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70 Q & A to prevent cervical Cancer
Regard
Scientific Chair of Prof. Abdullah Hussain Basalamah
for Gynecological cancer
J...
2
70 Q & A to prevent cervical
3
In the Name of God the Merciful
4
70 Q & A to prevent cervical
Page NOContent
5Prologue………………………….................................................……………….
...
5
Prologue
Well-beingisajewelinthecrownofthehealthythatcanonlybeenviedbythesick!
The mere mention or thought of the word c...
6
70 Q & A to prevent cervical
diagnosed with a malignant disease at some stage of their lives. Ignoring cancer can
only m...
7
Dedications
I have dedicated most of my adult life to studying and
treating cancer of the uterine cervix. This stubborn ...
8
70 Q & A to prevent cervical
In the name of Allah the Most Merciful, Most Compassionate
Allah Sobhanoh Wataala described...
9
Contributors
Prof. Khalid Hussain Sait
Consultant Obstetrics and Gynecology, Professor, Faculty of Medicine, King
Abdula...
10
70 Q & A to prevent cervical
11
Questions about human papilloma virus and Cervical Cancer
1)	 If patient has vulva warts and she is pregnant, do we nee...
12
70 Q & A to prevent cervical
transmission needs skin-to-skin contact and microscopic trauma so
the virus gains access t...
13
11)	 Can skin wart other than genital for example hand wart cause genital
infection?
This is theoretically possible how...
14
70 Q & A to prevent cervical
16)	 Effect of smoking both active and passive (second hand smoking)
Smoking is a co-facto...
15
16
70 Q & A to prevent cervical
Questions about HPV Vaccination
22)	 Vaccination? Is there any difference in cross protect...
17
27)	 HPV virus will act locally without viraemia, so how is the vaccine
will be effective replication and reach the sit...
18
70 Q & A to prevent cervical
31)	 Since that natural virus infection does not generate antibodies. How
will the vaccine...
19
exposure. In some countries this is best achieved by a school
based program of 11-14 year old girls. In Saudi Arabia th...
20
70 Q & A to prevent cervical
39)	 Why to vaccinate at 9-14 years, instead of vaccination before the start
of sexual act...
21
22
70 Q & A to prevent cervical
Questions about Cervical cancer screening
41)	 Why is a pap smear not done every year on y...
23
are the same for vaccinated and non-vaccinated women. Screening
recommendations are currently being changed in most cou...
24
70 Q & A to prevent cervical
49)	 In screening, I am little confused when to start with first (pap smear
or HPV test)?
...
25
54)	 Regarding the aim of the WHO to reduce mortality to 30% over 40
years, is it by pap smear or VIA (acetic acid)
In ...
26
70 Q & A to prevent cervical
27
Questions about Colposcopy
56)	 If a Pap smear reveals AGC, when do you need to perform
endometrial biopsy in addition ...
28
70 Q & A to prevent cervical
61)	 Is using green filter light is mandatory in colposcopy exam?
No this is an optional p...
29
65)	 What is the percent of metaplastic cells being misinterpreted as
dysplastic cell? How to avoid this error?
There i...
30
70 Q & A to prevent cervical
cone. The choice is up to the individual surgeon. The main concern
is assessing the margin...
31
Jeddah Cervical Screening Program
	Decrease the incidence of cervical cancer.
	Early detection of preinvasive cervica...
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  1. 1. 70 Q & A to prevent cervical Cancer Regard Scientific Chair of Prof. Abdullah Hussain Basalamah for Gynecological cancer Jeddah Cervical Screening Program First Edition 1434 - 2013
  2. 2. 2 70 Q & A to prevent cervical
  3. 3. 3 In the Name of God the Merciful
  4. 4. 4 70 Q & A to prevent cervical Page NOContent 5Prologue………………………….................................................………………. 7Dedications…….................................................................................................... 8Preface……............................................................................................................. 9Contributors…….................................................................................................. 11 - 14Questions about human papilloma virus and Cervical Cancer ...... 16 -20Questions about HPV Vaccination............................................................... 22 - 25Questions about Cervical cancer screening............................................. 27 - 30 31 Questions about Colposcopy.......................................................................... Jeddah Cervical Screening Program............................................................
