SlideShare a Scribd company logo
1 of 59
Cervical Cancer
Prevention
in Poor Resource Area :
See & Treat Approach
Dr. Sharda Jain
Director :-
Dr. Aruna Saxrna, MD
• Epidemiology
• Indian scenario
• Concept of See & Treat
(screening & treatment)
• Methods of (VIA & VILLI) screening
• Cryo Cautry
• Colposcopy / Biopsy Guidelines
Schema
Age-standardised incidence and mortality rates:
Indian women
India : Number One
New – 1.32
lakh Deaths -
o.74 lakh
GLOBOCAN 2008
Human
Suffering
Due To
Cervical
Cancer in India
Is depressing•women who die due to Cervical Cancer in
the world is an Indian
1 out of 4
Every 7Minutes,
1 Indian woman dies of Cervical Cancer
Disease Burden
Infact India is a Capital for Cervical Cancer
High Economic Burden
Due to the high number of cervical cancer
cases in the population, it has the highest
total cost of secondary care (100,000 INR
per 100,000 population) relative to all other
cancers.
“Report of the National Commission on Macroeconomics
and Health”, NCMH, Ministry of H &FW, Government of India, August 2005.
Screening- Why?
• In many developed countries, a significant decline
in the incidence of and mortality caused by cervical
cancer has been observed in the past 30 years as a
result of screening by cytology.
• Cervical cancer has precursor, low and high grade
intraepithelial lesion, which has effective treatments
available.
• Screening also gives an opportunity for educating
women who are constantly at high risk.
System Failures Leading to
Cervical Cancer Diagnosis
Women do not
come in for
screening
Health care providers
do not screen women
at visits
Colposcopy for
abnormal screen
not done
Patient does not get
appropriate therapy
Patient gets cervical
cancer
Courtesy of Connie Trimble, MD, Johns Hopkins University School of Medicine, Baltimore, MD
Cancer Cervix –
a Global Paradox
• Cancer cervix –100% Preventable disease
WHO
• Cancer cervix –Death by incompetence
Lancet
• Cancer cervix – the unmet challange
Disease Progression
Disease Regression
Natural History of Cervical Cancer
HPV
infection
CIN 1
CIN 2,3
HPV
disappearance
Invasive CA
Avg. 10-13 yrs
Avg. 6-
24 mo
Avg. 6-
12 mo.
AGE SCREENING
< 21 No Screening
21-29 Cytology alone every 3 years
30-65 Acceptable: Cytology alone every 3 years*
Preferred ??: Cytology + HPV every 5 years* OR
> 65 No screening, following 3 consequetive neg prior
screens in last decade
After total hysterectomy No screening, if no history of CIN2+ in the past 20
years of cervical cancer ever
HIV-positive
-Immunosuppressed (e.g., Annually
2013 Guidelines
for prevention of Cervical cancer
• 1st
time that all 3 organizations involved with cervical cancer prevention and the
USPSTF have endorsed equivalent guidelines
Type of screening
• Conventional cytology
• Liquid-based monolayer cytology
• Human papillomavirus testing
• Testing in resource-poor areas
Testing in
Resource-Poor areas
• Pap smears require skilled practitioners and
good laboratories to be effective,
• Most studies have found that VIA, and its
cousin VILI -- visual inspection with Lugol's
iodine -- are somewhat less specific than Pap
smears, but more sensitive
Overall, VIA seems to be an excellent
cervical cancer screening method for
use in low-resource settings where
Pap smears and HPV tests are
inappropriate due to either lack of
expertise or high per-test cost.
The general consensus is that
VIA is just as useful as the Pap
smear; it's just a matter of
determining which one is more
appropriate in any given
circumstance based on
availability of funds & trained
personnel for screening and
follow up
VIA generally detects more early
lesions but is associated with more
false positives.
This could conceivably lead to over
treatment, but in low-resource areas
where large numbers of women are
still dying of cervical cancer, some
governments have decided it is a
worthwhile trade-off. (African Countries)
in India ICPO( institute of cytology
and preventive oncology) took
initiative in developing simple
strategies like VIA in1980’s ,which
subsequently supported by other
international agencies like
IARC,LYON,FRANCE,JHPIEGO,a
nd PATH in USA etc.
India
Screening – not even tip of iceberg
GOI – has
O MONEY
for
universal
vaccination
Screening women at rural & slums
settings and following them is tedious
task for Gynaecologists
But
Motivating them once,examining and
treating them simultaneously if any
abnormality noted, can be easier
task to prevent cervical cancer!
Logic Behind See & Treat Approach
What is basics behind
VIA
Accesibility of CERVIX……..
• seen instantly after putting speculum inside the vagina
and becomes apparent.
• The success of VIA lies in visualising the cervix in the
region of transformation zone in its entirely.
TZ lies between the original squamo-columner junction
and the new (or the present ) squamo-columner junction.
This is a highly active zone of metaplastic tissues in
which the single layered columnar epithelium is transformed
by metaplastic cellular divisions into multilayered squamous
epithelium.
metaplasia and what triggers it
• Exposure of columnar epithelium during ectropion to
acidic environment of vagina leads to metaplasia.(healing
process of damaged columnar epithelium)
• Region that has undergone metaplasia is transformation
zone, bound distally by SCJ E and proximally by SCJ M,
is region of mitosis as cells are
rapidly dividing during metaplasia.
The mitotic rate is higher near SCJ M That's why it
appears white with acetic acid
E
Understanding of “Transformation Zone”
squamous epitheliumsquamous epithelium
ectocervixectocervix endocervixendocervix
SCJSCJ
GLAND OPENINGS in TZ
NYBOTHIAN
FOLLICLE
In TZ
SCJ in various ages
VIA
• Naked eye visual inspection of
cervix, after application of 3-5%
acetic acid to detect pre cancer
lesions is VIA
VIAC
• Magnifying cervix with an ordinary
lens is VIAC i.e visual inspection with
acetic acid aided by cervicography
VIAM
• Technique: is same as that of VIA but
viewning of cervix is done with magnifying
glasses of 4 mm
• Studies from South Africa and Kolkatta, India
have reported no benefit of VIAM over VIA
• Study from TMH also concluded same.
All of us can do it and
also can train our staff to
screen large number of
women with very little
cost
VIA
VIA & VILI
PROCEDURES
PATIENT POSITION
Lithotomy
Position
Consent
Time
STEPS FOR PERFORMING VIA
• Normal Inspection after cleaning with
normal saline
• Inspection after application of acetic acid
• Inspection after application of lugols Iodine
• Examination of Vagina
NORMAL INSPECTION AFTER CLEANING
WITH NORMAL SALINE….
ACETIC ACID TEST
• Coagulation of cell protein seen an interval of 1 mint.
• If white layer is very thick (opaque) that area becomes
area of concern.
• The impact of acetic acid fades away normally in 1-3 mints,
So repeated application is recommended for proper
visualization of pathological lesions.
Aceto white lesion
• Intensity
• Duration of stay
• speed of Appearance
• speed of disappearance
• margins Relation to SCJ
Inside TZ/ outside TZ
Grading of VIA Findings….
• Grade I: Flat acetowhite epithelium, snow white,
regular pattern
• Grade II: Flat but whiter acetowhite epithelium, gray
white,
• Grade-III dull oyster white,
Pre cancer lesions of cervix on VIA
Appearance
white translucent
ivory white
egg white with thick areas
remains for longer time
Margins
sharp and distinct
internal margins
Surface contour
Flat or raised
Abnormal vascular patterns
punctations
Wide inter capillary distance
Extent
Confined to TZ
Disappearing into
cervical canal
% of TZ involved
Satellite lesion
VIA and cervical cancer
screening
• 4% acetic acid is applied to cervix with the help of a cotton
pad after removing excess mucus.
• VIA recording 1 minute after application of acid.
• Positive result: acetowhite areas in the squamocolumnar
junction, or entire cervix or a growth over cervix
• WHITE PATCHES” appears due
to coagulation of cellular proteins and
indicate the abnormal epithelium.
VIA and cervical cancer
• What does positive VIA mean:
• Infection
• Dysplasia
• Intraepithelial lesion
• Cancer
• So, final conclusion is done by colposcopy
and biopsy which is the gold standard.
Effect of visual inspection with acetic acid (VIA)
screening by primary health workers on cervical
cancer mortality: A cluster randomized controlled
trial in Mumbai, India. 2013 ASCO Annual Meeting
Surendra Srinivas Shastri, Indraneel Mittra, Gauravi
Mishra, Subhadra Gupta, Rajesh Dikshit, Rajendra A.
Badwe; Tata Memorial Centre, Mumbai, India
Plenary Session, Plenary Session Including FDA Commissioner Address,
Public Service Award, and Science of Oncology Award and Lecture
• Cluster-randomized controlled trial in 1998 to investigate the efficacy of
VIA screening by primary health workers (PHWs) in reducing cervical
cancer mortality.
• Women aged 35-64 years with no prior history of cancer were included
• 20 clusters with an average of 7,500 eligible women per cluster.
• Four rounds of cancer education and VIA screening were conducted by
PHWs in the screening group, while cancer education was offered
once at recruitment to the control group
• Recruitment was completed in March 31, 2002. Analysed the results
at 12 years
• Recruited 75,360 women from 10 clusters in the
screening group and 76,178 women from 10
comparable clusters in the control group
Results
• The analysis is on an intention-to-treat basis.
• In the screening group, achieved 89% participation for screening and
79% compliance for post-screening diagnostic confirmation.
• The quality of screening by PHWs was comparable to that of an expert
gynecologist (κ=0.84).
• The incidence of invasive cervical cancer was 26.74 per 100,000 in the
screening group and 27.49 per 100,000 in the control group.
•
• The screening group showed a 31% reduction in cervical cancer
mortality (p=0.003) compared to the control group.
• A 7% reduction was also observed in all-cause mortality .
Conclusions
• VIA screening conducted by PHWs
significantly reduced cervical cancer
mortality.
• VIA screening is easily implementable
and could prevent 22,000 cervical cancer
deaths in India.
VILI
• Technique is same as that of VIA but instead of acetic acid, lugol’s
iodine is applied to cervix and end result is change in color to yellow
over positive areas.
• Sankaranarayanan et al did a multicenter study in South Africa and
India on VILI and screening of cervical cancer.
• Sensitivity of VILI turned out to be 86.7-90%.
• Authors gave the reason of such high sensitivity of VILI: the
yellow color changes associated with a positive VILI test result
are more easily recognized by the health workers compared with
the acetowhite changes associated with VIA.
Best Pract Res Clin Obstet Gynaecol. 2012
Mustard yellow
Making Gynaecologists
aware of common
cervical lesions
Treatment of pre cancer
lesions of cervix
• Cryo therapy
• Leep
• biopsy
Cryo therapy
Cryotherapy
• Cryotherapy destroys abnormal
tissue on the cervix by freezing it by
cold coagulation using ice cold gas .
• gases can destroy cells upto 3 mm
by co2 and 5 mm by nitrous oxide.
advantages
• Safe
• One visit treatment
• OPD procedure
• No anaesthesia
• No adverse effects on reproduction
LEEP
• Large loop electrical procedure
Criteria for LEEP
AWL covering > 75% of TZ
Lesion with abnormal blood vessels
Persistent lesion after cryo
Disparity between cytology, VIAC and
histology
Limits of lesion not visible.
To conclude
•Cervical cancer is a preventable cancer .
•We as gynecologists can do a lot to make
an impact to decrease this disease burden.
•See and treat can be a successful mantra
in our country if all gynecologists come
forward to give their due contribution to this
country where they have been trained.
Now this is our turn to give back

