This document discusses counseling for cervical cancer screening. It notes that cervical cancer is the third most common cancer in women worldwide, with over 450,000 new cases and 231,000 deaths each year. Nearly all cervical cancers are caused by infection with human papillomavirus (HPV). Screening methods like Pap smears and visual inspection with acetic acid (VIA) can detect precancerous lesions early to prevent the development of invasive cancer. Integrating cervical cancer screening and treatment with other reproductive health services in community-based settings can help improve access to care.

1. Counselling for cervical cancer
screening
1
Moderator:
Ms. Kusum Kumari
AIIMS, Rishikesh

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Magnitude of the Problem
 Third most common cancer in women
 Affects 1.4 million women worldwide
 Each year, 460,000 new cases occur
 Each year, 231,000 women die of the disease
 About 80% of new cases are in developing
countries

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Background
 99.7% of cervical cancers directly linked to previous
infection with human papillomavirus (HPV)
 Of more than 50 types of HPV that infect genital
tract, 15–20 types linked to cervical cancer
 Four of these types are most often detected in
cervical cancer
 HPV infections often cause no symptoms
 Most common signs of infection are small pink or
red warts, itching and burning in genital area

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Background (cont.)
After woman becomes infected with HPV:
 Infection may remain stable
 Infection may regress spontaneously
 If cervix infected, may develop into low-grade
squamous intraepithelial lesions (LGSILs), also
called mild cervical intraepithelial neoplasia (CIN
I) or early dysplasia

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Background (cont.)
For every 1 million women affected, 10% (100,000) will
develop precancerous changes in cervical tissue:
 These changes are usually in women ages 30–40
 About 8% of these women will develop precancer
limited to outer layers of cervix (carcinoma in situ)
(CIS)
 About 1.6% will develop invasive cancer unless CIS
detected and treated

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Background (cont.)
 Progression to cervical cancer from high-grade
squamous intraepithelial lesions (HGSILs)
usually occurs over 10–20 years
 Although rare, some precancer lesions become
cancerous within a year or two

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HIV/AIDS, HPV Infection, and
Cervical Cancer
 39.5 million people living with HIV/AIDS in
2006; almost half women
 Heterosexual contact main mode of
transmission in new cases
 In HIV-infected women:
 HPV detected more frequently; resolves more
slowly
 HPV-associated diseases more difficult to treat
 Progression of precancer accelerated

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HIV/AIDS, HPV Infection, and
Cervical Cancer (cont.)
 Cervical cancer screening important in this
population
 Where HIV endemic, 15–20% women positive
for precancer
 Cervical squamous cell cancer now an
“AIDS-defining illness”
 Antiretroviral drugs improve quality of life;
effect on progression of precancer not known

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Risk Factors for HPV and
Cervical Cancer
 Sexual activity before age 20
 Multiple sexual partners
 Exposure to sexually transmitted infections (STIs)
 Mother or sister with cervical cancer
 Previous abnormal Pap smear
 Smoking
 Immunosuppression
 HIV/AIDS
 Chronic corticosteroid use

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Age-Related Changes in the T-Zone: Puberty
 Columnar cells (red in
appearance) are
gradually replaced by
squamous
cells (pink in appearance).
 This is a slow process
and continues
throughout the
reproductive years.

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Preventing Cervical Cancer
 Preventing HPV infection will prevent cervical
cancer
 No conclusive evidence that condoms reduce
the risk of HPV infection, although they may
provide some protection against HPV-associated
diseases

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Primary Prevention:
Development of a Vaccine
 A vaccine would be the most effective way to
prevent cervical cancer
 Vaccine would protect woman against only some
types of HPV
 Vaccine would need to contain mixture of virus
types
 At least two vaccines currently being tested

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Secondary Prevention
 Women already infected should be screened to
determine whether they have early, easily treatable
precancerous lesions
 Pap smear is most well-established screening method
 Other screening methods:
 Visual screening
 HPV tests
 Automated cytology screening
 Pap smear, with its many steps, is problematic in low-
resource settings

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Screening: Visual Inspection with Acetic
Acid (VIA)
 VIA is at least as effective as Pap smear in
detecting disease
 VIA has fewer logistic and technical constraints
 Studies in South Africa, India and Zimbabwe in
1990s showed VIA as a good alternative to Pap
smear
 Later studies confirmed that VIA is viable option
for screening in low-resource settings

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Value of VIA in Low-Resource Settings
 Can effectively identify most precancerous lesions
 Is non-invasive, easy to perform and inexpensive
 Can be performed by all levels of health care
workers in almost any setting
 Provides immediate results that can be used to
inform decisions and actions regarding treatment
 Requires supplies and equipment that are readily
available locally

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Links to Other Reproductive Health
Services
 Linking cervical cancer screening and treatment
to other services is essential and logical
 These services are usually separate, leaving
women without access to care and contributing
to women’s poor health status
 Cervical cancer prevention must be integrated
with existing reproductive health care services

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Links to Other Reproductive Health
Services (cont.)
 District-based implementation of interventions
will ensure that health services are available
close to where people live
 Nurse or midwife who works in the community is
usually the best person to provide community-
based, appropriate, safe and cost-effective care

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