  5. 5. 5 Prologue Well-beingisajewelinthecrownofthehealthythatcanonlybeenviedbythesick! The mere mention or thought of the word cancer is enough to a send wave of fear and worry amongst us all. Cancer was first documented in Egypt 1500 BC. It was described as a fatal and incurable disease. Its only treatment then was palliation by poisonous concoctions, cautery or by amputation only to relieve the suffering and postpone the inevitable death. Three and a half thousand years later the world still finds itself in the same position, treatment virtually unchanged. Cancer, despite recent great advancements in most medical fields, remains a disease that is shrouded in mystery, for the keys to unlocking its causes and cures lie hidden deep within the cell. Recent breakthroughs in genetics and in molecular biology, promise a new era in our fight against this loathsome scourge. Now that we have a better understanding of what cancer is and what causes it, we can begin to unravel its mystery to finally find an ultimate cure for all cancers. However, until this dream is reached this recent new understanding of this disease can help us prevent cancer from ever happening or at least detecting it early when curing it becomes more realistic than just palliative treatment. The old proverb that says; Prevention is Better than Cure, cannot be less appropriate today as when it was first coined millennia ago. Stopping a disease before it begins should be the aim of everyone, especially cancer as it remains largely an incurable disease. Public cancer awareness is not intended to strike panic amongst our population. It is intended to educate people on how to avoid getting the disease and of the medical services that play a pivotal role in the early diagnosis and treatment of pre-malignant and early stage cancer. From a doctor’s point of view, there is nothing more frustrating than seeing healthy happy people in the prime of life coincidentally diagnosed with advanced cancer that had been silently and slowly eroding from the inside out, when their disease could have been stopped before even starting. Sadly, it seems that cancer itself is not the real problem when trying to prevent it. Culture and myth have scared people for centuries forcing them to avoid even thinking about it. “Ignore it and it will go away” is a comfortable proverbial thought. Unfortunately, this cannot be further from the truth, for one in three of us will be
  6. 6. 6 70 Q & A to prevent cervical diagnosed with a malignant disease at some stage of their lives. Ignoring cancer can only make matters much much worse. In the developed world one doesn’t go to a doctor because one is sick. One goes to a doctor to make sure that one is healthy and to stay healthy. For they believe in regular health check ups as a preventative measure against falling ill or to tackle any health problem in its early stages when it is easy to treat it. Nothing could be more relevant to cancer than this, for the chances for its cure are much higher if it is diagnosed early.
  7. 7. 7 Dedications I have dedicated most of my adult life to studying and treating cancer of the uterine cervix. This stubborn and incurable disease has had many doctors hopelessly turn their backs on it to find easier problems to deal with, but with the blessing of God and his guidance I found myself and my team of doctors in a unique position to save many lives that were at the brink of death, about to be take away from us by this terrible disease. God said in the holy book: {[He] who ever saved it [a life] should be regarded as though he had saved all mankind} Quran; al-Maeda By those words I have become emboldened in fight fight against this disease. I have also become more and more certain that after all the discoveries and collective new knowledge the entire world will come to admit that God and his prophet have mentioned to us a natural world full of solutions and cures to all our problems and ailments. The more that man discovers, the more this certainty becomes clearer and the way to finding the truth becomes easier. God said in the wholy book: {Decidedly it (is nothing) except a Remembrance to the worlds and indeed you will definitely know its tiding after a while} Quran; Sudd With God’s willing we have published this book which holds the answers to many of the questions relating to cervical cancer. It is hoped that our book will increase the awareness and spread the culture of early cervical disease diagnosis and prevention of cancer amongst our population. It is also hoped that our book will increase our doctors’ knowledge in how to tackle this disease according to modern evidence-based practices that have proven effective in the prevention of malignant uterine cervix disease. The eventual complete eradication of this scourge is now becoming a reality within our reach. This book is one of many accomplishments realised by Prof. Abdullah Hussain Basalamah Scientific Chair team at KAU. We shall always be indebted to his kind and unwavering contributions and support of our goals and achievements. Prof. Khalid Hussain Sait
