The document summarizes the 2013 guidelines for cervical cancer screening in the United States. The key points are:
1. Screening should begin at age 21 with cytology alone every 3 years until age 30.
2. From ages 30-65, co-testing with cytology and HPV testing every 5 years is the preferred method. Cytology alone every 3 years is acceptable.
3. Screening can stop at age 65 for women with adequate negative prior screening and no history of CIN2 or worse. Screening after a hysterectomy also depends on whether the cervix was removed.
Say no to cervical cancer-PUBLIC Awareness-Life Care Centre_Dr.Sharda JainLifecare Centre
Cervical Cancer in INDIA
Say no to cervical cancer
Dr.Sharda Jain
Life Care Centre
PUBLIC Awareness_Dr.Sharda Jain
HPV Infection
HPV Vaccination
Cervical Screening
SEE & TREAT Programme tp Prevent Cervical Cancer
HPV Infection , HPV Vaccination , Cervical cancer , Cancer in India , Dr. SHA...Lifecare Centre
HPV inefection , HPV disease prevention, Cervical cancer prevention , Cervical cancer treatment, Female cancer , Female cancer prevention , Uterine cancer , Cancer in india
UPDATE HPV Vaccination IN Cervical Cancer Prevention Dr Sharda Jain Lifecare Centre
Cervical Cancer In India: A Preventable Tragedy That Requires Urgent Attention
It is estimated that in India, about 160 million women aged 30-59 years are at risk of developing cervical cancer, with fatality rate of 50 per cent
HPV Vaccination, Cerviocal Cancer : Do we need it
for Prevention of cervical cancer &
other HPV related diseasesm,
Presentation Outlines
Cervical cancer disease burden
Prevention with HPV vaccination
Vaccination of sexually active women
Opportunity of Postpartum HPV vaccination
Importance of genital warts prevention
Real world effectiveness data
Safety of HPV vaccine
Say no to cervical cancer-PUBLIC Awareness-Life Care Centre_Dr.Sharda JainLifecare Centre
Cervical Cancer in INDIA
Say no to cervical cancer
Dr.Sharda Jain
Life Care Centre
PUBLIC Awareness_Dr.Sharda Jain
HPV Infection
HPV Vaccination
Cervical Screening
SEE & TREAT Programme tp Prevent Cervical Cancer
HPV Infection , HPV Vaccination , Cervical cancer , Cancer in India , Dr. SHA...Lifecare Centre
HPV inefection , HPV disease prevention, Cervical cancer prevention , Cervical cancer treatment, Female cancer , Female cancer prevention , Uterine cancer , Cancer in india
UPDATE HPV Vaccination IN Cervical Cancer Prevention Dr Sharda Jain Lifecare Centre
Cervical Cancer In India: A Preventable Tragedy That Requires Urgent Attention
It is estimated that in India, about 160 million women aged 30-59 years are at risk of developing cervical cancer, with fatality rate of 50 per cent
HPV Vaccination, Cerviocal Cancer : Do we need it
for Prevention of cervical cancer &
other HPV related diseasesm,
Presentation Outlines
Cervical cancer disease burden
Prevention with HPV vaccination
Vaccination of sexually active women
Opportunity of Postpartum HPV vaccination
Importance of genital warts prevention
Real world effectiveness data
Safety of HPV vaccine
Welcoming remarks by Dr Osborne E Nyandiva on Symposium: Cervical cancer and its prevention
Co-Presenter Dr Giama. We are happy to present to you this very crucial discussion on Cancer.
Cervical cancer is a type of cancer that develops in a woman's cervix (the entrance to the womb from the vagina).
Cancer of the cervix often has no symptoms in its early stages. If you do have symptoms, the most common is unusual vaginal bleeding, which can occur after sex, in between periods or after the menopause.
Cervical cancer kills 270,000 women each year — mainly women in the developing world and in the prime of their productive lives. But cervical cancer is preventable by screening asymptomatic women for precancerous cervical lesions and treating the lesions before they progress to invasive disease. In other words, those deaths are largely preventable. Studies suggest that even if a woman were screened for cervical cancer only once in her lifetime between the ages of 30 and 40, her risk of cancer would be reduced by 25-36%.
The presentation describes various facts about breast and cervical cancer including burden of disease, survival outcomes, need for early diagnosis and screening recommendations.
Welcoming remarks by Dr Osborne E Nyandiva on Symposium: Cervical cancer and its prevention
Co-Presenter Dr Giama. We are happy to present to you this very crucial discussion on Cancer.
Cervical cancer is a type of cancer that develops in a woman's cervix (the entrance to the womb from the vagina).
