cancer awareness program

1. CERVICAL CANCER SCREENING
PROCEDURE
Dr. Anjalatchi Muthukumaran
Vice principal
Professor cum vice principal
Era college of nursing
Era university

2. Content
 Cervical Cancer Screening
Enumerate the methods to prevent
Cancer Cervix
 VILII
 VIA
 Pap smear
 & Colposcopy

3. Introduction
 Cervical cancer second most common cancer in women
in India & other developing countries
 Most common cause of cancer death in women –India
 Prevention of cervical cancer is possible by screening
 It is a public health problem
 Primary etiological factor - Human Papilloma virus(HPV)
 Preinvasive cancer cervix---- Invasive cancer
 Prevention of Invasive cancer is by screening, diagnosis
& treatment of preinvasive diseases and by vaccination
against HPV

4. Definition
 Cervical intraepithelial neoplasia (CIN)is the
premalignant condition involving the uterine cervix.
 The cellular abnormalities are limited to surface
epithelium & do not extend beyond basement
membrane

5. Prevalence
 Infection by highrisk HPV occurs in 36%
women
 Prevalence is high in younger women
 The incidence decreases with age
 Prevalence of CIN I - 3%, regress 1%
progress to Invasive cancer
 CIN II &CIN III is 0.6 &0.4 % respectively
Caused due to persistent HPV infection

6. Terminology
 Previously
 Dysplasia – Mild, Moderate & Severe
 CIN I- Mild dysplasia
 CIN II- Moderate Dysplasia
 CIN III- Severe Dysplasia

7. Bethesda System
 CIN I – LSIL
 CIN II & III –HSIL
 Immunostaining of P16 is diagnostic for CIN
II
 CIN P16 negative – CIN I
 CIN P16positive CIN III

8. ACP & ASCCP
 New terminology by ACP & ASCCP
 CIN I
 CIN II P16 negative LSIL
 CIN II P16 positive
 CIN P16 positive - HSIL

9. Etiopathogenesis –Transformation
zone
 Most cervical malignancies occur at transformation
zone(TZ )
 Squamocolumnar junction (SCJ)
 Dynamic area –metaplastic activity – oncogenic
activity

10. HPV
 Low risk- genital warts-6 & 11
 40,42,43,44,54,61,72 &81
 High risk-60% of CIN2&CIN3- 16 & 18;
cervical cancer 50%- HPV 16;
 HPV 18 20% -
31,33,35,45,52,56,58,59,68,69,82– rest
19%
 Ca Cervix

11. Prevention of intraepithelial
neoplasia (IENP)& Cervical cancer
 Awareness
 Safe sex
 Use of barrier method to prevent STD
 Lifestyle modification
 HPV Vaccine
 WHO 2020-Triple intervention
 Vaccination by age of 15 – 90%
 70%of women screened at least twice in the lifetime
 Appropriate management of 90% of women foe prwcancerous
/cancerous lesion

12. Secondary Prevention
 Prevention of progression of Intraepithelial lesions
to invasive cancers
 Diagnosis, appropriate ,management of
precancerous lesion & follow up

13. Screening for Intraepithelial /
invasive cervical cancer
 Screening asymptomatic women
 Easy to do as cervix can be easily
visualized, long course 10-20 years
precancerous lesion –cancer cervix

14. Cervical Cytology
 The exfoliated cervical cells can be collected by scaping –
staining the smear
 The cells –abnormality seen –premalignant lesions/ malignant
lesions
 Papanicolaou stain – Pap test
 Cervical cancer screening by Pap smear – decrease the
incidence of cervical cancer by 60-70%

15. Methods used for cervical cancer
Screening
 Universal Screening methods
 Cytology
◦ Conventional
◦ LBC
◦ Manual interpretation
◦ Automated screening
HPV testing
Methods for resource setting
VIA
VIAM
VILI
Point of care HPV testing

16. Cytological screening
 Conventional cytology (Pap smear)
 Bivalve speculum
 Ayre’s spatula
 Scaping done from ectocervix
 Endocervix scraping – cyto brush
 Smear made – fixed in 95% alcohol or ether/ fixative
spray
 Stain –examine under ME
 Low sensitivity -, High specificity
 Metanalysis – sensitivity 51%; false negative 49%;
Specificity – 98%

17. LBC
 Cells are scraped using special broom
 Cells are collected in liquid medium & transported
to lab
 Processed , smear of monolayer of cells made &
fixed
 No drying, blood and debris are removed
 The residual sample used for HPV
 Detection rate of CC & LBC are same no difference
was found


