Screening for Female Genital Tract Malignancy


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Screening for Female Genital Tract Malignancy

  1. 1. Screening for Female Genital Tract Malignancy BY Prof.Mohammad Ahmed Emam M.D OB & GYN Director of Early Cancer Detection Unit OB & GYN Dept. Mansoura Faculty of Medicine
  2. 2. Screening Generally <ul><li>Is to seek about certain problem in certain high risk gp. </li></ul>
  3. 3. Validity of Screening Test <ul><li>Validity of test determined by ability to correctly categorise subjects to test-positive or test-negative </li></ul>
  4. 4. Validity of Screening Test cont... <ul><li>Sensitivity = ability of test to give a positive result when disease is present </li></ul><ul><li>= a / a+c </li></ul><ul><li>Specificity = ability of test to give a negative result when disease is absent </li></ul><ul><li>= d / b+d </li></ul>
  5. 5. <ul><li>Predictive value is determined by sensitivity & specificity and also by the prevalence of preclinical diseas </li></ul><ul><li>Positive predictive value </li></ul><ul><li>= probability that a person with a positive test actually has the disease = a / a+b </li></ul><ul><li>Negative predictive value </li></ul><ul><li>= probability that a person with a negative test is truly disease-free = d / c+d </li></ul>Validity of Screening Test cont...
  6. 6. When to Suspect Gynecologic Cancer <ul><li>Woman with: </li></ul><ul><li>Ovarian mass/cyst </li></ul><ul><li>Growth or ulcer of cervix, vagina or vulva </li></ul><ul><li>Abdominal mass, increased abdominal girth </li></ul><ul><li>Postcoital bleeding </li></ul><ul><li>New onset of hematuria or renal failure </li></ul><ul><li>New onset of bowel obstruction </li></ul>
  7. 7. When to Suspect Gynecologic Cancer cont…. <ul><li>Premenopausal woman with: </li></ul><ul><ul><li>Irregular menses </li></ul></ul><ul><li>Women older than 35 or with long history of irregular menses </li></ul><ul><li>Postmenopausal woman with: </li></ul><ul><ul><li>Vaginal bleeding </li></ul></ul><ul><ul><li>Abnormal vaginal discharge </li></ul></ul>
  8. 8. Concept <ul><li>Prevention is better than cure. </li></ul><ul><li>Cancer cx. Screening programs are in adulthood </li></ul><ul><li>But ov. cancer programs are still in relative infancy , why? </li></ul>
  9. 9. Phases of Tumourgenesis <ul><li>Dysplasia </li></ul>Invasive asymptomatic Invasive symptomati Cancer cx. End. C. As cancer ovary Normal cells
  10. 10. Most Cancers Develop In The Unscreened And The Underscreened.
  11. 11. CRITERIA FOR SCREENING <ul><li>Disease: </li></ul><ul><li>Must be serious enough </li></ul><ul><li>Must be widespread enough </li></ul><ul><li>Must be fairly reliably diagnosable </li></ul><ul><li>Must be treatable </li></ul><ul><li>Must be affordable </li></ul><ul><li>Hopefully legally defensible </li></ul>
  12. 12. Criteria for Screening Test <ul><li>1 . Simple & quick </li></ul><ul><li>2. Capable of being performed by paramedics </li></ul><ul><li>3 . Inexpensive </li></ul><ul><li>4 . Acceptable to population </li></ul><ul><li>5. Accurate </li></ul><ul><li>6. Repeatable </li></ul><ul><li>7. Sensitive </li></ul><ul><li>8. Specific </li></ul>
  13. 13. Incidence of Gynecologic Cancers in Egyptian Women with cancer 0 5 10 15 20 25 Breast Cancer Cervical Cancer Ovarian Cancer Uterine Cancer Percent Source: GLOBOCAN 2000.
  14. 14. Epidemiology of Cervical Cancer <ul><li>500,000 new cases identified each year </li></ul><ul><li>80% of the new cases occur in developing countries </li></ul><ul><li>At least 200,000 women die of cervical cancer each year </li></ul><ul><li>Cervical cancer is the third most common cancer worldwide </li></ul>Magnitude of the Problem : -
  15. 15. Epidemiology of Cervical Cancer cont…. <ul><li>Most common female cancer in developing countries: </li></ul><ul><ul><li>leading cause of cancer death in women. </li></ul></ul><ul><ul><li>80-85% cases seen at late incurable stages. </li></ul></ul>
  16. 16. Epidemiology of Cervical Cancer cont…. <ul><li>High risk patients: </li></ul>1)Exo cx: <ul><li>High parity?!! </li></ul><ul><li>Multiple partner </li></ul><ul><li>Genital infections </li></ul><ul><li>HPV & HSV II </li></ul><ul><li>Smoking </li></ul><ul><li>Sexual behaviour of women’s partner </li></ul>
  17. 17. 2. Endo cx Like endometrial C. <ul><li>Age </li></ul><ul><li>Obesity </li></ul><ul><li>D.M. </li></ul><ul><li>Hypertension </li></ul><ul><li>Nulligravida & Virgin </li></ul><ul><li>Low parity </li></ul><ul><li>Tamoxifen </li></ul>Epidemiology of Cervical Cancer cont….