Cancer of the cervix often has no symptoms in its early stages. If you do have symptoms, the most common is unusual vaginal bleeding, which can occur after sex, in between periods or after the menopause.
Cervical cancer kills 270,000 women each year — mainly women in the developing world and in the prime of their productive lives. But cervical cancer is preventable by screening asymptomatic women for precancerous cervical lesions and treating the lesions before they progress to invasive disease. In other words, those deaths are largely preventable. Studies suggest that even if a woman were screened for cervical cancer only once in her lifetime between the ages of 30 and 40, her risk of cancer would be reduced by 25-36%.
The presentation describes various facts about breast and cervical cancer including burden of disease, survival outcomes, need for early diagnosis and screening recommendations.
Nulife module 6 screening for malignancies editedManinder Ahuja
These six modules from 2-7 are on mid life health care of women and were made with intention of training general gynecologist and other speciality into care of mid life women and have Mid Life OPD cards as mainstay of care.
The Papanicolaou test (also called Pap smear, Pap test, cervical smear, or smear test) is a screening test used in gynecology to detect premalignant and malignant (cancerous) processes in the ectocervix. http://docturs.com/dd/pg/groups/2392/cervical-smear-test-pap-test/
The Newer Concepts In Endometriosis Management : Dr Sharda JainLifecare Centre
The Newer Concepts In
Endometriosis Management
ENDOMETRIOSIS IS ENIGMA
DIAGNOSTIC DELEMMA
DEBILITATING DISEASE QOL
PROGRESSIVE DISEASE
RECURRENCE IS BIG PROBLEM
NO FINAL VERDICT ON CAUSE
NO PERMANENT CURE
The exact prevalence of endometriosis is unknown, but estimates 10% in the general female population in India but up to 50% in infertile women
The Newer Concepts forReduced Surgery to preserve fertility in Endometrios...Lifecare Centre
The Newer Concepts forReduced Surgery to preserve fertility in Endometriosis
ENDOMETRIOSIS IS ENIGMA
DIAGNOSTIC DILEMMA
DEBILITATING DISEASE QOL
PROGRESSIVE DISEASE
RECURRENCE IS BIG PROBLEM
NO FINAL VERDICT ON CAUSE
NO PERMANENT CURE
The exact prevalence of endometriosis is unknown, but estimates 10% in the general female population in India but up to 50% in infertile women
Anemia Free India Gynaecologist to focuss on *12gm Haemoglobin at Delivery I...Lifecare Centre
Important Highlights
Prophylactic Iron and Folic Acid Supplementation in all six target age groups.
Intensified year-round Behaviour Change Communication (BCC) Campaign for:(a) improving compliance to IFA and deworming, (b) enhancing appropriate infant and young child feeding practices, (c) encouraging increase in intake of iron-rich food through diet and/or fortified foods (d) ensuring delayed cord clamping .
Testing and treatment of anaemia, using digital methods and point of care treatment, with special focus on pregnant women and school-going adolescents.
Addressing non-nutritional causes of anaemia
in endemic pockets with special focus on malaria, hemoglobinopathies and fluorosis
Strategies for Improving Success Rates in ART PARTLifecare Centre
Strategies for Improving Success Rates in ART
Part - 2
Strategies for Improving Success Rates in ART
Tailoring Controlled Ovarian Stimulation
Strategies for Luteal Phase in ART cycles
Endometrial Receptivity Array
How to optimize success rates in ART? : Dr Sharda JainLifecare Centre
How to optimize success rates in ART? : Dr Sharda Jain
How to improve success rates in ART?
The big debate कार्य में आनंद
Evolution of In-vitro Fertilization (IVF)
Factors Influencing IVF Success Ist Part
Strategies for Improving Success Rates in ART Second Part
Innovations & Breakthroughs in IVF Part Three
OPEN DEBATE
SOCIALEGG FREEZING : Dr Poorva Bhargav and Dr Sharda JainLifecare Centre
SOCIALEGG FREEZING : Dr Poorva Bhargav and Dr Sharda Jain
Introduction
Social egg freezing (oocyte cryopreservation for non-medical reasons) has evolved as a proactive option for women looking to extend their reproductive possibilities past their peak childbearing years
It is the process of saving or protecting eggs, or reproductive tissues so that a person can use them to have biological children in future
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
6. Every 7Minutes,
1 Indian woman dies of Cervical Cancer
Disease Burden
Infact India is a Capital for Cervical Cancer
7. IF YOU CAN PREVENT IT
100%
CANCER
You Don’t Need To Cure
8. Herold Zur Hausen
The Nobel Prize Winner, Medicine 2008
HPV is the necessary or the key cause of cervical
cancer
Cervical cancer does not and will not develop in
the absence of the persistent
presence of HPV DNA.
