DOC-20241220-WA0005[1].pptx screening of breast cancer

SPEAKER – DR S S NANDA
Associate Professor
Dept of O & G
OVERVIEW OFBREAST CANCER AND
CERVICAL CANCER SCREENING

Breast Cancer Facts
• 2nd leading cause of death 2nd most common cancer .
• lncidence increases with age
• AII women are at risk

WHAT CAUSES BREAST CANCER
• 90% of breast cancers are due to genetic
abnormalities- aging process and the "wear and
tear" of life.
• 5-10% of cancers are due to an abnormality
inherited from your mother or father.

RISK FACTORS FOR BREAST CANCER
• Gender: female (1% males)
• Race: more common in whites
• Age: increases as a woman gets older.
• Relative : (mother or sister)
• Menstrual history :early onset, late menopause
• @ Childbirth: first child After the age of 35 or having no children at all
• Pregnancy and breastfeeding are protective against breast cancer

RISK FACTORS FOR BREAST CANCER
• Obesity
• Diet: Fat
• Alcohol
• Lack of Physical Activity ; Stress
• Radiation Exposure
• History of cancer: breast, uterus, cervix, ovary
• Hormones: estrogens in Hormone replacement therapy & Birth control pills
> 70% have no risk factors

DOC-20241220-WA0005[1].pptx screening of breast cancer

SCREENING FOR BREAST CANCER
A Good Breast Health Plan
• Self Awareness- Monthly Self Exams
• Clinical Breast Examination
• Mammograms

SCREENING
Average-size lump found by woman
practicing occasional breast self-exam
(BSE)
Average-size lump found by woman
practicing regular breast self-exam
(BSE)
Average-size lump found by first
mammogram
Average-size lump found by getting regular
mammograms

BREAST SELF EXAMINATION (BSE)
• Opportunity for woman to become familiar with herbreasts
• Monthly exam of the breasts and underarm area
• May discover any changes early
• Begin at age 20, continue monthly

WHEN TO DO BSE
• Menstruating women- 5 to 7 days after the beginning of their period
• Menopausal women - same date each month
• Pregnant women — same date each month
• Takes about 10 minutes
• Perform BSE at least once a month
• Examine all breast tissue

CLINICAL BREAST EXAMINATION
• Performed by doctor or trained nurse practitioner
• Annually for women over 40yrs
• At least every 3 years for women between 20 and 40 yrs
• More frequent examination for high risk patients

MAMMOGRAPHY
• X-ray of the breast save lives in patients 50-70%
• Normal mammogram does not rule out possibility of cancer
completely
• Women (asymptomatic) 40 years of age and more should have
a MAMMOGRAM every year.

MYTHS
•Touching the breasts too often will lead to cancer
•Talking about cancer causes cancer
•Using illegal drugs causes cancer
•Herbs cure breast cancer
•A bruise on the breast will lead to breast cancer.
•If an incision is made during breast cancer
surgery the cancer will spread.
•Getting too many mammograms leads to
breast cancer.
•A breast cancer diagnosis is an automatic death
sentence.

FACTS
• Breast cancer commonly affects older women
• If you have a risk factor for breast cancer, you're likely to get
the disease
• Mammograms are only used to evaluate breast lumps.
• Breast cancer is preventable

SCREENING OF CERVICAL
SCREENING

INTRODUCTION
• Cervical cancer second most common cancer in women
in India & other developing countries
• Most common cause of cancer death in women -India
• Prevention of cervical cancer is possible by screening
• It is a public health problem
• Primary etiological factor - Human Papilloma virus(HPV)
• Preinvasive cancer cervix---- Invasive cancer
• Prevention of Invasive cancer is by screening, diagnosis
& treatment of preinvasive diseases and by vaccination
against HPV

PREVALENCE
• Infection by highrisk HPV occurs in 36% women .
• Prevalence is high in younger women .
• The incidence decreases with age .
• Prevalence of CIN I - 3%, regress 1% progress to Invasive cancer
CIN Il &CIN Ill is 0.6&0.4 % respectively
Caused due to persistent HPV infection

TERMINOLOGY
• Previously Dysplasia - Mild, Moderate & Severe
• CIN l- Mild dysplasia
• CIN ll- Moderate Dysplasia
• CIN Ill- Severe Dysplasia

BETHESDA SYSTEM
• CIN I-LSIL
• CIN Il & Ill -HSIL
• Immunostaining of P 16 is diagnostic for CIN
• CIN P16 negative - CIN I
• CIN P16positive CIN Ill