  8. 8. 8 70 Q & A to prevent cervical In the name of Allah the Most Merciful, Most Compassionate Allah Sobhanoh Wataala described Abraham peace be upon him said in Alshoaraa Chapter “If I get sick, Allah will cure my illness”. Prophet Mohammad Peace be upon him also SAID ”God has not created an illness without making the cure for it”. We are thankful to those who reminded us that prevention is better than cure. We thank God for bestowing upon us the knowledge by which we prevent and treat the diseases. The interest of people in the health and prevention of disease has increased nowadays, and more people are interested in knowing about the disease and its treatment and before that its prevention. In the following pages of this book, we have listed Questions &Answers for those who are interested in some topics of Medicine, Health, & Prevention of Diseases. The questions have been dealt with special care and answered carefully by experts in the field of Gyne-Oncology. We hope that it meets your expectations. Prof. Abdullah Hussain Basalamah
  9. 9. 9 Contributors Prof. Khalid Hussain Sait Consultant Obstetrics and Gynecology, Professor, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia Director of Gynecology Oncology Unit Chairman of Scientific Chair of Prof. Abdullah Hussain Basalamah for Gynecological Cancer Dr. Nisreen Mohammad Omar Anfinan Consultant Obstetrics and GynecologyAssistant Professor, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia Coordinator of Early Detection Unit and Jeddah Cervical Screening Program Prof. James Bentley Consultant Obstetrics and Gynecology Professor, Faculty of Medicine, Dalhousie University, Halifax, Canada Director of Gynecology Oncology Section Professor of Scientific Chair of Prof. Abdullah Hussain Basalamah for Gynecological Cancer We are her for you ... Because We Care
  10. 10. 10 70 Q & A to prevent cervical
  11. 11. 11 Questions about human papilloma virus and Cervical Cancer 1) If patient has vulva warts and she is pregnant, do we need to do C/S? No this may not be necessary, unless the warts are causing an obstruction. The neonatal complication is vertical transmission of HPV and oropharyngeal condyloma. This is rare and can occur despite caesarian section delivery. 2) What is the history of HPV? Is there any actual evidence of the first sighting of HPV? When and where did it come from? Researchers have estimated that diversity within a single HPV type evolved over 200,000 years and diversity between HPV type occurred over several million years. One mummy from the 16th century has been shown to have HPV 18 in a vulvar tumor. It is theorized that the virus evolved as man evolved and migrated from Africa. 3) What is the role of treatment of HPV positive cases (high risk) with antiviral therapy? There is no role for antiviral therapy in the treatment of HPV +ve women. Treatment with the immune modifier, topical imiquimod is effective for established condyloma. 4) Do you advise patient with vulva wart not to wash her underwear with other member of family? There is no evidence that warts can be transmitted through household tasks such as washing clothes. 5) Patient with wart in her hand can she transmitted to her children or to her vagina. Although this is theoretically possible it is rare to see condyloma from HPV types seen on the hands in the genital area. HPV
  12. 12. 12 70 Q & A to prevent cervical transmission needs skin-to-skin contact and microscopic trauma so the virus gains access to the basal layer of the epithelium. 6) Does none vaginal sex (intercourse) transmit HPV? Yes, any skin-to-skin genital contact can transmit HPV. 7) Is there any other way a child can get a genital wart apart from sexual abuse? Warts may be transmitted in various ways not just sexual transmission. It can occur vertically i.e. at delivery; horizontally i.e. from other non genital warts, and it has been postulated but not proven that it can occur by fomite transfer (via inanimate objects). 8) Since the virus is easy to collect (tampon-swab-pad). There is it possible for infection to occur on other ways besides skin-to-skin infection? Although the HPV virus has been detected on inanimate objects there is no good evidence of transmission. The virus will not survive intact for long when it is allowed to dry. 9) If the patient came with vulva wart and she is in monogamous relationship with her partner, knowing that we are relatively conservative society, what you will tell her of she ask from where she got it? This is a difficult discussion. What we know is that the virus was likely acquired sexually, what we don’t know is when or how or maybe there is other way of acquirement that not well proven. The virus may have been present for numerous years or maybe there is other way of transmission of this virus that is not yet proven 10) What about the effect of tobacco smoking and birth trauma on the progression of HPV? Smoking is certainly a co-factor that works with HPV to increase the risk of cancer, this is another reason that women should not smoke. Delivery does not have an adverse effect on HPV, some evidence shows that CIN often regresses after vaginal delivery.