9. HPV 16
HPV 18
HPV 6
HPV 11
Cancer causing Types1,2,4 Non-cancer causing types1,2
>75% of Cervical Cancer5,6
>50% of Vaginal & Vulvar Cancer5
90% of Anogenital warts5
HPV is a necessary cause of cervical cancer – 99.7%4
HPV
1.Schiffman M, Castle PE. Arch Pathol Lab Med. 2003;127:930–934. 2. Wiley DJ, Douglas J, Beutner K, et al. Clin Infect Dis. 2002;35(suppl 2):S210–S224. 3. Muñoz N, Bosch FX, Castellsagué X, et al. Int J
Cancer. 2004;111:278–285. Reprinted from J Virol. 1994;68:4503–4505 with permission from the American Society for Microbiology Journals Department. 4. Walboomers JM, Jacobs MV, Manos MM, et al. J
Pathol. 1999;189:12–19. 5. X. Castellsagué, S. de Sanjose, T. Aguado, K. S. Louie, L. Bruni, J.Muñoz, M. Diaz, K. Irwin, M. Gacic, O. Beauvais, G. Albero, E. Ferrer, S. Byrne,F. X. Bosch. HPV and Cervical
Cancer in the World. 2007 Report. WHO/ICO Information Centre on HPV and Cervical Cancer (HPV Information Centre). Available at: www.who.int/hpvcentre6. Bhatla N et al.Vaccine (2008;26; 2811-17
Human Papillomavirus (HPV)
10. Ca Cervix
Slow Growing Cancer
Many opportunities for detection &treatment
of Precancerous lesions
11. • CERVICAL mucosa goes
through the SERIES OF
CHANGES before
developing into full blown
carcinoma
• SCREENING in such
cases becomes a viable
option to catch disease
young.
Normal mucosa
Dysplasia
Low grade intraepithelial
lesion
High grade intraepithelial
lesion
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.
14. DISEASE PROGRESSION
Invasive
cervical cancer
Time YearsMonths
Normal
epithelium
HPV infection;
koilocytosis
CIN I CIN II CIN III
CIN I 57% CIN II 43% CIN III 32%
Approx. likelihood of regression
Borderline Mild Moderate Severe Dyskaryosis
18. Universal Screening- Why?
• In many DEVELOPED COUNTRIES, a SUCCESS
STORY of decline in the incidence of and
mortality caused by cervical cancer as a result
of screening by cytology.
• Cervical cancer has PRECURSOR, low and high
grade intraepithelial lesion, which have
EFFECTIVE TREATMENTS available.
• Screening also gives an opportunity for
educating women who are constantly at high
risk.
19. Type of screening
• Conventional cytology
• Liquid-based monolayer cytology
• Human papillomavirus testing
• Testing in resource-poor areas
20. Widespread
introduction of
the Pap begins
Conventional Pap smear LBC
1949 1996 2000’s
HPV testing
Vaccine
Cervical cancer prevention:
Evolution !!
Markers
21. A tribute to Dr.GeorgeA tribute to Dr.George
PapanicolaouPapanicolaou
22. After introduction in 1928 as new cancer diagnosis,
After 1943 PAP smear became a routine
USA
Mortality Due to Cancer
Cervix
1940
2000
14/100,000
women
4/100,000
women
Screening programmes successful in all developed countries
Screens only cervical cancer
23. Cervical cytology
GOLD STANDARD IN CERVICAL
CANCER SCREENING.
• Eight cross sectional studies from different
developing countries show SENSITIVITY ranging
from 28.9% to 76.9%.
• Recent reviews the mean SENSITIVITY and
SPECIFICITY of cytology was 75% and 94%
respectively.
American Journal of epidemiology,1995
Obstetrics and Gynaecology, 1998
Annals of intrnal Medicine, 2000
25. Comparison of HPV DNA to Pap
N Eng J Med, 2007: Canadian Cervical Cancer Screening
Trial (CCCaST)
94.6%
55.4%
94.1%
96.8%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Sensitivity HPV
DNA
Sensitivity Pap Specificity HPV
DNA
Specificity Pap
Missed CIN2+
N Eng J Med 2007; 357: 1,579 - 88
95% CI: 84.2-100 95% CI: 33.6–77.2
P=0.01
95% CI: 96.3-97.3
P<0.001
95% CI: 93.4-94.8
26. Why ca cervix prevention not given
importance by Govt. in India?
