Dr Chintana Hapuachchige MBBS, MD, MRCOG Consultant Gynaecological Oncologist, National Cancer Institute, Maharagama

1. Dr Chintana Hapuachchige
MBBS, MD, MRCOG
Consultant Gynaecological Oncologist
National Cancer Institute, Maharagama
01.09.2017
Prevention of Cervical Cancer
and where we are and
the way forwards

3. Father of Gynae- Oncology in Sri Lanka

6. National Cancer Institute
Sri Lanka
• Established in 1958 (50 years old)
• Average 15000 patients referred annually
• 60% female cancers - 40% male cancers
• 850 in ward patients ( One of the largest in the World)
• 100 children
• 700 patients attend clinics every day
• Referrals from all parts of country including North
and East

7. Cervical Cancer

8. Cervical cancer
• is caused by the sexually transmitted HPV,
(A preventable non-communicable disease )
• Almost all sexually active individuals will be
infected with HPV at some point in their lives and
some may be repeatedly infected.
• The peak time for infection is shortly after becoming
sexual active.

9. Common early symptoms
• Inter-menstrual bleeding
• post-menopausal bleeding
• Post-coital bleeding
• Abnormal vaginal bleeding
• An unusual vaginal discharge
• Excessive sero-purulent discharge

10. Cause
• Human Papilloma Virus infection (99.7%) [essential factor]
• Other co-factors
– Multiple sexual partners (Female commercial sex workers)
– Early age at coitarche
– Giving birth at very young age
– Multiple pregnancies
– Presence of other sexually transmitted infections
– Weakened immune system (HIV / organ Transplant )
– Smoking
– Long term use of contraceptive pills more than 10 years
– Low socio economic status

11. HPV types and disease association

12. Natural history of HPV cervical
infection
• 90% would clear it within 6-14 months.
• 10% become latent infection(due to viral
persistence)
• 10-20% of these latent infections will progress to a
productive infection.
• 10% of women with a productive infection and very
rarely latent infection will progress to transforming
infection - cancer

13. Normal cervix
HPV related changes
Low grade SIL(CIN1)
High Grade SIL(CIN 2/3 and CIS
Invasive Cancer
2/3 regress
within 2-3 yrs
HPV Infection
High risk HPV
Types-
16,18,33,45High Risk HPV Types
16,18,31,33,45
1/3 progress
within 3-4 yrs
30-70%
progress within
10yrs

14. Prevention
• Primary prevention - Lifestyle factors
HPV vaccine

17. HPV vaccination
• was introduced in the UK in September 2008
• By 2014, 2.3 million girls had been vaccinated in
England
• coverage of 85% of the eligible population.
• Cross protection against less common HPV types.
• vaccines work best if administered prior to exposure to
HPV
• vaccines require 2/ 3 doses, administered over 6 months
• At present the vaccine is thought to be efficacious for at
least 8-9 years after the initial regime
• still recommended to have cervical cancer screening.

18. HPV vaccine types
• Bivalent HPV (HPV2) vaccine (for prevention of 70% of cervical cancer cases)
– Contains HPV types 16 and 18 (high risk)
– Approved for females aged 10 through 25 years
• Quadrivalent HPV (HPV4) vaccine (for prevention of 70% of cervical cancer
cases)
– Contains HPV types 16 and 18 (high risk) and types 6 and 11 (low risk)
– Approved for females and males aged 9 through 26
Years
• Ninevalent HPV vaccine (9v HPV) (for prevention of 90% of cervical cancers)
- Contains HPV geno types 6, 11, 16, 18, 31, 33, 45, 52, and 58
- for use in girls and young women 9 to 26 years of age
- for the prevention of cervical, vulvar, vaginal, and anal cancers
- pre-cancerous or dysplastic lesions genital warts caused by HPV
types 6 and 11