18. Causes for failure of screening program
 Lack of awareness
 Lack of infrastructure
 Lack of technical expertise
 Need for repeated testing
 Lack of good referral system
 Poor resources
 Poor facility of treatment of test positive

19. HPV testing for screening cervical
cancer
 Detects high risk HPV’s
 DNA based test used often, mRNA tests are available
 More sensitive than cytology alone
 Has high negative predictive value
 Reduces cervical cancer incidence & mortality
 Can be used for
 Cotesting with cytology
 Primary HPV testing
 Reflex testing
 Recommended as primary testing for all women >30 years
 Frequency –every 5 years

20.  The overall sensitivity- 98%
 Specificity- 85%
 HPV testing identifies those at risk for developing
cancer
 Cytology detects existing diseases
 Primary HPV testing
 Cotesting – cytology +HPV
 Reflex testing- high risk HPV is found cytology is
equivocal- colposcopy is required

21. Screening modalities used in low
resource setting
 Cytology & HPV testing is difficult to implement
 VIA-
 3-5%freshly prepared acetic acid is used
 Low grade lesions –dull white plaque and faint borders
 High grade lesions- sharp borders
 Inexpensive
 Does not require expertise
 Minimal training required
 Can be performed by health workers
 Sensitivity 60%; Specificity- 79%; PPV-10-20%; NPV -92-97 %
 False positive rate is high –high number of referral

22. VIA Positive
 Referral for colposcopy & cervical biopsy &
treatment
 Screen –see- treat
 Immediate treatment depends on VIA report screen
& treat
 Referral for VIA with magnification VIAM followed
by biopsy & treatment
 VIAM-After acetic acid application handheld
magnification lens is used for reducing false
positive cases

23. Visual inspection after Lugol’s
iodine
 On application of iodine, the normal cervical
epithelium which is reach in glycogen stains
mahogany brown (Schiller’s test).
 The abnormal areas, columnar epithelium and
areas lined by immature metaplastic epithelium do
not contain iodine and appear mustard yellow
 The test has the same specificity and similar
advantage and disadvantage as VIA

25. After application of acetic acid, dense acetowhite areas appear rapidly (within 18 seconds of application of acetic acid), with
well-defined margins. The squamo-columnar junction is not seen in this image.
This different than thin aceto-whitening seen on the columnar epithelium due to squamous metaplasia
Dense acetowhite area (blue arrows) application of acetic acid, dense acetowhite areas appear rapidly (within 18 seconds of
application of acetic acid), with well-defined margins. The squamo-columnar junction is not seen in this image.
This is different than thin aceto-whitening seen on the columnar epithelium due to squamous metaplasia
Dense acetowhite area (blue arrows)

26. Normal cevix
Nabothian cysts
Strawberry Cervix

28. Point of care ( rapid result) HPV
testing
 Point of care or rapid result HPV test is a rapid test that identifies
high risk HPV and is less expensive.
 The results are available in 2.5 hours
 The test is superior to VIA, and comparable to standard HPV
testing.
 Self collected sample by using vaginal tampon, cotton swab or
cytobrush can be used for HPV testing in low resource sitting
 No significant difference in self collected /provider collected
samples
 Xpert HPV testing using PCR, similal to Gene Xpert for
tuberculosis is also available in some countries
 Combining VIA & HPV testing performed together or sequentially
improves sensitivity & reduces false positive

29. Colposcopy
 Visualization of Cervix vagina &vulva under magnification to detect premalignant
lesions of vulva , vagina and cervix
 Place the patient in dorso lithotomy position
 Place colposcopy one foot from vulva
 Insert bivalve speculum
 Focus colposcope on the cervix
 Use low power for overall visualization initially
 Shift to high power for closer visualization
 Clean with saline, remove mucus and note findings
 Apply 3% acetic acid note findings
 Apply Lugol’s iodine and note findings
 Document colposcopic findings
 Biopsy if indicated

30. Use of Colposcope
 Localization of lesion
 Making a diagnosis
 Taking a direct biopsy
 Guiding ablative procedures

31. Colposcopy finding
 See for adequacy – no inflammation, bleeding or
scarring
 SCJ is visible type 1,2,3
 TZ type 1,2,3,
 Typical appearance of CIN
 Mosaic & punctation- abnormal capillary distribution
 grade 1 or grade 2
 Inner border sign – sharp acetowhite demarcation with
in a les opaque acetowhite area
 Ridge sign- thick opaque ridges of acetowhite
epithelium growing irregularly in the SCJ,

32. Continued
 Screening for cervical cancer is hallmark for
prevention of cervical cancer