More Related Content

What's hot

fertililty sparing surgeries in gynecological cancers
fertililty sparing surgeries in gynecological cancersfertililty sparing surgeries in gynecological cancers
fertililty sparing surgeries in gynecological cancersSreelasya Kakarla
 
Medical Management of Fibroids
Medical Management of FibroidsMedical Management of Fibroids
Medical Management of FibroidsSujoy Dasgupta
 
Say no to cervical cancer-PUBLIC Awareness-Life Care Centre_Dr.Sharda Jain
Say no to cervical cancer-PUBLIC Awareness-Life Care Centre_Dr.Sharda JainSay no to cervical cancer-PUBLIC Awareness-Life Care Centre_Dr.Sharda Jain
Say no to cervical cancer-PUBLIC Awareness-Life Care Centre_Dr.Sharda JainLifecare Centre
 
CERVICAL CANCER & ITS PREVENTION
CERVICAL CANCER & ITS PREVENTIONCERVICAL CANCER & ITS PREVENTION
CERVICAL CANCER & ITS PREVENTIONO. E.Nyandi PhD
 
Presentation for public awareness
Presentation for public awarenessPresentation for public awareness
Presentation for public awarenessdrmcbansal
 
Fertility Preservation for Gynecologic Cancer Patients
Fertility Preservation for Gynecologic Cancer PatientsFertility Preservation for Gynecologic Cancer Patients
Fertility Preservation for Gynecologic Cancer PatientsJibran Mohsin
 
Carcinoma Vulva
Carcinoma VulvaCarcinoma Vulva
Carcinoma Vulvadrmcbansal
 
Cervical cancer screening modalities
Cervical cancer screening modalitiesCervical cancer screening modalities
Cervical cancer screening modalitieschaimingcheng
 
Genital tb in infertility & our experience dr. sharda jain, dr. jyoti agarwal...
Genital tb in infertility & our experience dr. sharda jain, dr. jyoti agarwal...Genital tb in infertility & our experience dr. sharda jain, dr. jyoti agarwal...
Genital tb in infertility & our experience dr. sharda jain, dr. jyoti agarwal...Lifecare Centre
 
CIN and Cervical Screening
CIN and Cervical ScreeningCIN and Cervical Screening
CIN and Cervical ScreeningPro Faather
 
Prevention of Gynecologic Cancer
Prevention of Gynecologic CancerPrevention of Gynecologic Cancer
Prevention of Gynecologic CancerAboubakr Elnashar
 
Evidence Based Guide of Screening for Prevention of Cervical Cancer
Evidence Based Guide of Screening for Prevention of Cervical Cancer  Evidence Based Guide of Screening for Prevention of Cervical Cancer
Evidence Based Guide of Screening for Prevention of Cervical Cancer Lifecare Centre
 
Pet in gynecological malignancies
Pet in gynecological malignancies Pet in gynecological malignancies
Pet in gynecological malignancies ikramdr01
 