19. After vaccination

20. Secondary Prevention
or Screening
• Conventional (Pap) 1940
• liquid based cytology (LBC) 2004
• LBC with concomitant use of HPV testing 2013 for
‘Triage’ in women with borderline and low-grade
dyskaryosis and also as ‘Test of Cure’ following
treatment for CIN and CGIN.
• Visual inspection with Acetic Acid(VIA)
• Coverage in Sri Lanka 30%

21. Future of screening
• UK National Screening Committee recommended in January
2016 that HPV primary screening should be adopted by the
screening programme.
• HPV-based primary screening provides a 60-70% greater
protection against cervical carcinomas compared with LBC.
• HPV testing in more sensitive and has a very high negative
predictive value.
• It is cost-effective as it will save more lives and reduce costs
through extension of screening intervals.

22. Conventional cytology: Pap smear
.
a) Combined spatula
b) Endocervical brush
c) Cervical broom

23. Cyto brush

25. Referral criteria for colposcopy
• Hans Hinselmann first described this method in 1925
• All smears with HGSIL
• Two consecutive LGSIL smears
• Following treatment of pre malignant and malignant
lesions

27. Cervical changes

28. Normal variations-colposcopic view
Post menopausal
Cervical ectropion

29. CERVICAL TRANSFORMATION ZONE
NORMAL PREINVASIVE

30. Pre malignant lesions- Cervix
LGSIL
HGSIL

31. Abnormal cervix

32. Treatment of CIN
• CIN can be treated by ablative and excisional
techniques. Both have a cure rate of >90% and there
is no difference between the two techniques when it
comes to treating and eradicating CIN.
• Both methods aim to remove the transformation zone
and the lesion. All techniques used should remove
tissue to a depth 7e10 mm so as to ensure eradication
of CIN that may involve the gland crypt.

33. Treatment of CIN
• Ablative techniques destroy the cervical epithelium.
Hence accurate pre-treatment punch biopsy samples are
required to exclude invasion prior to ablative treatment.
• Ablative techniques
Various ablative techniques are available such as
1. Cryocautery,
2.Cold Coagulation,
3. Laser Ablation and
4. Diathermy Ablation.
Cryocautery is the commonest ablative technique used.

34. Treatment of CIN
• Excisional techniques
• Various excisional techniques are available. These
include LLETZ/Loop Biopsy, NETZ/SWETZ
(Needle/Straight Wire Exci- sion of Transformation
Zone), Cold Knife Conization, Laser Conisation .
• Hysterectomy.

35. 2.Loop excision(LLETZ)

36. 3.Cone biopsy

37. Where we are

38. Cervical cancer
• Cervical cancer is the second most common
cancer in women worldwide.
• 530 000 new cervical cancer cases diagnosed every year.
• Globally 1.4 million women were living with cervical cancer (2012)
• Globally most affected age group – 30-55 years causing grave
morbidity and mortality to women
• Every year more than 270 000 women die from cervical cancer,
more than 85% of these deaths are in low and middle income
countries.

39. National Cancer Institute
Sri Lanka
Annually
• 8000 new cancer patients registered
• 1200 – oral cancer
• 1100 – breast cancer
• 500-600 – cervical cancer

40. National Cancer Control Programme, Cancer
Incidence data 2007,
2nd
commonest
female
cancers – 10%
of all female
cancers are
cervical
cancer (2008)
This translates to nearly 850-950
cervical cancer cases annually
(hospital data)
500- 600 cases in Maharagama
Situation in
Sri Lanka

41. 41Source: National Cancer Control Programme
Cervical Cancer : age distribution in Sri Lanka - 2009

42. Cervical Cancer Screening Programme –
Well Woman Clinics
42Annual Report on Family Health 2013, Family Health Bureau, Ministry of health , Sri Lanka
Total Pap smears at WWC :
132,385 (2013)

