive cancer
- Visualisation of the entire SCJ and upper limits of all
lesions of colposcopy
- Endocervical sampling should be negative for high
grade CIN
- Concordant cytology and HPE reports
Modalities- Cryosurgery and CO2
Decline in ablative procedures due to lesser
morbidity and ease of LEEP
52. CRYOTHERAPY
Ablates transformation zone and CIN
Cryoprobe Gas(NO2) Cold
temperature Expanding layer of ice
(ICEBALL)-20 deg celsius- LETHAL
ZONE Necroses cervical epithelium
-20 deg celsius: Cell death
Used for:
- Ectocervical lesions
- Circumferential cervical length adequate
to avoid thermal damage to the vagina
- CIN limited to 2 quadrants
54. CO2 LASER
ABLATION
Under colposcopic guidance
CO2 Infrared laser Heat Boils intracellular
tissueVaporises tissue
For large, irregular CIN lesions ifTZ is seen fully in
colposcopy
Can be used if CIN lesion extends to the vagina
Cervical tissue vaporised to a depth of 5-7mm
56. EXCISION
-LEEP/ LLETZ
-COLD KNIFE
CONISATION
-CO2 LASER
CONISATION
Favoured when:
-Risk of invasive cancer is high
-In case of lesions or SCJ not completely visualised under
colposcopy
-Lesions extends >75% of the ectocervix
-Endocervical sample indicates high grade CIN or
glandular neoplasia
- Persistence/ recurrence of high grade CIN post therapy
ADVANTAGE: Provided tissue for HPE
DIAGNOSTIC EXCISION-Invasive lesion not ruled out by
colposcopy
THERAPEUTIC EXCISION- for CIN diagnosed by HPE
and colposcopy
57. LEEP/ LLETZ COLD KNIFE CONISATION
ADVANTAGES
- Better safety profile
- Easy
- OPD procedure
- Cheaper
- Tissue available for HPE
- Patient anesthetised
- No margin compromise
- Better patient support in
case of haemorrhage
DISADVANTAGES
- Thermal damage may
obscure margin status
- Training required
- Postprocedure bleeding
- Haemorrhagge
- Longer time
- Post-op discomfort
- GA/ RA needed
- OT needed
- Costlier
- Larger amount of stroma
removed
- Poorer reproductive
outcome
60. CONISATION
Indications-
Abnormal endo cervical curettage (ECC)
CIN-2 or CIN-3
Lesion extends to ECC and extent not possible
to confirm
Extent exceeds capability of LEEP(1.5 cm )
Cytology shows atypical glandular cells
Colposcopy suggest glandular dysplasia or
adenocarcinoma in situ
Invasive cancer cannot be ruled out
Suspected micro invasion
Lack of correlation between cytology, biopsy,
and colposcopy results
61. MANAGEMENT
OF INVASIVE
CERVICAL
CANCER
EARLY DISEASE ADVANCED DISEASE
Irregular spotting/
bleeding PV
Postmenopausal
bleeding
Post coital bleeding
Copious/ foul smelling
discharge PV
Loss of weight/ appetite
Persistent leg/ back/
pelvic pain
Lower limb swelling
Decreased urine output
General physical examination especially to examine the
supraclavicular, axillary, inguinofemoral lymph nodes
Per speculum examination of the cervix and vagina
Digital examination of the cervix
Per rectal examination
TERTIARY PREVENTION
67. WHO
RESPONSE
Adapted from the WORLD HEALTH ASSEMBLY to
accelerate the elimination of cervical cancer as public
health problem
ELIMINATION- a country reaching a threshold of <4
cases per 100000 women per year
90-70-90TARGETS to be reached by 2030 and
maintained
>90% of the girls fully vaccinated by the age of 15
years
70% of them women screened by a high performance
test by the age of 35years and repeated by the age of
45 years
90% of the patients identified with cervical disease
managed for the same