IT IS NOT
27. Cervical Cancer Screening In India
• There are No Organized Screening Programs
available in India
• Cytology based screening programmes are
difficult to organize because:
1. Lack of political will
2. Limited infrastructure
3. Few trained personnel
4. Lack of funds
29. In India,
Universal Vaccination
can haveSubstantial effect in
reducing the morbidity of cervical
cancer in,where an organization
screening program may not exist
for all women in near future.
Villa LL. Vaccine. 2006; 24 (suppl 1) : S2# - 8
GOI – has NO MONEY for
universal vaccination
30. The Recently Launched National Program
for Prevention & Control of Cancer,
Diabetes, Cardiovascular Diseases & Stroke
(NPCDCS, Ministry of Health & FW,
Government of India) has among its major
objectives
cervical cancer control through opportunistic
screening of women above 30 years.
31. Kudos to FOGSI members
• ↓ MMR – we are close to realise MDG -5
• Big Challenge of 2013 - ↓ Cancer
Cervix Rate in India
32. •1940-1989: annual “pap smear” for all women
-Linkage of “annual pap smear” to “annual health exam”
•1987: Walton Commission (British Columbia)
-Cytology screening every 3 years
•1989: AMA, ACOG, AMWA Consensus Statement
-Annually, starting at sexual activity or 18 years old
-After 3 negative smears, testing may be done less frequently
-Longer intervals based on the absence of risk factors
Evolution of Cervical Cancer
Screening / Intervals
34. 1. American Cancer Society (ACS)
2.American Society for Colposcopy and Cervical
Pathology (ASCCP),
3. American Society for Clinical Pathology (ASCP)
4. U.S. Preventive Services Task Force (USPSTF)
5. American College of Obstetricians and Gynecologists
(ACOG)
Endorsed by
35. FOCUS Of
Cervical Cancer Screening
Guidelines 2013
• When to start screening
• Screening method and intervals
• When to stop screening
• Screening after Hysterectomy
• Pelvic exams
• Screening among women who have been
vaccinated against human papillomavirus (HPV)
36. Current Recommendation 2013
• Apply to women who have a cervix,
regardless of sexual history.
• Do not apply to women who have received a
diagnosis of a
- high – grade precancerous cervical lesion or
- Cervical cancer.
- Who are immunocompromised
(such as those, who are HIV positive)
38. SHOULD NOT BE SCREENED REGARDLESS
OF THE AGE OF SEXUAL INITIATION OR
OTHER RISK FACTORS.
(STRONG RECOMMENDATION)
Age 21.
Women aged <21 years
39. •Most HPV infections are transient
•When HPV infection persists, transit to cancer is quite long
•Spontaneous regression of low grade lesions is common
•Invasive cervical cancer is very rare in 15-19 year olds
-14 cervical cancers annually
-1-2 cases per 1 million women
•In teens, screening does not reduce mortality
-Cervical cancer rates have not changed since 1973-
1977, before practice of screening at 18 or first
intercourse
Why Start Cervical Cytology at 21?
ACOG Practice Bulletin No. 109, Dec 2009
40. Screening method and intervals
21 to 65 Years
• Cytology 21-29 years of age EVERY 3 YEARS.
(conventional or 30-65 years of age
liquid based)
Strong recommendation
Second Recommendation
41. Statement about annual screening
FOR SCREEN NEGATIVE
If Screening Negative
Repeat after 3 years
Women of any age should not be screened annually
by any screening method.
(Strong recommendation)
However , they should come for annual check-up
42. HPV + Cytology Co-Testing: Benefits
• Compared to cytology alone, improved accuracy
and earlier diagnosis of CIN 2+
• High negative predictive value important in
women unable or unwilling to have every 3 year
screening
• While each co-test is more expensive, longer
intervals and very high NPV could reduce overall
costs
43. Atypical Squamous Cells of Undetermined
Significance (ASC-US)
• Most common cytological abnormality
• Option 1 : repeat Cytology in 12 months
-If Negative-Cytology in 3 years
-If ASC or greater-Colposcopy
• Option 2 : Preferred: Reflex HPV Testing
-If Positive: colposcopy
-If Negative: Repeat Co-testing in 3 years
44. HPV Positive, Cytology Negative
Occurs in 11% of women aged 30 to 34 years;
2.6% of women aged 60 to 65 years
• Option 1: repeat co-testing in 12 months
-If HPV-positive or ASC-US+: colposcopy
-If HPV-negative or Cytology negative: rescreen with co-
testing in 3 years
• Option 2: reflex test for HPV16 or HPV16/18 genotypes
-If HPV16 or HPV 16/18 positive: colposcopy
-If HPV16 or HPV 16/18 negative: co-test in 12 months
• Do not immediately colposcope HPV positive/cyto negatives
45. HPV co-testing SHOULD NOT
BE USED for women
aged <30 years.
