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See & treat prog dr. sharda jain


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See & treat prog dr. sharda jain

  1. 1. See & Treat Approach to Decrease Cervical Cancer in India Dr. Sharda Jain Director :- Sec General : Delhi Gynae Forum
  2. 2. • Epidemiology • Indian scenario • Concept of See & Treat (screening & treatment) • Methods of (VIA & VILLI) screening • Cryo Cautry • Colposcopy / Biopsy Guidelines Schema
  3. 3. Age-standardised incidence and mortality rates: Indian women India : Number One New – 1.32 lakh Deaths - o.74 lakh GLOBOCAN 2008
  4. 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. 5. Every 7Minutes, 1 Indian woman dies of Cervical Cancer Disease Burden Infact India is a Capital for Cervical Cancer
  6. 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. 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. 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. 9. Cancer Cervix – a Global Paradox • Cancer cervix –100% Preventable disease WHO • Cancer cervix –Death by incompetence Lancet • Cancer cervix – the unmet challange
  10. 10. Disease Progression
  11. 11. Disease Regression
  12. 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. 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. 14. Type of screening • Conventional cytology • Liquid-based monolayer cytology • Human papillomavirus testing • Testing in resource-poor areas
  15. 15. Testing in Resource-Poor areas
  16. 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. 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. 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. 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. 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. 21. India Screening – not even tip of iceberg
  22. 22. GOI – has O MONEY for universal vaccination
  23. 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. 24. What is basics behind VIA
  25. 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. 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. 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. 28. E
  29. 29. Understanding of “Transformation Zone” squamous epitheliumsquamous epithelium ectocervixectocervix endocervixendocervix SCJSCJ
  30. 30. GLAND OPENINGS in TZ
  32. 32. SCJ in various ages
  33. 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. 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. 35. All of us can do it and also can train our staff to screen large number of women with very little cost VIA
  37. 37. PATIENT POSITION Lithotomy Position Consent Time
  38. 38. 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. 40. 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.
  41. 41. Aceto white lesion • Intensity • Duration of stay • speed of Appearance • speed of disappearance • margins Relation to SCJ Inside TZ/ outside TZ
  42. 42. 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,
  43. 43. 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
  44. 44. 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.
  45. 45. 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.
  46. 46. 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
  47. 47. • 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
  48. 48. 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 .
  49. 49. 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.
  50. 50. 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
  51. 51. Mustard yellow
  52. 52. Making Gynaecologists aware of common cervical lesions
  53. 53. Treatment of pre cancer lesions of cervix • Cryo therapy • Leep • biopsy
  54. 54. Cryo therapy
  55. 55. 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.
  56. 56. advantages • Safe • One visit treatment • OPD procedure • No anaesthesia • No adverse effects on reproduction
  57. 57. 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.
  58. 58. 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