  13. 13. 13 11) Can skin wart other than genital for example hand wart cause genital infection? This is theoretically possible however HPV types seen on the hands are rare to find in the genital area. 12) If there is no previous history of sexual contact for both partners, is there any risk of having HPV if there is not cofactors? If both partners have not been sexually active there is no risk of HPV or cervical cancer. 13) Does treatment of genital wart affect the incidence of cancer cervix? What is the best treatment of vulval and vaginal warts especially large ones? a. Women who have warts are at a greater risk of cervical dysplasia, this means that they need to be a screened. b. Treating warts can be difficult but has several options, large warts may need a combination of therapies including surgical: i. Patient applied therapies: podopyhlin or imiquimod ii. Physician applied: Trichloroacetic acid, cryotherapy iii. Surgical: excision, laser, cautery 14) What precautions you should tell a patient to take if she has vaginal wart. Research has shown that couples will be colonized rapidly by the same HPV types. There is little evidence that she needs to take special precautions, however you should avoid sharing towels, razors as warts may survive in damp places. 15) HPVisoftena“silentinfection”sohowistheimmunesystemprovoked? The immune response to HPV is variable and only 50% of individuals will develop antibodies that can be detected. The virus does however activate the immune system through the antigen presenting cells in the epithelium
  14. 14. 14 70 Q & A to prevent cervical 16) Effect of smoking both active and passive (second hand smoking) Smoking is a co-factor for CIN and other HPV associated precancerous changes. This is another reason not to smoke. Second hand smoking is likely not safe either. 17) Is HPV infection more aggressive during pregnancy and why? Pregnancy is a relatively immunocompromised state and as such a HPV infection may progress during this time, i.e. warts may grow, CIN may be more apparent. These changes often resolve after the pregnancy. 18) Is there any relation between severity of HPV infection and presence of associated infection e.g. candida or Chlamydia or herpes. There is some evidence that history of infection with chlamydia is a risk factor for cervical cancer, however there is no relationship with worse or high grade CIN changes. 19) Can HPV transmitted via infected toilet (i.e. non sexual infection). There is no evidence that this happens. The virus does not survive long outside of the body, so they might be theoretical concern 20) If somebody gets perineal warts or HPV infection, is it lifelong infection? Evidence showed that 80-90 % of HPV infection can be cleared completely by help of immunity within one to two years (complete resolution). 21) What is the chance for patient who got HPV infection to develop cervical cancer? From recent epidemiological study, we now have definite data that 99.9% of cervical cancer links to HPV. However, only very small number of patients (less than 1%) has the HPV infection will get cervical cancer.
  15. 15. 15
  16. 16. 16 70 Q & A to prevent cervical Questions about HPV Vaccination 22) Vaccination? Is there any difference in cross protection between cervarix and gardasil? The studies done this far suggest that there is greater cross- protectionwithCervarix,thismayormaynotbeclinicallyimportant. This is balanced against the added benefit against wart causing HPV types with Gardasil. 23) When the second shot of the vaccine should be? and if I miss it, what should I do, shall I repeat it? Ideally the second dose of either available vaccines should be given within 2 months, if however it is missed the second dose should be given as soon as possible. The third dose should be six months after the second. There is no evidence that you need to start again if a dose is missed. 24) What about vaccination for HIV patient? HIV patients can and should be vaccinated, there is no evidence of any harm. 25) How about vaccinating the boys? The current evidence shows the quadrivalent vaccine Gardasil is effective at preventing condyloma and pre-invasive anal intraepithelial neoplasia in males. Vaccinating males is also beneficial to women by helping prevent cervical cancer by herd immunity. 26) Is the vaccine option for sexual assault patient? The use of HPV vaccine in this situation may or may not be helpful. Vaccination has not been shown to provide “post exposure prophylaxis”.