Gtn 1 ppt
Gtn 1 pptGtn 1 ppt
Gtn 1 pptmadurai
 
Laparoscopic Tubal Recanalization Mob: 7289915430, www.drpradeepgarg
Laparoscopic Tubal Recanalization  Mob: 7289915430, www.drpradeepgargLaparoscopic Tubal Recanalization  Mob: 7289915430, www.drpradeepgarg
Laparoscopic Tubal Recanalization Mob: 7289915430, www.drpradeepgargPradeep Garg
 
Role of Stem Cells in Obstetrics and Gynecology Practice
Role of Stem Cells in Obstetrics and Gynecology PracticeRole of Stem Cells in Obstetrics and Gynecology Practice
Role of Stem Cells in Obstetrics and Gynecology PracticeAsha Jain
 

What's hot (20)

fertililty sparing surgeries in gynecological cancers
fertililty sparing surgeries in gynecological cancersfertililty sparing surgeries in gynecological cancers
fertililty sparing surgeries in gynecological cancers
 
Medical Management of Fibroids
Medical Management of FibroidsMedical Management of Fibroids
Medical Management of Fibroids
 
Say no to cervical cancer-PUBLIC Awareness-Life Care Centre_Dr.Sharda Jain
Say no to cervical cancer-PUBLIC Awareness-Life Care Centre_Dr.Sharda JainSay no to cervical cancer-PUBLIC Awareness-Life Care Centre_Dr.Sharda Jain
Say no to cervical cancer-PUBLIC Awareness-Life Care Centre_Dr.Sharda Jain
 
CERVICAL CANCER & ITS PREVENTION
CERVICAL CANCER & ITS PREVENTIONCERVICAL CANCER & ITS PREVENTION
CERVICAL CANCER & ITS PREVENTION
 
Presentation for public awareness
Presentation for public awarenessPresentation for public awareness
Presentation for public awareness
 
Fertility Preservation for Gynecologic Cancer Patients
Fertility Preservation for Gynecologic Cancer PatientsFertility Preservation for Gynecologic Cancer Patients
Fertility Preservation for Gynecologic Cancer Patients
 
Carcinoma Vulva
Carcinoma VulvaCarcinoma Vulva
Carcinoma Vulva
 
Cervical cancer screening modalities
Cervical cancer screening modalitiesCervical cancer screening modalities
Cervical cancer screening modalities
 
Colposcopy
Colposcopy Colposcopy
Colposcopy
 
Genital tb in infertility & our experience dr. sharda jain, dr. jyoti agarwal...
Genital tb in infertility & our experience dr. sharda jain, dr. jyoti agarwal...Genital tb in infertility & our experience dr. sharda jain, dr. jyoti agarwal...
Genital tb in infertility & our experience dr. sharda jain, dr. jyoti agarwal...
 
CIN and Cervical Screening
CIN and Cervical ScreeningCIN and Cervical Screening
CIN and Cervical Screening
 
Prevention of Gynecologic Cancer
Prevention of Gynecologic CancerPrevention of Gynecologic Cancer
Prevention of Gynecologic Cancer
 
Evidence Based Guide of Screening for Prevention of Cervical Cancer
Evidence Based Guide of Screening for Prevention of Cervical Cancer  Evidence Based Guide of Screening for Prevention of Cervical Cancer
Evidence Based Guide of Screening for Prevention of Cervical Cancer
 
Cervical Cancer
Cervical CancerCervical Cancer
Cervical Cancer
 
Hysteroscopy
HysteroscopyHysteroscopy
Hysteroscopy
 
Ca endometrium-1.pptx
Ca endometrium-1.pptxCa endometrium-1.pptx
Ca endometrium-1.pptx
 
Pet in gynecological malignancies
Pet in gynecological malignancies Pet in gynecological malignancies
Pet in gynecological malignancies
 
Gtn 1 ppt
Gtn 1 pptGtn 1 ppt
Gtn 1 ppt
 
Laparoscopic Tubal Recanalization Mob: 7289915430, www.drpradeepgarg
Laparoscopic Tubal Recanalization  Mob: 7289915430, www.drpradeepgargLaparoscopic Tubal Recanalization  Mob: 7289915430, www.drpradeepgarg
Laparoscopic Tubal Recanalization Mob: 7289915430, www.drpradeepgarg
 
Role of Stem Cells in Obstetrics and Gynecology Practice
Role of Stem Cells in Obstetrics and Gynecology PracticeRole of Stem Cells in Obstetrics and Gynecology Practice
Role of Stem Cells in Obstetrics and Gynecology Practice
 

Viewers also liked

Cervical Screening and pre-cancer treatment: what are the options?
Cervical Screening and pre-cancer treatment: what are the options?Cervical Screening and pre-cancer treatment: what are the options?
Cervical Screening and pre-cancer treatment: what are the options?Tamar Naskidashvili
 
Dr. nisreen cervical cancer screening in park hayat
Dr. nisreen cervical cancer screening in park hayatDr. nisreen cervical cancer screening in park hayat
Dr. nisreen cervical cancer screening in park hayatTariq Mohammed
 
Loop electrosurgical excision procedure
Loop electrosurgical excision procedureLoop electrosurgical excision procedure
Loop electrosurgical excision procedureAkhil Kapoor
 
Screening c cervix slideshare 2015 (1)
Screening c cervix   slideshare 2015 (1)Screening c cervix   slideshare 2015 (1)
Screening c cervix slideshare 2015 (1)Mohammad Emam
 
Screening for cervical cancer
Screening for  cervical cancerScreening for  cervical cancer
Screening for cervical cancerAboubakr Elnashar
 
Visual Inspection with AceticAcid of the Cervix Uteri
Visual Inspection with AceticAcid of the Cervix UteriVisual Inspection with AceticAcid of the Cervix Uteri
Visual Inspection with AceticAcid of the Cervix UteriDr Dirk Grothuesmann
 
Visual inspection with Lugol’s iodine
 Visual inspection with Lugol’s iodine Visual inspection with Lugol’s iodine
Visual inspection with Lugol’s iodineAsha Reddy
 
The Accuracy of Diagnostic Colposcopy using IFCPC 2011 Terminology
The Accuracy of Diagnostic Colposcopy using IFCPC 2011 TerminologyThe Accuracy of Diagnostic Colposcopy using IFCPC 2011 Terminology
The Accuracy of Diagnostic Colposcopy using IFCPC 2011 TerminologySujoy Dasgupta
 
An Introduction to Colposcopy Grothuesmann
An Introduction to Colposcopy GrothuesmannAn Introduction to Colposcopy Grothuesmann
An Introduction to Colposcopy GrothuesmannDr Dirk Grothuesmann
 
4 prof james bently management guidelines 2014
4  prof james bently management guidelines 20144  prof james bently management guidelines 2014
4 prof james bently management guidelines 2014Tariq Mohammed
 
Colposcopy case studies2
Colposcopy case studies2Colposcopy case studies2
Colposcopy case studies2Tariq Mohammed
 
Colposcopy
ColposcopyColposcopy
Colposcopydrsubir
 
Cervical Cancer Awareness
Cervical Cancer AwarenessCervical Cancer Awareness
Cervical Cancer Awarenessdharshinee-shri
 
Adenocarcinoma in situ management
Adenocarcinoma in situ managementAdenocarcinoma in situ management
Adenocarcinoma in situ managementAsha Reddy
 
1 prof james bently cervical cancer screening 2014
1  prof james bently cervical cancer screening 20141  prof james bently cervical cancer screening 2014
1 prof james bently cervical cancer screening 2014Tariq Mohammed
 
Nulife module 6 screening for malignancies edited
Nulife module 6 screening for malignancies editedNulife module 6 screening for malignancies edited
Nulife module 6 screening for malignancies editedManinder Ahuja
 

Viewers also liked (20)

Cervical Screening and pre-cancer treatment: what are the options?
Cervical Screening and pre-cancer treatment: what are the options?Cervical Screening and pre-cancer treatment: what are the options?
Cervical Screening and pre-cancer treatment: what are the options?
 
