The document summarizes the 2013 guidelines for cervical cancer screening in average-risk women. It recommends that screening should begin at age 21 with conventional or liquid-based cytology every 3 years. From ages 30-65, it is acceptable to continue cytology alone every 3 years, but preferred is co-testing with cytology and HPV testing every 5 years. Screening should stop at age 65 for women with adequate negative prior screening or after total hysterectomy with no history of precancerous lesions. The guidelines do not recommend annual screening or primary HPV testing alone for screening.
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
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.
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
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.
Advance in diagnosis & treatment of cancers has led to high cure rate & longer survival.
Nearly 1 in 12 cases detected before 40 years age.
Survivors have to face infertility or early menopause.
Management of Early Stage Carcinoma CervixSubhash Thakur
This presentation covers the management of early stage carcinoma cervix (FIGO stage I to IIA). A brief introuduction to different surgical procedures and the radiation treatment techninques have been described.
Advance in diagnosis & treatment of cancers has led to high cure rate & longer survival.
Nearly 1 in 12 cases detected before 40 years age.
Survivors have to face infertility or early menopause.
Management of Early Stage Carcinoma CervixSubhash Thakur
This presentation covers the management of early stage carcinoma cervix (FIGO stage I to IIA). A brief introuduction to different surgical procedures and the radiation treatment techninques have been described.
What Are the Key Statistics About Cervical Cancer?
The American Cancer Society's estimates for cervical cancer in the United States for 2017 are:
About 12,820 new cases of invasive cervical cancer will be diagnosed.
About 4,210 women will die from cervical cancer.
Cervical pre-cancers are diagnosed far more often than invasive cervical cancer.
Cervical cancer was once one of the most common causes of cancer death for American women. But over the last 40 years, the cervical cancer death rate has gone down by more than 50%. The main reason for this change was the increased use of the Pap test. This screening procedure can find changes in the cervix before cancer develops. It can also find cervical cancer early − in its most curable stage.
Cervical cancer tends to occur in midlife. Most cases are found in women younger than 50. It rarely develops in women younger than 20. Many older women do not realize that the risk of developing cervical cancer is still present as they age. More than 15% of cases of cervical cancer are found in women over 65. However these cancers rarely occur in women who have been getting regular tests to screen for cervical cancer before they were 65. See the section, " Can cervical cancer be prevented?" and Cervical Cancer Prevention and Early Detection for more information about tests used to screen for cervical cancer.
In the United States, Hispanic women are most likely to get cervical cancer, followed by African-Americans, Asians and Pacific Islanders, and whites. American Indians and Alaskan natives have the lowest risk of cervical cancer in this country.
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.
Cervical cancer by dr alka mukherjee dr apurva mukherjee nagpur m.s.alka mukherjee
Cervical cancer develops in a woman's cervix (the entrance to the uterus from the vagina).
Almost all cervical cancer cases (99%) are linked to infection with high-risk human papillomaviruses (HPV), an extremely common virus transmitted through sexual contact.
Although most infections with HPV resolve spontaneously and cause no symptoms, persistent infection can cause cervical cancer in women.
Cervical cancer is the fourth most common cancer in women. In 2018, an estimated 570 000 women were diagnosed with cervical cancer worldwide and about 311 000 women died from the disease.
Effective primary (HPV vaccination) and secondary prevention approaches (screening for, and treating precancerous lesions) will prevent most cervical cancer cases.
When diagnosed, cervical cancer is one of the most successfully treatable forms of cancer, as long as it is detected early and managed effectively. Cancers diagnosed in late stages can also be controlled with appropriate treatment and palliative care.
With a comprehensive approach to prevent, screen and treat, cervical cancer can be eliminated as a public health problem within a generation.
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
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!
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
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
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Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
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.
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.
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
Title: Sense of Smell
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 primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
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.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
4. Every 7Minutes,
1 Indian woman dies of Cervical Cancer
Disease Burden
Infact India is a Capital for Cervical Cancer
5. IF YOU CAN PREVENT IT
CANCER
You Don’t Need To Cure
6. 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.
7. 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)
8. Ca Cervix
Slow Growing Cancer
Many opportunities for detection &treatment
of Precancerous lesions
9. • 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
10. 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.
12. 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
16. Universal Screening- Why?
• In many DEVELOPED COUNTRIES, a SUCCESS
STORY of 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 have EFFECTIVE
TREATMENTS available.
• Screening also gives an opportunity for educating
women who are constantly at high risk.
17. Type of screening
• Conventional cytology
• Liquid-based monolayer cytology
• Human papillomavirus testing
• Testing in resource-poor areas
18. Widespread
introduction of
the Pap begins
Conventional Pap smear LBC
1949 1996 2000’s
HPV testing
Vaccine
Cervical cancer prevention:
Evolution !!
Markers
19. A tribute to Dr.GeorgeA tribute to Dr.George
PapanicolaouPapanicolaou
20. 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
21. 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
23. 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
24. Why ca cervix prevention not given
importance by Govt. in India?
IT IS NOT
25. 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
27. 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
28. 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.
29. Kudos to FOGSI members
• ↓ MMR – we are close to realise MDG -5
• Big Challenge of 2013 - ↓ Cancer
Cervix Rate in India
30. •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
32. 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
33. 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)
34. 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)
36. SHOULD NOT BE SCREENED REGARDLESS
OF THE AGE OF SEXUAL INITIATION OR
OTHER RISK FACTORS.
(STRONG RECOMMENDATION)
Age 21.
Women aged <21 years
37. •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
38. 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
39. 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
40. 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
41. 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
42. 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)
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. 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
46. 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
47. Primary HPV testing (alone)
For
Screening
screening by HPV testing alone is not
recommended in most clinical settings.
(Weak recommendation)
48. 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
49. 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
50. 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.”
51. 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”
52. 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
53. Women who have had a SUPRA-CERVICAL
HYSTERECTOMY (cervix intact) should
continue screening
according to Age guidelines.
(Strong recommendation)
SCREENING IN
POST – HYSTERECTOMY CASE
54. 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
55. 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
56. The need for a BIMANUAL PELVIC EXAM
in subsequent yearly check-ups
<21 – No need
21 - shared decision
58. 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
59. 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
60. 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.