  17. 17. 17 27) HPV virus will act locally without viraemia, so how is the vaccine will be effective replication and reach the site of virus without blood dissemination. I am a little confused how it works? With natural infection the virus only infects the epithelium and there is no viraemia. In vaccination the antigen is delivered to the subcutaneous tissue, an immune response then results, this is systemic and antibodies are made. These antibodies are present in cervical secretions and prevent HPV infection. 28) If a 48 year old lady got vulvar warts and pap smear negative after treatment with cauterization. Would you recommend HPV testing and vaccination. Firstly women of any age may benefit from HPV vaccination. The benefit is larger in younger women prior to any HPV exposure. Thus this patient may benefit however she does need to continue with cervical cancer screening. HPV testing does not have a role in this situation to help guide vaccination or not. 29) Consider that the data from Saudi that HPV 45 is the second common subtype if we have to choose a vaccine, what is best choice in our society? HPV 45 is related to HPV 18 and globally is the 3rd commonest HPV type in cancer. This may be a true difference or a feature of the sample analysed. Current information shows that cross protection to include HPV 45 is greater with vaccination by Cervarix. 30) I just wish to verify that reinfection following vaccination was always found to be by types other than those in the vaccines? This is what we believe, i.e. the vaccine is very effective. What we don’t know is the duration of protection, current evidence shows that the vaccine protection lasts at least 9.5 years.
  18. 18. 18 70 Q & A to prevent cervical 31) Since that natural virus infection does not generate antibodies. How will the vaccine give protection? With natural infection the virus only infects the epithelium and there is no viraemia. In vaccination the antigen is delivered to the subcutaneous tissue, an immune response then results, this is systemic and antibodies are made. These antibodies are present in cervical secretions and prevent HPV infection. 32) Regarding Bivalent and Quadrivalent vaccines, is there any head-to- head trial to compare their efficacy and immunogenicity? There is no head to head trial comparing the efficacy of Cervarix and Gardasil. This would be very difficult to show given the high efficacy shown by both vaccines. There is a head-to-head trial looking at immunogenicity which demonstrated significantly higher antibody levels for Cervarix. What we don’t know how this will translate into long-term efficacy. 33) With Quadrivalent vaccine, there was decline in antibodies to HPV 18, will this impact long-term immunity and efficacy? Will we need booster with Gardasil? In the information we have the antibodies for HPV 18 with Cervarix drop down to natural infection levels at 5 years. We have no evidence that this is translated into lack of efficacy over at least 5-8 years. We do not know if a booster will be necessary. 34) We have seen date up to 8.4 years with Cervarix. Is there is similar long-term date regarding (Gardasil)? The data for Cervarix shows efficacy in a cohort that now goes to 9.4 years. With Gardasil the clinical trials finished at 5 years of follow-up. Long term follow-up of cohorts of women vaccinated in Scandinavia during the trials will give further information. 35) When should you start vaccination and how many doses? a. HPV vaccination should be done before any potential
  19. 19. 19 exposure. In some countries this is best achieved by a school based program of 11-14 year old girls. In Saudi Arabia there is more time and vaccination could be done prior to marriage. HPV vaccination is however recommended for all women up to the age of 25 and even up to 45 in many countries. b. HPV Vaccination should be done with 3 doses 0, 1 or 2 and 6 months. 36) If a woman received the 1st dose of the bivalent vaccine and for an unpredictable reason, she has to move to an area where only vaccine is the quadrivalent valent vaccine. Would you recommend to start the other vaccine doses from the start (0) dose or can she continue the remaining only 2 doses. And if she has to start the new vaccine from the start, at what interval is recommended. There is no trial information to help with this situation however we would recommend that the patient continue with the bivalent vaccine at month 2 and 6. Ideally the three doses should be given within a year. 37) Can the pregnant women with warts receive vaccine HPV? Safely? i. The HPV vaccines are not recommended for use during pregnancy. ii. This woman would be better vaccinated after the pregnancy, this can be done while breast feeding. iii. Wart during pregnancy can be treated with topical agents, they often will resolve postpartum. 38) If patient had warts before will HPV vaccine be helpful for her same as other population. Yes these patient will still get protection against future HPV infection and hence may be less likely to get warts again or CIN. The reduction is over 50% of new warts/ CIN.