Dr. nisreen cervical cancer screening in park hayat
Dr. nisreen cervical cancer screening in park hayatDr. nisreen cervical cancer screening in park hayat
Dr. nisreen cervical cancer screening in park hayat
 
Loop electrosurgical excision procedure
Loop electrosurgical excision procedureLoop electrosurgical excision procedure
Loop electrosurgical excision procedure
 
Screening c cervix slideshare 2015 (1)
Screening c cervix   slideshare 2015 (1)Screening c cervix   slideshare 2015 (1)
Screening c cervix slideshare 2015 (1)
 
Screening for cervical cancer
Screening for  cervical cancerScreening for  cervical cancer
Screening for cervical cancer
 
Visual Inspection with AceticAcid of the Cervix Uteri
Visual Inspection with AceticAcid of the Cervix UteriVisual Inspection with AceticAcid of the Cervix Uteri
Visual Inspection with AceticAcid of the Cervix Uteri
 
Cervical cancer ppt
Cervical cancer pptCervical cancer ppt
Cervical cancer ppt
 
Visual inspection with Lugol’s iodine
 Visual inspection with Lugol’s iodine Visual inspection with Lugol’s iodine
Visual inspection with Lugol’s iodine
 
Cervical cancer1
Cervical cancer1Cervical cancer1
Cervical cancer1
 
The Accuracy of Diagnostic Colposcopy using IFCPC 2011 Terminology
The Accuracy of Diagnostic Colposcopy using IFCPC 2011 TerminologyThe Accuracy of Diagnostic Colposcopy using IFCPC 2011 Terminology
The Accuracy of Diagnostic Colposcopy using IFCPC 2011 Terminology
 
An Introduction to Colposcopy Grothuesmann
An Introduction to Colposcopy GrothuesmannAn Introduction to Colposcopy Grothuesmann
An Introduction to Colposcopy Grothuesmann
 
4 prof james bently management guidelines 2014
4  prof james bently management guidelines 20144  prof james bently management guidelines 2014
4 prof james bently management guidelines 2014
 
Colposcopy
Colposcopy Colposcopy
Colposcopy
 
Colposcopy case studies2
Colposcopy case studies2Colposcopy case studies2
Colposcopy case studies2
 
Colposcopy
ColposcopyColposcopy
Colposcopy
 
Cervical Cancer Awareness
Cervical Cancer AwarenessCervical Cancer Awareness
Cervical Cancer Awareness
 
colposcopy
colposcopycolposcopy
colposcopy
 
Adenocarcinoma in situ management
Adenocarcinoma in situ managementAdenocarcinoma in situ management
Adenocarcinoma in situ management
 
1 prof james bently cervical cancer screening 2014
1  prof james bently cervical cancer screening 20141  prof james bently cervical cancer screening 2014
1 prof james bently cervical cancer screening 2014
 
Nulife module 6 screening for malignancies edited
Nulife module 6 screening for malignancies editedNulife module 6 screening for malignancies edited
Nulife module 6 screening for malignancies edited
 

Similar to Cervical Cancer Prevention in Poor Resource areas : See & treatapproach dr. sharda jain.ppt corrected

See & treat prog dr. sharda jain
See & treat prog  dr. sharda jainSee & treat prog  dr. sharda jain
See & treat prog dr. sharda jainLifecare Centre
 
Cervical cancer screening guidelines 2013
Cervical cancer screening guidelines 2013Cervical cancer screening guidelines 2013
Cervical cancer screening guidelines 2013Lifecare Centre
 
Dept. of Health cervical cancer fogsi_ screening test npcdcs_dept. of genera...
Dept. of Health  cervical cancer fogsi_ screening test npcdcs_dept. of genera...Dept. of Health  cervical cancer fogsi_ screening test npcdcs_dept. of genera...
Dept. of Health cervical cancer fogsi_ screening test npcdcs_dept. of genera...drdduttaM
 
Cervical cancer screening guidelines 2013 on 7th sept
Cervical cancer screening guidelines 2013 on 7th septCervical cancer screening guidelines 2013 on 7th sept
Cervical cancer screening guidelines 2013 on 7th septLifecare Centre
 
New microsoft office power point presentation
New microsoft office power point presentationNew microsoft office power point presentation
New microsoft office power point presentationMahwish Afzal
 
Screening when where why
Screening when where why Screening when where why
Screening when where why Kawita Bapat
 
1. dr r saha breast cancer screening npcdcs_dept. of community med
1. dr r saha  breast cancer screening npcdcs_dept. of community med1. dr r saha  breast cancer screening npcdcs_dept. of community med
1. dr r saha breast cancer screening npcdcs_dept. of community meddrdduttaM
 
Presentation for public awareness
Presentation for public awareness Presentation for public awareness
Presentation for public awareness drmcbansal
 
ROLE_OF_CERVICAL_CYTOLOGY_IN_SCREENING.pptx
ROLE_OF_CERVICAL_CYTOLOGY_IN_SCREENING.pptxROLE_OF_CERVICAL_CYTOLOGY_IN_SCREENING.pptx
ROLE_OF_CERVICAL_CYTOLOGY_IN_SCREENING.pptxNirupama kothari
 
Cervical cancer by dr alka mukherjee dr apurva mukherjee nagpur m.s.
Cervical cancer by dr alka mukherjee dr apurva mukherjee nagpur m.s.Cervical cancer by dr alka mukherjee dr apurva mukherjee nagpur m.s.
Cervical cancer by dr alka mukherjee dr apurva mukherjee nagpur m.s.alka mukherjee
 
Chapter 2.4 cancer screening
Chapter 2.4 cancer screeningChapter 2.4 cancer screening
Chapter 2.4 cancer screeningNilesh Kucha
 
Gynecologic Cancer Screening
Gynecologic Cancer Screening Gynecologic Cancer Screening
Gynecologic Cancer Screening Niranjan Chavan
 
Ovarian cancer screening
Ovarian cancer screening Ovarian cancer screening
Ovarian cancer screening Niranjan Chavan
 
Organ preservation in kenyan breast cancer patients by peter bird
Organ preservation in kenyan breast cancer patients by peter birdOrgan preservation in kenyan breast cancer patients by peter bird
Organ preservation in kenyan breast cancer patients by peter birdKesho Conference
 
Organ preservation in kenyan breast cancer patients by peter bird
Organ preservation in kenyan breast cancer patients by peter birdOrgan preservation in kenyan breast cancer patients by peter bird
Organ preservation in kenyan breast cancer patients by peter birdKesho Conference
 
Breast cancer
Breast cancerBreast cancer
Breast cancerjas sodhI
 
2013-cervical-cancer-guideline-presentation-en.pptx
2013-cervical-cancer-guideline-presentation-en.pptx2013-cervical-cancer-guideline-presentation-en.pptx
2013-cervical-cancer-guideline-presentation-en.pptxssuser45ba6e
 

Similar to Cervical Cancer Prevention in Poor Resource areas : See & treatapproach dr. sharda jain.ppt corrected (20)

See & treat prog dr. sharda jain
See & treat prog  dr. sharda jainSee & treat prog  dr. sharda jain
See & treat prog dr. sharda jain
 
Cervical cancer screening guidelines 2013
Cervical cancer screening guidelines 2013Cervical cancer screening guidelines 2013
Cervical cancer screening guidelines 2013
 
Dept. of Health cervical cancer fogsi_ screening test npcdcs_dept. of genera...
Dept. of Health  cervical cancer fogsi_ screening test npcdcs_dept. of genera...Dept. of Health  cervical cancer fogsi_ screening test npcdcs_dept. of genera...
Dept. of Health cervical cancer fogsi_ screening test npcdcs_dept. of genera...
 
