cervical cancer fogsi screening test npcdcs_

1. Prof Rajendra Prasad Ganguly
Dept of G & O
R G Kar Medical College
KOLKATA.

2. Screening for Cervical Cancer
State TOTs for Population
Based Screening of NCDs,
May 2017

3. Outline
• What is Screening?
• Screening methods
• Cytology
• Conventional cytology
• LBC
• VIA
• HPV DNA testing
• Triage tools
• Screening guidelines

4. Screening
• Screening means universal testing of all eligible persons at
risk of a particular disease, irrespective of risk factor profile
• Cervical cancer is suitable for screening because it fulfills the
following criteria:
• Sufficient burden of disease to pose a serious public health
problem
• Identifiable and treatable long precancerous phase
• Simple, non-invasive tests
• Effective treatments are available

5. Incidence rate per 100,000 women
0 5.8 12.2 21.0 34.7 57 GLOBOCAN, IARC 2012
Age Standardized Incidence Rates of Cervical Cancer

6. 122,844 women are diagnosed with cervical cancer annually
67,477 die of cervical cancer
432.2 million women aged 15 years and older are at risk of
developing cancer

7. Cervical Cancer Screening
normal
cervix
HPV
infection
Persistent
infection
High grade
CIN
Invasive
cancer
Screening for precursor lesions
Pap smear cytology
VIA / VIAM / VILI
HPV DNA Testing
Pap Smear detection range
HPV DNA HC2 Test detection range
Low grade
CIN
VIA / VILI detection range

8. Cytology testing
• Conventional cytology – the Pap smear – was developed by Dr George
Papanicolaou in 1928 and implemented since the 1940s
• The Pap smear has been the most successful test that brought down
cervical cancer incidence and mortality by 70%
• In developed countries, cervical cytology programs involved
screening of sexually active women annually, or once every 3-5 years.
• Coverage of > 70% of the target population, based on a computerized
call and recall system, resulted in the decline in cervical cancer over
the last 50 years.

9. Reporting of Pap Testing
Normal LSIL CancerHSIL
Pap testing is reported according to The Bethesda
System. It can identify precancerous cell changes
before they progress to cancer

10. British Columbia Study
Impact of Pap smear screening programs on cervical
cancerous and precancerous lesions

11. • Pap has poor sensitivity
• However, it has high specificity for detection of high grade
precancerous lesions or cancer
• Mean sensitivity of 58% (range 30-70%) and mean
specificity of 96% (range 95-99%)
• It is effective only when done repeatedly
1. Nanda K et al. Accuracy of Pap test in screening for and follow-up of cervical cytologic abnormalities :a
systematic review. Annals Int Med. 2000;132:810-19.
2. Fahey MT et al . Meta-analysis of pap test accuracy. Am J Epidemiol. 1995;141:680-9.
Cervical cytology (Pap smear)

12. Even the most successful cytology screening program was effective
in reducing the incidence and mortality from cervical cancer only
when –
 Wide population coverage (> 70%) was ensured by implementing
target performance by GPs
 Computerised call and recall system ensured regular screening at
frequent intervals
 Quality assurance at all levels of screening was implemented .
NHS CSP

13. Inadequate
cervical
cancer
screening
Lack of
infrastructure
Lack of
manpower
Lack of funds
Lack of
awareness
Barriers to cervical cancer screening

14. Crude and Effective Cervical Cancer Screening Coverage for
Women Ages 25–64
Emmanuela Gakidou et al. PLoS Medicine.June 2008 ; Volume 5 Issue 6 e132

15. Indian Scenario
• Pap smear screening cannot be implemented in India because of
lack of infrastructure and trained personnel (ICMR 1992)
• A Government of India–WHO joint committee constituted in 2006
to develop national guidelines for cervical cancer screening in
India also observed that for the large population, infrastructure
and resources do not permit a Pap smear–based national
screening program
• Alternative strategies that are feasible and scientifically valid to
be identified
Guidelines for Cervical Cancer Screening Programme Recommendationsof the expert group meeting, 18–19 November
2006; Government ofIndia–World Health Organization Collaborative Programme (2004–2005). Department of Cytology
& Gynecological Pathology, PostgraduateInstitute of Medical Education and Research, Chandigarh, India, June 2006.
http://www.cytoindia.com/cytology%20eqa/ccsp%20guidelines.pdf, Accessed 6th Feb 2017