  20. 20. 20 70 Q & A to prevent cervical 39) Why to vaccinate at 9-14 years, instead of vaccination before the start of sexual activity (like at 18 or 19 or even 20) which will give longer cover duration. i. In most countries the age at onset of sexual activity is about 16, hence we choose to vaccinate at 9-14. ii. The immune response is better in younger women. iii. If vaccination is done in a school based program, this is easier to organize at 9-14 years old. A school based program gets better vaccination coverage. iv. However in Saudi Arabia 18-20 may be the better option! 40) Do you recommend screening for high risk HPV subtypes before giving vaccine for older women? There is no need to screen women of any age with HPV testing prior to vaccination. All women can benefit, even those that have a current or previous infection or dysplasia.
  21. 21. 21
  22. 22. 22 70 Q & A to prevent cervical Questions about Cervical cancer screening 41) Why is a pap smear not done every year on young female as we know that we have many false abnormal pap smear. It is true that a pap test has poor sensitivity (50%, however the specificity is 95%) There are thus few falsely abnormal paps. Development of abnormal precancerous cells and cancer is a slow process and screening at 3 year intervals is an effective way to prevent cervical cancer by treatment of CIN 2/3. 42) Is there any interventional ratio for +ve result for pap smear (ASCUS or AGC) Research has shown that 15-20 % of women with an ASCUS pap test will have CIN2/3 and likely need treatment. With an AGC pap test this rate of abnormality is higher and close to 30% for CIN 2/3 and up to 10% for glandular changes, cancer is also higher in this group. These rates will vary depending on the lab that reads the pap. 43) Do you think that VIA would be an appropriate method of screening in addition to the Pap smear in clinics where colposcopists are no readily available in the area or at least to decrease the waiting period? This may be appropriate, however all of the research is done in areas where the prevalence of cervical dysplasia is high and resources are poor. It is not an appropriate triage to decide who needs a pap or not. It is valuable as a test when done in a none screened population with the use of cryotherapy as the treatment for acetowhite lesions. 44) Is the screening program is the same for those who were vaccinated and those who were not? Currently the screening recommendations in all parts of the world
  23. 23. 23 are the same for vaccinated and non-vaccinated women. Screening recommendations are currently being changed in most countries and moving to screening at 3-5 year intervals. In many places HPV testing as the primary screen is being introduced. 45) If women received vaccine should she have a pap smear/ cervical cancer screening? Yes even if vaccinated women need to continue with screening. Vaccination should prevent at least 70% of cervical cancer. So we need to continue with screening for the remaining cancer and precancerous changes. 46) Why is a Pap smear test not preferred during pregnancy? Screening during pregnancy has advantages and disadvantages. It may be the only time that a woman sees a doctor and hence is a great opportunity to screen. If however abnormalities are detected we usually will defer any treatment to after the pregnancy. When screening is organized an additional pap does not need to be done during pregnancy. 47) In spite of proper cervical cancer screening program, why do advance cases of cancer cervix still present in Canada? Different countries have different screening programs, the UK has a truly organized program with invitation to participate and reminders sent to patients. In Canada the system is really opportunistic however 70% of eligible women are screened every 3 years. Unfortunately some women are not adequately screened, and about 40% of cancers occur in women who have had some form of screening. Cancers in women who have been screened tend to be of a lower stage that can be cured. 48) Do we need to screen patient for other STD if she has cervical dysplasia? Women should have appropriate STD screening if at risk. There is no evidence that they need HIV testing routinely.