Cervical cancer screening guidelines 2013 on 7th sept
Cervical cancer screening guidelines 2013 on 7th septCervical cancer screening guidelines 2013 on 7th sept
Cervical cancer screening guidelines 2013 on 7th sept
 
New microsoft office power point presentation
New microsoft office power point presentationNew microsoft office power point presentation
New microsoft office power point presentation
 
Screening when where why
Screening when where why Screening when where why
Screening when where why
 
SS 2017: Prevention of cervical cancer
SS 2017: Prevention of cervical cancerSS 2017: Prevention of cervical cancer
SS 2017: Prevention of cervical cancer
 
1. dr r saha breast cancer screening npcdcs_dept. of community med
1. dr r saha  breast cancer screening npcdcs_dept. of community med1. dr r saha  breast cancer screening npcdcs_dept. of community med
1. dr r saha breast cancer screening npcdcs_dept. of community med
 
Presentation for public awareness
Presentation for public awareness Presentation for public awareness
Presentation for public awareness
 
ROLE_OF_CERVICAL_CYTOLOGY_IN_SCREENING.pptx
ROLE_OF_CERVICAL_CYTOLOGY_IN_SCREENING.pptxROLE_OF_CERVICAL_CYTOLOGY_IN_SCREENING.pptx
ROLE_OF_CERVICAL_CYTOLOGY_IN_SCREENING.pptx
 
Cervical cancer by dr alka mukherjee dr apurva mukherjee nagpur m.s.
Cervical cancer by dr alka mukherjee dr apurva mukherjee nagpur m.s.Cervical cancer by dr alka mukherjee dr apurva mukherjee nagpur m.s.
Cervical cancer by dr alka mukherjee dr apurva mukherjee nagpur m.s.
 
Chapter 2.4 cancer screening
Chapter 2.4 cancer screeningChapter 2.4 cancer screening
Chapter 2.4 cancer screening
 
Gynecologic Cancer Screening
Gynecologic Cancer Screening Gynecologic Cancer Screening
Gynecologic Cancer Screening
 
Ovarian cancer screening
Ovarian cancer screening Ovarian cancer screening
Ovarian cancer screening
 
Organ preservation in kenyan breast cancer patients by peter bird
Organ preservation in kenyan breast cancer patients by peter birdOrgan preservation in kenyan breast cancer patients by peter bird
Organ preservation in kenyan breast cancer patients by peter bird
 
Organ preservation in kenyan breast cancer patients by peter bird
Organ preservation in kenyan breast cancer patients by peter birdOrgan preservation in kenyan breast cancer patients by peter bird
Organ preservation in kenyan breast cancer patients by peter bird
 
Breast cancer
Breast cancerBreast cancer
Breast cancer
 
Ca cervix
Ca cervixCa cervix
Ca cervix
 
Cervical carcinoma
Cervical carcinomaCervical carcinoma
Cervical carcinoma
 
2013-cervical-cancer-guideline-presentation-en.pptx
2013-cervical-cancer-guideline-presentation-en.pptx2013-cervical-cancer-guideline-presentation-en.pptx
2013-cervical-cancer-guideline-presentation-en.pptx
 

More from Lifecare Centre

Liver Dialogue for Gynaecologists : Dr Sharda Jain
Liver Dialogue for Gynaecologists : Dr Sharda JainLiver Dialogue for Gynaecologists : Dr Sharda Jain
Liver Dialogue for Gynaecologists : Dr Sharda JainLifecare Centre
 
National Tuberculosis elimination programme (NIKSHAY) Big Challenge to GOI : ...
National Tuberculosis elimination programme (NIKSHAY)Big Challenge to GOI : ...National Tuberculosis elimination programme (NIKSHAY)Big Challenge to GOI : ...
National Tuberculosis elimination programme (NIKSHAY) Big Challenge to GOI : ...Lifecare Centre
 
Innovations & Breakthrough in IVF PART 3
Innovations & Breakthrough in IVF PART 3Innovations & Breakthrough in IVF PART 3
Innovations & Breakthrough in IVF PART 3Lifecare Centre
 
Strategies for Improving Success Rates in ART PART
Strategies for Improving Success Rates in ART PARTStrategies for Improving Success Rates in ART PART
Strategies for Improving Success Rates in ART PARTLifecare Centre
 
20 Simple ways for the Indian public to save water on World Water Day : Dr Sh...
20 Simple ways for the Indian public to save water on World Water Day : Dr Sh...20 Simple ways for the Indian public to save water on World Water Day : Dr Sh...
20 Simple ways for the Indian public to save water on World Water Day : Dr Sh...Lifecare Centre
 
Vaccination during Pregnancy & its Importance : Dr Sharda Jain
Vaccination during Pregnancy & its Importance : Dr Sharda JainVaccination during Pregnancy & its Importance : Dr Sharda Jain
Vaccination during Pregnancy & its Importance : Dr Sharda JainLifecare Centre
 
How to optimize success rates in ART? : Dr Sharda Jain
How to optimize success rates in ART? : Dr Sharda JainHow to optimize success rates in ART? : Dr Sharda Jain
How to optimize success rates in ART? : Dr Sharda JainLifecare Centre
 
SOCIALEGG FREEZING : Dr Poorva Bhargav and Dr Sharda Jain
SOCIALEGG FREEZING : Dr Poorva Bhargav  and Dr Sharda JainSOCIALEGG FREEZING : Dr Poorva Bhargav  and Dr Sharda Jain
SOCIALEGG FREEZING : Dr Poorva Bhargav and Dr Sharda JainLifecare Centre
 
White Coat Hypertension During Pregnancy : Dr Sharda Jain
White Coat Hypertension During Pregnancy : Dr Sharda JainWhite Coat Hypertension During Pregnancy : Dr Sharda Jain
White Coat Hypertension During Pregnancy : Dr Sharda JainLifecare Centre
 
White Coat hypertension Why it is Important? : Dr Sharda Jain
White Coat hypertension Why it is  Important? : Dr Sharda JainWhite Coat hypertension Why it is  Important? : Dr Sharda Jain
White Coat hypertension Why it is Important? : Dr Sharda JainLifecare Centre
 
Understanding Blood Pressure Reading During Pregnancy : Dr Sharda Jain
Understanding Blood Pressure Reading During Pregnancy : Dr Sharda JainUnderstanding Blood Pressure Reading During Pregnancy : Dr Sharda Jain
Understanding Blood Pressure Reading During Pregnancy : Dr Sharda JainLifecare Centre
 
Know Your Blood Pressure Understanding Blood Pressure Reading : Dr Sharda Jain
Know Your Blood Pressure Understanding Blood Pressure Reading : Dr Sharda JainKnow Your Blood Pressure Understanding Blood Pressure Reading : Dr Sharda Jain
Know Your Blood Pressure Understanding Blood Pressure Reading : Dr Sharda JainLifecare Centre
 
