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Screening in Gynecology
- 1. Screening in Gynaecology Dr RKSaxena Professor (O&G) MVJ MC & RH
- 2. Screening • To detectdisease among healthy population • Without symptoms of disease • Purpose: decrease mortality due to the disease screened
- 3. Disease appropriate forscreening • High prevalence of disease • Known natural history, precursor lesion and course of progression • Detection of early stage disease, amenable to cure • Method used is simple, cheap, specific and sensitive, acceptable, risk-free and accessible
- 4. Screening • Cervical cancer •Ovarian cancer • Endometrial cancer • Breast cancer
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- 6. Carcinoma of thecervix • Commonest lower genital tract cancer • Current age-standardized rate is 22 per 100 000 per annum • Median age: 50 years
- 7. Natural history oflow-grade HPV cervical lesion • Cervical HPV is very common, related to sexual behaviour • High spontaneous remission rate • LSIL progress to HSIL in 70% in 10 yrs
- 8. Cervical cytology Sensitivity andSpecificity • Overall sensitivity: 61-64%, • Overall specificity : 60-70% New technology • Automation for cervical cancer screening • Liquid-based cytology(LBC) - thin layer preparation (Eliminate air-dried artifact, Inflammatory cells, Blood, mucus) • HPV testing combined with PAP smear improves screening
- 9. How to takea cervical smear? Procedure
- 10. When not totake a cervical smear • Blood in vagina, on the cervix - usually because of menstruation • Obvious or gross growth on the cervix - a biopsy is more appropriate • Cervix cannot be seen
- 11. How to interpreta cytology report?
- 12. PAPANICOLAOU SMEAR REPORTING –BETHESDA SYSTEM n Satisfactory / Unsatisfactory for reporting n Negative for Intraepithelial Lesion - Normal n Infection ( Organism to be specified) n Benign (Reactive /Reparative) cellular changes n ASCUS ( Atypical squamous cells of undetermined significance) n LSIL ( Low grade sq intra-epithelial lesion) n HSIL (High grade sq intra-epithelial lesion) n Squamous cell carcinoma
- 13. How to manageabnormal smear?
- 14. Inflammatory changes with atypia –couldbe due to vaginitis or infection such as monilia, trichomonas, herpes or condyloma. –Treat the cause and repeat the smear 4 to 6 months later to ensure that dysplastic cells were not masked by the previous inflammatory cells.
- 15. Management of LSIL Managementof LSIL •Only about 1% of LSIL associated with cancer •Options: –repeat smear 4-6 months interval Management of HSIL / ASCUS •Colposcopy •Biopsy of abnormal area
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- 17. COLPOSCOPY PROCEDURE • Dorsallithotomy position • Clean and drape • Cusco’s speculum • Focus Colposcope – Clean with saline – 3-5% acetic acid (Abnormal areas seen as acetowhite areas) – Lugol’s Iodine (Abnormal areas seen as Iodine negative areas) – Take biopsy from edge of abnormal areas (include small part of normal areas in biopsy specimen) Biopsy Area
- 18. Colposcopy nAcetic acid –coagulation ofnuclear protein preventing light to pass through the epithelium –Higher nuclear density and higher concentration of protein => white intensity increase
- 19. n Schiller /Lugol’s Iodine – Normal, mature squamous epithelium contains abundant glycogen – Produce dark brown stain – Abnormal epithelium contains relatively little or no glycogen – Remain relative unstained
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- 21. Treatment of highgrade CIN • Ablative therapy –cryotherapy –cold coagulation –diathermy –laser evaporisation • Excision therapy –cone (knife, laser, loop excision) • Hysterectomy is rarely indicated
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- 25. Ovarian Cancer -Importance § 4th common cause of cancer mortality § Most (70%) diagnosed at advanced stage where cure is uncommon. § Ranks 3rd among gynecologic cancers § Ranks 5th among women cancers. 0 5 10 15 20 25 Breast Cancer Cervical Cancer Ovarian Cancer Per lac women 30 Incidence of Gynecolgical Cancers in India
- 26. Family History Family historyRisk None 1.5 % First degree relative 5 % Two 1st degree relative 35-40 % Hereditary ovarian cancer syndrome 40 % Mutation in BRCA 1 & 2 35-65 % Breast ca & BRCA1 & 2 56-87 %