  24. 24. 24 70 Q & A to prevent cervical 49) In screening, I am little confused when to start with first (pap smear or HPV test)? In North America cervical cancer screening starts at age 21 and then is every three years. In some European countries screening starts at age 25. Regardless there is no need to start screening prior to sexual activity. In a conservative society such as Saudi Arabia it is likely unnecessary to screen before marriage. 50) Sensitivity of liquid based cytology versus conventional cytology. There is no evidence that there is a difference in sensitivity or accuracy of liquid based cytology (LBC) vs. conventional cytology. The advantage of LBC is less unsatisfactory smears and the ability to do other tests such as HPV testing. 51) What do you recommend to a post menopausal women with negative smear to do if her husband has recently been diagnosed with HPV positive penile squamous cell carcinoma? In this situation the woman will likely have been already exposed to the HPV virus. She should have cervical screening with a pap or HPV test. it will not prevent this woman from effects of the HPV exposure. 52) Can you comment on indication (or lack of) vault cytology in female that have had a hysterectomy. If a woman has had a hysterectomy for benign indications she does not need any cytological screening. If she had a previous history of treatment for dysplasia or cancer she should continue with vault smears annually. 53) Is it advisable not using the K-Y Jelly when doing a pap smear? Lubrication such as K-Y jelly on the speculum helps make the procedure more comfortable. If a small amount is used it does not interfere with a pap test. Another option is to use warm water to warm and lubricate the speculum.
  25. 25. 25 54) Regarding the aim of the WHO to reduce mortality to 30% over 40 years, is it by pap smear or VIA (acetic acid) In order to reduce cervical cancer there needs to be screening programs. The most effective method is likely to use HPV testing perhaps only 2-3 times in a lifetime. Pap testing or VIA are reasonable options but have limitations in their implementation in the developing world. A screening program using VIA does however develop an infrastructure that can be used when cheap HPV testing becomes available. 55) Why is high risk HPV testing not done as primary screening test. For HPV (can be done for both partners before intercourse or as premarital screening). i. HR-HPV testing may become the method of choice. It however is very sensitive and not specific enough. Hence there would be excessive unnecessary referrals to colposcopy (particularly in western society). In country like Saudi Arabia where is this low prevalence of HPV this might be an option. ii. If used it may be need to be followed by a pap test to aid the triage. This approach is being done in JCSP. iii. There is no benefit of using HPV testing as a premarital screen. The benefit is as a cervical cancer prevention test by detecting cervical dysplasia that can be treated.
  26. 26. 26 70 Q & A to prevent cervical
  27. 27. 27 Questions about Colposcopy 56) If a Pap smear reveals AGC, when do you need to perform endometrial biopsy in addition to colposcopy? a. This needs to be done in cases where the pap test is AGC favor endometrial cells (AGC-E) b. In any woman with a history of abnormal uterine bleeding c. In all women with a AGC pap over the age of 35 57) Do we have to do ECC for an AGC pap? a. Yes an ECC is mandatory for an AGC pap, this is done to exclude significant glandular and squamous cells in the endocervical canal. 58) Do we apply acetic acid before or after green filter? The green filter can be uses both before and after the application of acetic acid. The filter helps delineate vessel patterns. 59) How did cauterization or cryotherapy effect the results of colposcopy? Previous cryotherapy or cautery may make the new squamo- columnar move higher into the cervical canal, i.e. a type 2TZ or 3 TZ. This makes full evaluation difficult. 60) Do you have a colposcopist in every hospital or you are referring abnormal pap smear to higher center? In Canada colposcopy is usually done in hospitals. Most hospitals will have dedicated colposcopy clinics, some complicated cases will be referred for specialist opinion. In Saudi Arabia most colposcopy are done by gynecological oncologist.