HPV Co -Test
(cytology + HPV test administered together)
21-29 years of age
46. 30 – 65 years of age
• If Screen Negative
Every 5 years
(Strong recommendation)
• THIS IS THE PREFERRED METHOD
• (Weak recommendation).
HPV co-test
(cytology + HPV test administered together)
47. Proposed Algorithm for the
Management of Women ≥30
HPV Negative HPV Positive
Repeat both
tests at 5
years
HPV 16 - / 18 –
Other HR HPV
+
HPV 16 + and /
or HPV 18 +
ColposcopyRepeat both
tests at 1 year
Cytology
Negative
+ HPV
Testing
48. Annual cervical cancer screening
should NOT be performed. (Level A
evidence)
Patients should be counseled that
annual well-woman visits are recommended
even if cervical cancer screening is not
performed at each visit.
HPV Co- Test
Screen Negative
inwomen aged 30–65 years
49. Primary HPV testing (alone)
For
Screening
screening by HPV testing alone is not
recommended in most clinical settings.
(Weak recommendation)
50. When to Stop Screening
• Stop at age 65 for women with adequate
negative prior screening, no CIN2+ within
the last 20y.
Definition of adequate negative screening:
• 3 consecutive negative Paps or
• 2 consecutive negative HPV tests
51. Rationale for stopping at 65 years
• CIN2+ is rare after age 65
– Most abnormal screens, even HPV+, are false +
and do not reflect precancer
• HPV risk remains 5-10%
• Incident HPV infection unlikely to lead to
cancer within remaining lifetime
Chen HC et al. JNCI 2011;103:1387-96;
Rodrigues AC et al. JNCI 2009;101:721-8
52. When NOT to stop at age 65 years
If history of CIN2, CIN3, or AIS
– Continue “routine screening” for at least 20
years, “even if this extends screening past age
65.”
53. When to stop screening - 2
• Stop after HYSTERECTOMY with
removal of cervix and no history of
CIN2+
• “Evidence of adequate negative
prior screening is not required”
54. Rationale for stopping after
Hysterectomy
• Vag cancer rate is 7/million/year
• 663 vag cuff Paps needed to find one VAIN
• 2,066 women followed after hyst. for average 89
months
– 3% had VAIN, 0 had cancer
• Risk of Pap abnormality after hyst = 1%.
Pearce KF et al. NEJM 1996;335:1559-62;
Piscitelli JT et al. AJOG 1995;173:424-30
55. Women who have had a SUPRA-CERVICAL
HYSTERECTOMY (cervix intact) should
continue screening
according to Age guidelines.
(Strong recommendation)
SCREENING IN
POST – HYSTERECTOMY CASE
56. Women at any age with a history
of HPV Vaccination should be
screened according to the age
specific recommendations for the
general population.
Screening among those immunized
against HPV 16/18
5th Recommendation
57. SCREENING A VACCINATED COHORT
• Vaccination against HPV 16/18
– Reduces CIN3+ by 17-33%
– Reduces colposcopy by 10%
– Reduces treatment by 25%
• “ Recommended screening practices
should not change on the basis of HPV
vaccination.”
Paavonen J et al. Lancet 2009;374:301-14
58. The need for a BIMANUAL PELVIC EXAM
in subsequent yearly check-ups
<21 – No need
21 - shared decision
60. 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 : ACS, ASCCP,
American Society for Clinical Pathology
CA Cancer J CLIN March 2012
• 1st
time that all 3 organizations involved with cervical cancer prevention and the
USPSTF have endorsed equivalent guidelines
61. How to prepare for your pap test
- Not to schedule during periods.
- If you are going to have a pap testing in the next two days
• You should not douche (rinse the vagina with water or another fluid).
• You should not use a tampon
• You should not use a birth control foam, cream or jelly
• You should not use a medicine or cream in your vagina
62. Summary
1. 27% of the world burden of Cervical Cancer is seen in India.
2. Screening is recommended in women of >21yrs 2013
3. No screening required before 21 yrs
4. Screening should stop at 65 yrs and after hysterectomy
“The biggest gain in reducing cervical cancer incidence and mortality
would be achieved by increasing screening rates among women rarely
or never screened. . .
Clinicians, hospitals, health planners, and public health officials should
seek to identify and screen these women.”
ACS, 20002
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'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.