- 27. Neoplastic Ovarian Tumors Surfaceepithelial – 65-70% Germ cell tumors – 15-20% Sex cord Stromal Tu – 10-15% Metastatic tumors – 5% 4 basic categories of ovarian neoplasms:
- 28. Ovarian Cancer Vague non-specificsymptoms responsible for late diagnosis & poor survival rates Symptoms of ovarian cancer : •Asymptomatic •Lower abdominal pain / pressure •Mass abdomen / Abdominal enlargement •Vaginal bleeding •Urinary / bowel symptoms
- 29. Why screening forovarian cancer is difficult? • Anatomic location of the ovary, not easily accesible • Lack well defined precursor lesion and has poorly defined natural history • Low prevalence, need exquisite specificity to avoid unnecessary intervention • Lack of a good method
- 30. Ovarian cancer screening •Recommended only for high risk patients – Serum CA125 – Transvaginal ultrasonogram • Serum CA125 • Elevated in 82% of epithelial ovarian cancer and <1% of healthy women • Limitations: lack of sensitivity in Stage I disease, poor specificity (elevated in benign and other malignant conditions)
- 31. TVS: Features suggestiveof malignancy • Bilateral • Fixed • Variegated consistency • Solid • Nodules in pouch of Douglas • Ascites - Haemorrhagic
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- 33. Bilateral: Cyst andmass in each ovary
- 34. Ultrasound for Detection ofAscites
- 35. Ovarian malignancy containingtwo papillary excrescences (arrows)
- 36. Ovarian screening • Notcost-effective • May be considered in high risk population • No place for population screening yet
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- 38. Should endometrial cancerbe screened? • Precursor lesion, atypical endometrial hyperplasia • Accessibility of endometrium to sampling • High cure rate for early disease Majority detected at early stage because of abnormal bleeding esp PMB
- 39. Endometrial Cancer Screening •Tools explored –Pelvic ultrasound (>8mm endometrial thickness in postmenopausal women) –Endometrial aspirate (inadequate sampling in menopausal women)
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- 43. Endometrial cancer screening •Not justified in population screening • excellent prognosis of majority of Ca endometrium unlikely will result in decreased mortality rates
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- 45. Breast Ca :India • Current age-standardized rate is 19.1 per 100 000 per annum • Incidence rate peaks below age 50. • Cases presenting for treatment are locally advanced • Availability and level of facilities for treatment are variable • Survival rates are consequently low
- 46. Screening Tests • Mammography •Clinical breast exam (CBE) • Breast self-exam (BSE) • The two cornerstones of early detection are – awareness of the disease & – opportunistic and population-based screening.
- 47. Screening: Mammography Mammography Mammography reducesthe rate of death from breast cancer by 7%–23%, with a median of 15%.1 •Current Recommendation: Mammography •(CBE & BSE widely used as tools to increase breast awareness) 1. Berry DA, et al. N Eng J Med. 2005;353:1784-1792.
- 48. Clinical Breast Examination •May identify 4.5%–10.7% of breast cancers that mammography misses • Clinician proficiency impacts effectiveness • Recommendations vary: – American Cancer Society • Every 3 years for average-risk women in 20s and 30s • Annually for women aged 40 – U.S. Preventive Services Task Force • No recommendation/Not enough evidence
- 49. • IARC WorkingGroup concluded in 2002 that there is inadequate evidence that breast screening by CBE, either alone or together with mammography, can reduce mortality from breast cancer • However, cancers detected by CBE tend to be diagnosed at an earlier stage than those not detected by screening • A greater potential for effectiveness in a setting where stage at diagnosis is generally poor Clinical Breast Exam
- 50. Reasons for ScreeningDisparities • Inadequate access to facilities and equipment • Financial restraints, including a lack of adequate health insurance • Lack of patient knowledge of breast cancer risk and the need for screening • Any mass in the breast is regarded as carcinoma until proven otherwise • Patient Education is the key to early detection of breast cancer
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