Still Birth:An Update : Dr Sharda Jain
Still Birth:An Update : Dr Sharda JainStill Birth:An Update : Dr Sharda Jain
Still Birth:An Update : Dr Sharda JainLifecare Centre
 
IRON DEFICIENCY ANEMIA OVERVIEW WITH FOCUS ON PARENTRAL IRON THERAPY : Dr ...
IRON DEFICIENCY ANEMIA  OVERVIEW  WITH FOCUS ON PARENTRAL IRON THERAPY  : Dr ...IRON DEFICIENCY ANEMIA  OVERVIEW  WITH FOCUS ON PARENTRAL IRON THERAPY  : Dr ...
IRON DEFICIENCY ANEMIA OVERVIEW WITH FOCUS ON PARENTRAL IRON THERAPY : Dr ...Lifecare Centre
 
Iron Deficiency Anemia in Pregnancy Role of IV Ferric Carboxymaltose and its ...
Iron Deficiency Anemia in PregnancyRole of IV Ferric Carboxymaltose andits ...Iron Deficiency Anemia in PregnancyRole of IV Ferric Carboxymaltose andits ...
Iron Deficiency Anemia in Pregnancy Role of IV Ferric Carboxymaltose and its ...Lifecare Centre
 
CHECK LIST FOR ART SPECIALIST BEFORE IVF-ICSI FOR PATIENTS SEEKING IVF -ICSI ...
CHECK LIST FOR ART SPECIALIST BEFORE IVF-ICSI FOR PATIENTS SEEKING IVF -ICSI ...CHECK LIST FOR ART SPECIALIST BEFORE IVF-ICSI FOR PATIENTS SEEKING IVF -ICSI ...
CHECK LIST FOR ART SPECIALIST BEFORE IVF-ICSI FOR PATIENTS SEEKING IVF -ICSI ...Lifecare Centre
 
CMV UPDATE Few solid facts about cytomegalovirus (CMV) Infection & New devel...
CMV UPDATE Few solid facts  about cytomegalovirus (CMV) Infection & New devel...CMV UPDATE Few solid facts  about cytomegalovirus (CMV) Infection & New devel...
CMV UPDATE Few solid facts about cytomegalovirus (CMV) Infection & New devel...Lifecare Centre
 
Addressing the challenge of lack of Sleep in INDIA
Addressing the challenge of lack of Sleep in INDIA Addressing the challenge of lack of Sleep in INDIA
Addressing the challenge of lack of Sleep in INDIA Lifecare Centre
 
Addressing Professional stress among Doctors is a crucial issue : Dr Sharda J...
Addressing Professional stress among Doctors is a crucial issue : Dr Sharda J...Addressing Professional stress among Doctors is a crucial issue : Dr Sharda J...
Addressing Professional stress among Doctors is a crucial issue : Dr Sharda J...Lifecare Centre
 
Stress Urinary Incontinence (SUI) : Dr Sharda Jain
Stress Urinary Incontinence (SUI) : Dr Sharda Jain Stress Urinary Incontinence (SUI) : Dr Sharda Jain
Stress Urinary Incontinence (SUI) : Dr Sharda Jain Lifecare Centre
 

More from Lifecare Centre (20)

Liver Dialogue for Gynaecologists : Dr Sharda Jain
Liver Dialogue for Gynaecologists : Dr Sharda JainLiver Dialogue for Gynaecologists : Dr Sharda Jain
Liver Dialogue for Gynaecologists : Dr Sharda Jain
 
National Tuberculosis elimination programme (NIKSHAY) Big Challenge to GOI : ...
National Tuberculosis elimination programme (NIKSHAY)Big Challenge to GOI : ...National Tuberculosis elimination programme (NIKSHAY)Big Challenge to GOI : ...
National Tuberculosis elimination programme (NIKSHAY) Big Challenge to GOI : ...
 
Innovations & Breakthrough in IVF PART 3
Innovations & Breakthrough in IVF PART 3Innovations & Breakthrough in IVF PART 3
Innovations & Breakthrough in IVF PART 3
 
Strategies for Improving Success Rates in ART PART
Strategies for Improving Success Rates in ART PARTStrategies for Improving Success Rates in ART PART
Strategies for Improving Success Rates in ART PART
 
20 Simple ways for the Indian public to save water on World Water Day : Dr Sh...
20 Simple ways for the Indian public to save water on World Water Day : Dr Sh...20 Simple ways for the Indian public to save water on World Water Day : Dr Sh...
20 Simple ways for the Indian public to save water on World Water Day : Dr Sh...
 
Vaccination during Pregnancy & its Importance : Dr Sharda Jain
Vaccination during Pregnancy & its Importance : Dr Sharda JainVaccination during Pregnancy & its Importance : Dr Sharda Jain
Vaccination during Pregnancy & its Importance : Dr Sharda Jain
 
How to optimize success rates in ART? : Dr Sharda Jain
How to optimize success rates in ART? : Dr Sharda JainHow to optimize success rates in ART? : Dr Sharda Jain
How to optimize success rates in ART? : Dr Sharda Jain
 
SOCIALEGG FREEZING : Dr Poorva Bhargav and Dr Sharda Jain
SOCIALEGG FREEZING : Dr Poorva Bhargav  and Dr Sharda JainSOCIALEGG FREEZING : Dr Poorva Bhargav  and Dr Sharda Jain
SOCIALEGG FREEZING : Dr Poorva Bhargav and Dr Sharda Jain
 
White Coat Hypertension During Pregnancy : Dr Sharda Jain
White Coat Hypertension During Pregnancy : Dr Sharda JainWhite Coat Hypertension During Pregnancy : Dr Sharda Jain
White Coat Hypertension During Pregnancy : Dr Sharda Jain
 
White Coat hypertension Why it is Important? : Dr Sharda Jain
White Coat hypertension Why it is  Important? : Dr Sharda JainWhite Coat hypertension Why it is  Important? : Dr Sharda Jain
White Coat hypertension Why it is Important? : Dr Sharda Jain
 
Understanding Blood Pressure Reading During Pregnancy : Dr Sharda Jain
Understanding Blood Pressure Reading During Pregnancy : Dr Sharda JainUnderstanding Blood Pressure Reading During Pregnancy : Dr Sharda Jain
Understanding Blood Pressure Reading During Pregnancy : Dr Sharda Jain
 
Know Your Blood Pressure Understanding Blood Pressure Reading : Dr Sharda Jain
Know Your Blood Pressure Understanding Blood Pressure Reading : Dr Sharda JainKnow Your Blood Pressure Understanding Blood Pressure Reading : Dr Sharda Jain
Know Your Blood Pressure Understanding Blood Pressure Reading : Dr Sharda Jain
 
Still Birth:An Update : Dr Sharda Jain
Still Birth:An Update : Dr Sharda JainStill Birth:An Update : Dr Sharda Jain
Still Birth:An Update : Dr Sharda Jain
 
IRON DEFICIENCY ANEMIA OVERVIEW WITH FOCUS ON PARENTRAL IRON THERAPY : Dr ...
IRON DEFICIENCY ANEMIA  OVERVIEW  WITH FOCUS ON PARENTRAL IRON THERAPY  : Dr ...IRON DEFICIENCY ANEMIA  OVERVIEW  WITH FOCUS ON PARENTRAL IRON THERAPY  : Dr ...
IRON DEFICIENCY ANEMIA OVERVIEW WITH FOCUS ON PARENTRAL IRON THERAPY : Dr ...
 