16. • VIA/VILI
• HPV DNA testing
Various studies have reported that sensitivity and specificity of VIA and
HPV testing is better than cytology in detection of cervical
precancerous lesions
VILI is not recommended in public health programs due to cost and
non-availability of Lugol’s iodine
HPV testing is still very expensive and not widely available
Alternatives studied…

17. MoHFW
Guidelines
2016

18. Naked eye visual inspection of the uterine cervix
after application of 5% acetic acid, a simple test for
early detection pre-invasive and early invasive
cervical cancer.
What is VIA?

19. VIA
Expose cervix
Examine under good quality light
Clean mucus from cervix
Apply 4-5% acetic acid liberally on
cervix with cotton swab, wait for
1 min and interpret
Abnormal epithelium turns white,
then fades after 30-40 sec

20. • VIA NEGATIVE
• No significant acetowhite
• Pale white
• Faint focal areas away from TZ
• VIA POSITIVE
• Dense white sharp borders
• One border at TZ
TEST DEFINITION OF VIA

21. VIA positive lesions

22. VIA negative lesions
Large cervical ectopy with
metaplasia
Chronic cervicitis with Nabothian follicles
Streak-like acetowhitening
in columnar epithelium
Faint line-like
acetowhitening at SCJ
Transparent
acetowhitening of
columnar epithelium

23. Sankaranarayanan R, Wesley R A Practical Manual on Visual Screening for Cervical
Neoplasia http://screening.iarc.fr/doc/viavilimanual.pdf
http://screening.iarc.fr/doc/viavilimanual.pdf Accessed 6th Feb 2017

24. Inexpensive,
simple, no lab
support
Immediate
availability of
test result
Large number of
women can be
screened
‘Screen and
treat’ policy
Rapid training of health
workers : primary health
care
VIA: Advantages

25. Subjective:
Training & Quality
Control
Low specificity:
triage to avoid
overtreatment
Cannot be used in
postmenopausal
women
VIA: Drawbacks

26. VIAM
• Visual inspection with acetic acid under magnification
• Magnivisualiser developed by ICMR
• Hand held device, battery powered
• VIAM has not been shown to have better test performance than VIA
alone
• However, the device has the provision of a good quality battery
powered light

27. HPV Testing

28. Link Between HPV & Cervical Cancer
“The presence of HPV in virtually all cervical cancers implies
the highest worldwide attributable fraction so far reported
for a specific cause of any major human cancer.”
HPV STRUCTURE

30. Countries that have not
already established cytology
programs should not start to
do so now

32. Secondary Prevention : 2 Approaches
Screen and Treat
Screen, Diagnose and
Treat

34. Screening & Management Algorithm
Visual inspection using Acetic Acid (VIA)
VIA negative VIA positive
Repeat VIA after 5 years
Refer to Gynecologist/ Lady Medical Officer
wherever possible PHC/CHC/ DH
Cryotherapy High grade (CIN 2 &
3)
Low grade (CIN 1) Cancer
Cryotherapy LEEP Refer to TCC
Follow up after one year with VIA
Follow up after one
year with VIA
Biopsy (naked eye or colposcopic guided
Eligibility for cryotherapy
 Lesion not be > 2 quadrants of cervix
 Entire lesion in ectocervix without
extension to vagina and/or endocervix
 Lesion visible in its entire extent
 Lesion can be adequately covered by
largest available cryotherapy probe
 No suspicion of invasive cancer
Operational Framework: Management of Common Cancers, MoHFW, 2016
Cryotherapy not recommended if
 Symptoms:
-Post coital bleeding
-Postmenopausal bleeding
 Examination:
-Overt cervical growth
-Irregular surface
-Bleeds on touch

35. Conclusions
• Cervical cancer screening is an important public health
priority
• There are many screening tests
• VIA is a good option, comparable to Pap
• Treatment of screen detected women is important to achieve
the impact on cervical cancer incidence

36. Thank you for
your attention!