  18. 18. Pathogenesis of CIN <ul><li>Columner epith. </li></ul>St.sq. epith. CIN <ul><li>Dysplasia by oncogen </li></ul>Chlamydia – H.S.V. - H.P.V- TV. Histones & protamines Metaplasia Dysplasia Micro-organism. Sperm Ptn.
  19. 19. Morphological Changes of Cervical Cancer
  20. 20. Prevention of Cervical Cancer <ul><li>Cervical cancer is a preventable disease </li></ul><ul><li>Primary prevention: </li></ul><ul><ul><li>Education to reduce high risk sexual behaviour </li></ul></ul><ul><ul><li>Measures to reduce/avoid exposure to HPV and other STIs </li></ul></ul><ul><li>Secondary prevention: </li></ul><ul><ul><li>Treatment of precancerous lesions before they progress to cervical cancer (implies practical screening test) </li></ul></ul><ul><ul><li>Now : HPV vaccines. </li></ul></ul>
  21. 21. Secondary Prevention of Ca.Cx. <ul><li>Key Point is to detect precancerous lesions – BY </li></ul><ul><li>A good screening method </li></ul><ul><li>PAP smear test is considered to be the gold standard – Has limitations ? </li></ul><ul><ul><li>Alternatives to Pap Smear – What are they? </li></ul></ul>
  22. 22. Why screening for cervical cancer? <ul><li>1. Is relatively common in unscreened women . </li></ul><ul><li>2. Has a relatively good prognosis if found early stage in its natural course of disease. </li></ul><ul><li>3.Has a characteristic natural course that is a slow progression through a premalignant stage. </li></ul>
  23. 23. Why screening for cervical cancer? Cont… <ul><li>4. A premalignant stage can be detected by noninvasive means (the Pap smear , cervicography& VIA ). </li></ul><ul><li>5. There are effective treatment modalities to eradicate premalignant lesions and early invasive cervical cancer. </li></ul>
  24. 24. Screening by Pap. Cx. Smear unscreened female have ten fold risk > screened female - Every sexually active female (18-35 y) - Specially, high risk group. - Annually up to the age of 35y - No need to extend screening > 35y if smear is N. - At each pregnancy - If new risk factors appear after 35y. d- If + ve smear colposcopy c. When: b. To whom : a. Importance:
  25. 25. Alternatives to Cytology <ul><li>Visual Inspection of the cervix: </li></ul><ul><ul><li>Unaided: Downstaging . </li></ul></ul><ul><ul><li>Aided with acetic acid: VIA: </li></ul></ul><ul><ul><ul><li>Naked eye </li></ul></ul></ul><ul><ul><ul><li>Aided with acetic a and magnification( VIAM) </li></ul></ul></ul><ul><ul><ul><ul><li>Cervicography </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Colposcopy </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Speculoscopy </li></ul></ul></ul></ul><ul><li>Automated pap smear </li></ul><ul><li>HPV DNA test </li></ul><ul><li>Infrared Spectroscopy & Laser Fluorescence </li></ul>
  26. 26. Limitations of Pap Smear <ul><li>Complex laboratory test </li></ul><ul><li>Requires trained cytotechnician for reading and pathologist for review </li></ul><ul><li>Continuous monitoring needed to maintain high-quality results </li></ul><ul><li>Reports often take minimum 1-2 weeks to obtain </li></ul><ul><li>Follow-up of women is difficult </li></ul><ul><li>Usually available only in large cities in many countries </li></ul>
  27. 27. COMPARISON BETWEEN SCREENING METHODS Source-Program for Appropriate Technology in Health [PATH] 1997.