Iron Deficiency Anemia in Pregnancy Role of IV Ferric Carboxymaltose and its ...
Iron Deficiency Anemia in PregnancyRole of IV Ferric Carboxymaltose andits ...Iron Deficiency Anemia in PregnancyRole of IV Ferric Carboxymaltose andits ...
Iron Deficiency Anemia in Pregnancy Role of IV Ferric Carboxymaltose and its ...
 
CHECK LIST FOR ART SPECIALIST BEFORE IVF-ICSI FOR PATIENTS SEEKING IVF -ICSI ...
CHECK LIST FOR ART SPECIALIST BEFORE IVF-ICSI FOR PATIENTS SEEKING IVF -ICSI ...CHECK LIST FOR ART SPECIALIST BEFORE IVF-ICSI FOR PATIENTS SEEKING IVF -ICSI ...
CHECK LIST FOR ART SPECIALIST BEFORE IVF-ICSI FOR PATIENTS SEEKING IVF -ICSI ...
 
CMV UPDATE Few solid facts about cytomegalovirus (CMV) Infection & New devel...
CMV UPDATE Few solid facts  about cytomegalovirus (CMV) Infection & New devel...CMV UPDATE Few solid facts  about cytomegalovirus (CMV) Infection & New devel...
CMV UPDATE Few solid facts about cytomegalovirus (CMV) Infection & New devel...
 
Addressing the challenge of lack of Sleep in INDIA
Addressing the challenge of lack of Sleep in INDIA Addressing the challenge of lack of Sleep in INDIA
Addressing the challenge of lack of Sleep in INDIA
 
Addressing Professional stress among Doctors is a crucial issue : Dr Sharda J...
Addressing Professional stress among Doctors is a crucial issue : Dr Sharda J...Addressing Professional stress among Doctors is a crucial issue : Dr Sharda J...
Addressing Professional stress among Doctors is a crucial issue : Dr Sharda J...
 
Stress Urinary Incontinence (SUI) : Dr Sharda Jain
Stress Urinary Incontinence (SUI) : Dr Sharda Jain Stress Urinary Incontinence (SUI) : Dr Sharda Jain
Stress Urinary Incontinence (SUI) : Dr Sharda Jain
 

Cervical Cancer Prevention in Poor Resource areas : See & treatapproach dr. sharda jain.ppt corrected