43. Number of Well Woman Clinics

44. Percentage of women attending Well Woman
Clinics

45. Percentage of 35 year age cohort screened
with Pap smear

47. Pap smear statistics
• WWC
• National Cancer Control programme : 2000/year
[reading at FHB lab]
• STD clinic: 1000-1500 per year [Annual Report 2015]
• Government Hospitals: Gynecological wards and
clinics- published data not available
• Private sector /semi Government/ NGO-
published data not available
47

48. number
needed to
screen to
prevent one
cervical
cancer case
1130 [>35
years]
Minimum
unit cost
of Pap
smear
screening
Rs. 308/-
Rs. 348,040/-
Prevention of reported
annual case load of 850-
900 cases : 313 m SLR/yr
[Excludes treatment of screen
detected cases]
48
Cost for Pap smear screening
Total invasive cervical cancer detected at pap smear screening
1.15/2000

49. Sri lankan guidelines
• Sexually active above age of 35
• Or 5 years after 1st coitarche
• Only conventional Pap test
• LBC / HPV testing in Private sector

50. Why still common?
• widely available screening centers island-
wide
– But coverage is low 30-40%
– Lack of awareness among general public
– No proper referral and feed back system
– No proper follow up system

51. • HPV vaccine was Introduced under EPI
programme in 2017

54. A woman should
not die or suffer
from cervical
cancer when it is
preventable!
54

55. Dr. Deepa Gamage-
Community Medicine Consultant

56. Treatment follow-up
• Patients after CIN treatment remain at risk of
recurrent disease. The risk of a future cancer is
approximately 4-5 times that of the background risk
and usually due to poor compliance with follow up.
• Majority of recurrences are usually detected within 24
months of treatment.
• Other factors that contribute to the risk of treatment
failure include age >40 years, high-grade lesions,
glandular lesions and positive treatment margins.

57. HPV test of cure
• After treatment of all grades of CIN women are
invited for screening after 6 months for LBC and
HPV testing.
• HPV testing has a higher sensitivity and negative
predictive value compared with cytology or
colposcopy alone in identifying residual/recur-
rent disease.
• HPV testing in addition to LBC allows early
return to routine recall if these tests are negative
at 6 months.

58. HPV test of cure
• CGIN treated patients are at higher risk of
recurrent disease. If the excision was incomplete,
these women should be followed up with cytology
and colposcopy at 6 months, 12 months and then
annually for another 9 years.
• If excision was complete then women should be
offered LBC and HPV testing at 6 and 18 months
and can be returned to normal recall if these are
negative.

59. Future of colposcopy
• DySIS is a digital video colposcope that also uses
dynamic spectral imaging to evaluate the ‘whitening’
effect of acetic acid on the epithelium
• The Niris Imaging System uses optical coherence
tomography as an adjunct to a standard colposcope. It
uses near-infrared light
• NICE have recommended that DySIS is a clinically
and cost- effective option, compared with standard
colposcopy

61. Annually
• 266,000 deaths, and
85% are from
developing countries
Without urgent
action deaths due to
cervical cancers are
projected to rise by
almost 25% over the
next 10 years
Global mortality

62. Papillomavirus phylogenetic tree
• The alpha-papillomavirus genus of the papillomavirus
phylogenetic tree is shown*
• Oncogenic types closely related to HPV 16 and 18 are
highlighted
• HPV 16 is most closely related to HPV 31
• HPV 18 is most closely related to HPV 45
40
7 32
42
39
59
5544
PCV1
13
11
6
73
34
61
27
2a
57
3
28
10
29
51
26 30
53
56
66
RhPV1
70
18
45
58
33
52
16
35
31

63. Factors to be considered in secondary
prevention
Increase Pap smear coverage
– Health care institutional demand/facilities
– Creating public awareness (Demand by women/ beneficiaries )
– Increasing accessibility and availability of services
Follow up of screen detected cases
– Adequate treatment opportunities & follow up
– Monitor and evaluation of programme impact
Feasibility/cost assessment for newer techniques : combine
methods
63