  28. 28. “ VIA ..represents a proven, simple means of identifying cervical intraepithelial neoplasia in developing countries .” <ul><li>Commentary: P. Blumenthal. Detection of cervical intraepithelial neoplasia in developing countries. The Lancet March 13, 1999 </li></ul>
  29. 29. Comparison between : VIA and Cytology <ul><li>Sensitivity(%) Specificity (%) </li></ul><ul><li>Cytology 47--62 60-95 </li></ul><ul><li>VIA 76-84 79-83 </li></ul>
  30. 30. VIA& PAP SMEAR <ul><li>Recent studies have demonstrated that &quot;VIA is a safe, simple and effective adjunct to the Papanicolaou smear for cervical cancer screening ” an d can be helpful in reducing referrals for colposcopy without compromising quality of care . </li></ul>
  31. 31. MEANING OF Acetowhite <ul><li>All acetowhite patches are not cancer: </li></ul><ul><li>Any of these epithelial changes can become acetowhite: </li></ul><ul><ul><li>Healing or regenerating epithelium </li></ul></ul><ul><ul><li>Congenital transformation zone </li></ul></ul><ul><ul><li>Inflammation </li></ul></ul><ul><ul><li>Immature squamous metaplasia </li></ul></ul>
  32. 32. MEANING OF Acetowhite cont…. <ul><ul><li>HPV infection </li></ul></ul><ul><ul><li>CIN / CGIN </li></ul></ul><ul><ul><li>Adenocarcinoma </li></ul></ul><ul><ul><li>Invasive squamous cell carcinoma </li></ul></ul>
  33. 33. Endometrial Cancer Screening <ul><li>Screening of unproven benefit </li></ul><ul><li>Transvaginal ultrasound examinations </li></ul><ul><ul><li>Helpful in evaluating vaginal bleeding </li></ul></ul><ul><li>Endometrial sampling </li></ul><ul><ul><li>Risks include discomfort, bleeding, infection, uterine perforation (rare) </li></ul></ul>
  34. 34. PRE-INVASIVE LESIONS OF END. 23% over 10y Atypisim + back to back + budding Atypical hyperplasia 3-4% over 13y Back to back glands, budding, papillary process, minor stratification Complex hyperplasia 1-3% over 15y Irregular glands, minor budding or out pouching Simle hyperplasia Little or none Replacement of usual gland cell by cells having cilia, sq. cells Metaplasia Malig. Potential Pathology
  35. 35. Early Cancer Detection of ENDO. <ul><li>Fractional curettage </li></ul><ul><li>Isaac Aspiration curette </li></ul><ul><li>Aspiration cannula (cytology) </li></ul><ul><li>Manual Vacum aspirator(MVA). </li></ul>
  36. 36. Ovarian Cancer Screening <ul><li>Benefit to screening is unproven </li></ul><ul><li>Annual bimanual gynecologic examination </li></ul><ul><li>Transvaginal ultrasound </li></ul><ul><li>CA 125 serum levels </li></ul><ul><li>Screening may result in more unnecessary surgeries than new ovarian cancers </li></ul>
  37. 37. Screening For Early Diagnosis Ovarian Malignancy <ul><li>Modalities: </li></ul><ul><li>1-  Clinical. </li></ul><ul><li>2-  Cul-de-sac aspiration. </li></ul><ul><li>3-  Imaging techniques. </li></ul><ul><li>4-  Tumour markers. </li></ul><ul><li>5-   Radio immuno scientography. </li></ul><ul><li>6-  Multimodels. </li></ul>
  38. 38. PRE-INVASIVE LESIONS OF VULVA <ul><li>Risk factor: </li></ul><ul><li>Postmenopausal + </li></ul><ul><ul><li>Vulva dystrophy   VIN </li></ul></ul><ul><ul><li>Vulval infectious disease. </li></ul></ul><ul><ul><li>Chronic granulomatous. </li></ul></ul><ul><li>VIN: I, II & III </li></ul><ul><li>Paget`s: may be associated with paget`s of breast. </li></ul>Dermatoses Leukoplekia Krausons vulva Lichen simplex
  39. 39. Early Cancer Detection of Vulva <ul><li>Colposcopy Taulidine blue VIN Biopsy Acetic Acid </li></ul>
  40. 40. Breast <ul><li>Population - women, age 20 + Breast self-examination Monthly, starting at age 20 Clinical breast examination Every three years, age 20-39 Annual, starting at age 40 * Mammography Annually, starting at age 40 * Beginning at age 40, annual clinical breast examination should be performed prior to mammography. Most other affluent countries recommend mammography every other year between ages 50 and 70. </li></ul>
  41. 41. OB& GYN, Mansoura Faculty of Medicine Mansoura Integrated Fertility Center (MIFC) EGYPT Telfax 0020502319922 & 0020502312299 Email. Prof. MOHAMMAD EMAM Thank you