  • 1. Cervical Cancer Prevention in Poor Resource Area : See & Treat Approach Dr. Sharda Jain Director :- Dr. Aruna Saxrna, MD
  • 2. • Epidemiology • Indian scenario • Concept of See & Treat (screening & treatment) • Methods of (VIA & VILLI) screening • Cryo Cautry • Colposcopy / Biopsy Guidelines Schema
  • 3. Age-standardised incidence and mortality rates: Indian women India : Number One New – 1.32 lakh Deaths - o.74 lakh GLOBOCAN 2008
  • 4. Human Suffering Due To Cervical Cancer in India Is depressing•women who die due to Cervical Cancer in the world is an Indian 1 out of 4
  • 5. Every 7Minutes, 1 Indian woman dies of Cervical Cancer Disease Burden Infact India is a Capital for Cervical Cancer
  • 6. High Economic Burden Due to the high number of cervical cancer cases in the population, it has the highest total cost of secondary care (100,000 INR per 100,000 population) relative to all other cancers. “Report of the National Commission on Macroeconomics and Health”, NCMH, Ministry of H &FW, Government of India, August 2005.
  • 7. Screening- Why? • In many developed countries, a significant decline in the incidence of and mortality caused by cervical cancer has been observed in the past 30 years as a result of screening by cytology. • Cervical cancer has precursor, low and high grade intraepithelial lesion, which has effective treatments available. • Screening also gives an opportunity for educating women who are constantly at high risk.
  • 8. System Failures Leading to Cervical Cancer Diagnosis Women do not come in for screening Health care providers do not screen women at visits Colposcopy for abnormal screen not done Patient does not get appropriate therapy Patient gets cervical cancer Courtesy of Connie Trimble, MD, Johns Hopkins University School of Medicine, Baltimore, MD
  • 9. Cancer Cervix – a Global Paradox • Cancer cervix –100% Preventable disease WHO • Cancer cervix –Death by incompetence Lancet • Cancer cervix – the unmet challange
  • 12. Natural History of Cervical Cancer HPV infection CIN 1 CIN 2,3 HPV disappearance Invasive CA Avg. 10-13 yrs Avg. 6- 24 mo Avg. 6- 12 mo.
  • 13. AGE SCREENING < 21 No Screening 21-29 Cytology alone every 3 years 30-65 Acceptable: Cytology alone every 3 years* Preferred ??: Cytology + HPV every 5 years* OR > 65 No screening, following 3 consequetive neg prior screens in last decade After total hysterectomy No screening, if no history of CIN2+ in the past 20 years of cervical cancer ever HIV-positive -Immunosuppressed (e.g., Annually 2013 Guidelines for prevention of Cervical cancer • 1st time that all 3 organizations involved with cervical cancer prevention and the USPSTF have endorsed equivalent guidelines
  • 14. Type of screening • Conventional cytology • Liquid-based monolayer cytology • Human papillomavirus testing • Testing in resource-poor areas
  • 16. • Pap smears require skilled practitioners and good laboratories to be effective, • Most studies have found that VIA, and its cousin VILI -- visual inspection with Lugol's iodine -- are somewhat less specific than Pap smears, but more sensitive
  • 17. Overall, VIA seems to be an excellent cervical cancer screening method for use in low-resource settings where Pap smears and HPV tests are inappropriate due to either lack of expertise or high per-test cost.
  • 18. The general consensus is that VIA is just as useful as the Pap smear; it's just a matter of determining which one is more appropriate in any given circumstance based on availability of funds & trained personnel for screening and follow up
  • 19. VIA generally detects more early lesions but is associated with more false positives. This could conceivably lead to over treatment, but in low-resource areas where large numbers of women are still dying of cervical cancer, some governments have decided it is a worthwhile trade-off. (African Countries)
  • 20. in India ICPO( institute of cytology and preventive oncology) took initiative in developing simple strategies like VIA in1980’s ,which subsequently supported by other international agencies like IARC,LYON,FRANCE,JHPIEGO,a nd PATH in USA etc.
  • 21. India Screening – not even tip of iceberg
  • 22. GOI – has O MONEY for universal vaccination
  • 23. Screening women at rural & slums settings and following them is tedious task for Gynaecologists But Motivating them once,examining and treating them simultaneously if any abnormality noted, can be easier task to prevent cervical cancer! Logic Behind See & Treat Approach
  • 24. What is basics behind VIA
  • 25. Accesibility of CERVIX…….. • seen instantly after putting speculum inside the vagina and becomes apparent. • The success of VIA lies in visualising the cervix in the region of transformation zone in its entirely.
  • 26. TZ lies between the original squamo-columner junction and the new (or the present ) squamo-columner junction. This is a highly active zone of metaplastic tissues in which the single layered columnar epithelium is transformed by metaplastic cellular divisions into multilayered squamous epithelium.
  • 27. metaplasia and what triggers it • Exposure of columnar epithelium during ectropion to acidic environment of vagina leads to metaplasia.(healing process of damaged columnar epithelium) • Region that has undergone metaplasia is transformation zone, bound distally by SCJ E and proximally by SCJ M, is region of mitosis as cells are rapidly dividing during metaplasia. The mitotic rate is higher near SCJ M That's why it appears white with acetic acid
  • 28. E
  • 29. Understanding of “Transformation Zone” squamous epitheliumsquamous epithelium ectocervixectocervix endocervixendocervix SCJSCJ
  • 33. VIA • Naked eye visual inspection of cervix, after application of 3-5% acetic acid to detect pre cancer lesions is VIA VIAC • Magnifying cervix with an ordinary lens is VIAC i.e visual inspection with acetic acid aided by cervicography
  • 34. VIAM • Technique: is same as that of VIA but viewning of cervix is done with magnifying glasses of 4 mm • Studies from South Africa and Kolkatta, India have reported no benefit of VIAM over VIA • Study from TMH also concluded same.
  • 35. All of us can do it and also can train our staff to screen large number of women with very little cost VIA
  • 38.
  • 39. STEPS FOR PERFORMING VIA • Normal Inspection after cleaning with normal saline • Inspection after application of acetic acid • Inspection after application of lugols Iodine • Examination of Vagina
  • 40. NORMAL INSPECTION AFTER CLEANING WITH NORMAL SALINE….
  • 41. ACETIC ACID TEST • Coagulation of cell protein seen an interval of 1 mint. • If white layer is very thick (opaque) that area becomes area of concern. • The impact of acetic acid fades away normally in 1-3 mints, So repeated application is recommended for proper visualization of pathological lesions.
  • 42. Aceto white lesion • Intensity • Duration of stay • speed of Appearance • speed of disappearance • margins Relation to SCJ Inside TZ/ outside TZ
  • 43. Grading of VIA Findings…. • Grade I: Flat acetowhite epithelium, snow white, regular pattern • Grade II: Flat but whiter acetowhite epithelium, gray white, • Grade-III dull oyster white,
  • 44. Pre cancer lesions of cervix on VIA Appearance white translucent ivory white egg white with thick areas remains for longer time Margins sharp and distinct internal margins Surface contour Flat or raised Abnormal vascular patterns punctations Wide inter capillary distance Extent Confined to TZ Disappearing into cervical canal % of TZ involved Satellite lesion
  • 45. VIA and cervical cancer screening • 4% acetic acid is applied to cervix with the help of a cotton pad after removing excess mucus. • VIA recording 1 minute after application of acid. • Positive result: acetowhite areas in the squamocolumnar junction, or entire cervix or a growth over cervix • WHITE PATCHES” appears due to coagulation of cellular proteins and indicate the abnormal epithelium.
  • 46. VIA and cervical cancer • What does positive VIA mean: • Infection • Dysplasia • Intraepithelial lesion • Cancer • So, final conclusion is done by colposcopy and biopsy which is the gold standard.
  • 47. Effect of visual inspection with acetic acid (VIA) screening by primary health workers on cervical cancer mortality: A cluster randomized controlled trial in Mumbai, India. 2013 ASCO Annual Meeting Surendra Srinivas Shastri, Indraneel Mittra, Gauravi Mishra, Subhadra Gupta, Rajesh Dikshit, Rajendra A. Badwe; Tata Memorial Centre, Mumbai, India Plenary Session, Plenary Session Including FDA Commissioner Address, Public Service Award, and Science of Oncology Award and Lecture
  • 48. • Cluster-randomized controlled trial in 1998 to investigate the efficacy of VIA screening by primary health workers (PHWs) in reducing cervical cancer mortality. • Women aged 35-64 years with no prior history of cancer were included • 20 clusters with an average of 7,500 eligible women per cluster. • Four rounds of cancer education and VIA screening were conducted by PHWs in the screening group, while cancer education was offered once at recruitment to the control group • Recruitment was completed in March 31, 2002. Analysed the results at 12 years • Recruited 75,360 women from 10 clusters in the screening group and 76,178 women from 10 comparable clusters in the control group
  • 49. Results • The analysis is on an intention-to-treat basis. • In the screening group, achieved 89% participation for screening and 79% compliance for post-screening diagnostic confirmation. • The quality of screening by PHWs was comparable to that of an expert gynecologist (κ=0.84). • The incidence of invasive cervical cancer was 26.74 per 100,000 in the screening group and 27.49 per 100,000 in the control group. • • The screening group showed a 31% reduction in cervical cancer mortality (p=0.003) compared to the control group. • A 7% reduction was also observed in all-cause mortality .
  • 50. Conclusions • VIA screening conducted by PHWs significantly reduced cervical cancer mortality. • VIA screening is easily implementable and could prevent 22,000 cervical cancer deaths in India.
  • 51. VILI • Technique is same as that of VIA but instead of acetic acid, lugol’s iodine is applied to cervix and end result is change in color to yellow over positive areas. • Sankaranarayanan et al did a multicenter study in South Africa and India on VILI and screening of cervical cancer. • Sensitivity of VILI turned out to be 86.7-90%. • Authors gave the reason of such high sensitivity of VILI: the yellow color changes associated with a positive VILI test result are more easily recognized by the health workers compared with the acetowhite changes associated with VIA. Best Pract Res Clin Obstet Gynaecol. 2012
  • 53. Making Gynaecologists aware of common cervical lesions
  • 54. Treatment of pre cancer lesions of cervix • Cryo therapy • Leep • biopsy
  • 56. Cryotherapy • Cryotherapy destroys abnormal tissue on the cervix by freezing it by cold coagulation using ice cold gas . • gases can destroy cells upto 3 mm by co2 and 5 mm by nitrous oxide.
  • 57. advantages • Safe • One visit treatment • OPD procedure • No anaesthesia • No adverse effects on reproduction
  • 58. LEEP • Large loop electrical procedure Criteria for LEEP AWL covering > 75% of TZ Lesion with abnormal blood vessels Persistent lesion after cryo Disparity between cytology, VIAC and histology Limits of lesion not visible.
  • 59. To conclude •Cervical cancer is a preventable cancer . •We as gynecologists can do a lot to make an impact to decrease this disease burden. •See and treat can be a successful mantra in our country if all gynecologists come forward to give their due contribution to this country where they have been trained. Now this is our turn to give back

Editor's Notes

  1. He first reported that uterine cancer could be diagnosed by means of a vaginal smear in 1928, but the importance of his work was not recognized until the publication, together with Herbert Traut, of  Diagnosis of Uterine Cancer by the Vaginal Smear  in 1943. The book discusses the preparation of vaginal and cervical smears, physiologic cytologic changes during the  menstrual cycle , the effects of various pathological conditions, and the changes seen in the presence of  cancer  of the  cervix  and of the  endometrium  of the  uterus . He thus became known for his invention of the Papanicolaou test, commonly known as the  Pap smear  or  Pap test , which is used worldwide for the detection and prevention of cervical cancer and other cytologic diseases of the female reproductive system. In 1961 he moved to Miami, Florida, to develop the Papanicolaou Cancer Research Institute at the University of Miami, but died in 1962 prior to its opening. Papanicolaou was the recipient of the Albert Lasker Award for Clinical Medical Research in 1950. [3] Papanikolaou&apos;s portrait appeared on the obverse of the Greek 10,000-drachma banknote of 1995-2001, [4]  prior to its replacement by the Euro. In 1978 his work was honored by the U.S. Postal Service with a 13-cent stamp for early cancer detection.