  28. 28. 28 70 Q & A to prevent cervical 61) Is using green filter light is mandatory in colposcopy exam? No this is an optional part of the exam that may give more information. 62) During colposcopy after applying acetic acid can we put Logol’s stain directly to make the lesion clear before biopsy? Lugols staining is an important adjunct to acetic acid in the identification of dysplstic lesions. Its use is optional and not mandatory. 63) Do you recommend giving the vaccine to patients after being treated and cured from CINI, CINll, if yes how long after cure can we start the vaccine? Yes women who have been treated migh benefit from vaccination. Reanalysis of the Future I and II trials shows a benefit of at least 50% in reducing recurrence or failure within 2 years. Threated women can be vaccinated at anytime after treatment, there is no need to wait for negative paps. 64) Can we use Estrogen for 2-3 weeks in postmenopausal women will unsatisfactory transformation zone with abnormal looking cervix, so as to evert the transformation zone out. a. Firstly if the cervix looks abnormal it should be examined colposcopically and appropriate biopsies taken. b. If at colposcopy the transformation zone cannot be seen a short course of estrogen is unlikely to help make the colposcopy satisfactory. Estrogen makes the epithelium healthier and will help clarify what is inflammation and the location of any dysplastic cells. This is particularly helpful in sorting out an ASCUS smear in a postmenopausal patient that is due to arophy.
  29. 29. 29 65) What is the percent of metaplastic cells being misinterpreted as dysplastic cell? How to avoid this error? There is no clear data on how often metaplasia and dyspasia are confused. However, at colposcopy, particularly after referral for a low grade abnormality (ASCUS or LSIL) , the patient may have faint aceto-white changes with fine mosaic. These findings are seen with both LSIL (CIN1) or metaplasia. The best way to accurately assess this is to take a biopsy. 66) What do you think of treating ectropion with cryotherapy despite normal cytology. This rarely needs to be done, unless the ectropion or glandular epithelium is symptomatic. I rarely see the need to do this other than for post-coital bleeding. 67) Can you do the colposcopy during menstrual cycle? Yes colposcopy can be done when menstruating. If the patient wishes to wait this is reasonable. But.. if the patient has bleeding as a symptom colposcopy should not be delayed. 68) Colposcopic features aid in differentiation between CIN 1 and CIN 2 /3, but is it clinically helpful? I will still depend on histological diagnosis for management. Differentiating CIN1 from CIN 2/3 is important as it directs the colposcopist where to take a biopsy. It also allows one to put the cytology, colposcopy and histology together in a composite diagnosis. 69) Currently, what are the Methods of doing cone biopsy In modern colposcopy there are many ways to perform a diagnostic excision procedure. This can be done with a large LEEP/LLETZ, needle excision of the transformation zone or a classical cold knife
  30. 30. 30 70 Q & A to prevent cervical cone. The choice is up to the individual surgeon. The main concern is assessing the margins and making sure a potential microinvasive cancer or AIS is excised entirely. 70) What is the significance of Schiller test (applying lugols Iodine) does it improve sensitivity of colposcopy? Lugols is helpful in improving the diagnostic ability of colposcopy. Poor iodine uptake with a yellow color is suggestive of a high grade lesion, whereas patch uptake is suggestive of a low grade lesion or metaplasia. It is not a substitute for acetic acid and the classical colposcopic appearances.
  31. 31. 31 Jeddah Cervical Screening Program  Decrease the incidence of cervical cancer.  Early detection of preinvasive cervical disease.  Provide treatment and optimal management for patients with cervical cancer.  Provide recall and reminder systems to ensure adequate follow-up of women with screen-detected abnormalities.  Ensuring optimal quality of Pap smear reading through a quality assurance program for laboratories Who’s legible for the program?  Women at or above 30 year and not more the 65 year old,  who has been married for 3 years. Requirement to register in the program  You have to call to book an appointment.  You need to bring your ID. What are the unique about this program  Free test .  Saudi and Non Saudi.  Screening , diagnosis ( colposcopy) and treatment in one center  Continuous follow up and recall and reminder  Maintaining confidentiality  Academic staff and comfortable environment  Raise awareness and education on prevention methods  Allow self registration online  Kauh file is not required  Tel: 6401000 - 6402000  Ext : 11521-11851-11480 – 11523  fax : 6401000 - 6402000 Ext : 11199  Mobile: 0540963815 -0540964759  The possibility of registration through the website  Email: scgc.kau@gmail.com  Website: cabwt.kau.edu.sa / www.jcsp.sa.com

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