NEW TERMINOLOGY BY ACP & ASCCP
• CINI
• CIN Il P16 negative LSIL
• CIN Il P16 positive
• CIN P16 positive - HSIL

• Etiopathogenesis -Transformation zone
• Most cervical malignancies occur at transformation zone(TZ )
• Squamocolumnar junction (SCJ)
• Dynamic area -metaplastic activity - oncogenic
activity

HPV
• Low risk- genital warts-6 & 11
• 40,42,43,44,54,61,72&81
• High risk-60% of CIN2&ClN3- 16 & 18;
• cervical cancer 50%- I-IPV 16; HPV 18
31,31,35,45,52,56,58,59,68,69,82 rest can
cause 19% ca cervix

PREVENTION OF INTRAEPITHELIAL
NEOPLASIA (IENP)& CERVICAL CANCER
• Awareness
• Safe sex
• Use of barrier method to prevent STD
• Lifestyle modification
• HPV Vaccine
WHO 2020-Triple intervention
• Vaccination by age of 15-90%
• 70%of women screened at least twice in the lifetime
• Appropriate management of 90% of women foe precancerous
/cancerous lesion

Prevention of intraepithelial neoplasia (IENP)& Cervical cancer
Awareness
• Safe sex
• Use of barrier method to prevent STD
• Lifestyle modification
• HPV Vaccine
WHO 2020-Triple intervention
• Vaccination by age of 15-90%
70%of women screened at least twice in the lifetime
Appropriate management of 90% of women foe precancerous
/cancerous lesion

Secondary Prevention
Prevention of progression of Intraepithelial lesions
to invasive cancers
Diagnosis, appropriate ,management of
precancerous lesion & follow up
Screening for Intraepithelial / invasive cervical cancer
Screening asymptomatic women
Easy to do as cervix can be easily visualized, long course 10-20 years
precancerous lesion -cancer cervix

CERVICAL CYTOLOGY
• The exfoliated cervical cells can be collected by scaping -
staining the smear
• The cells -abnormality seen -premalignant lesions/ malignant
lesions
• Papanicolaou stain - Pap test
• Cervical cancer screening by Pap smear - decrease the
incidence of cervical cancer by 60-70%

Methods used for cervical cancer
Screening
Universal Screening methods
• Cytology
• Conventional
• LBC
• HPV testing
Methods for resource setting
• VIA
• VIAM
• VILI
• Point of care HPV testing

CYTOLOGICAL SCREENING
• Conventional cytology (Pap smear)
• Bivalve speculum
• Ayre's spatula
• Scaping done from ectocervix
• Endocervix scraping - cyto brush
• Smear made - fixed in 95% alcohol or ether/ fixative spray
• Stain -examine under ME
• Low sensitivity -, High specificity
• Metanalysis - sensitivity 51%; false negative 49%;
• Specificity - 98%

LBC
• Cells are scraped using special broom
• Cells are collected in liquid medium & transported
to lab
• Processed , smear of monolayer of cells made &
fixed
• No drying, blood and debris are removed
• The residual sample used for HPV
• Detection rate of CC & LBC are same no difference
was found

CAUSES FOR FAILURE OF SCREENING
PROGRAM
• Lack of awareness
• Lack of infrastructure
• Lack of technical expertise
• Need for repeated testing
• Lack of good referral system Poor resources Poor facility of
treatment of test positive

HPV TESTING FOR SCREENING CERVICAL CANCER
• Detects high risk HPV’s
• DNA based test used often, mRNA tests are available
• More sensitive than cytology alone
• Has high negative predictive value
• Reduces cervical cancer incidence & mortality
• Can be used for Cotesting with cytology
• Primary HPV testing
• Recommended as primary testing for all women >30 years
Frequency -every 5 years

• The overall sensitivity- 98%
• Specificity- 85%
• HPV testing identifies those at risk for developing cancer
• Cytology detects existing diseases
• Cotesting - cytology +HPV
• Reflex testing- high risk HPV is found cytology is
• Equivocal- colposcopy is required

SCREENING MODALITIES USED IN LOW
RESOURCE SETTING
• Cytology & HPV testing is difficult to implement
• VIA- 3-5% freshly prepared acetic acid is used
• Low grade lesions -dull white plaque and faint borders
• High grade lesions- sharp borders
• Inexpensive
• Does not require expertise
• Minimal training required
• Can be performed by health workers
• Sensitivity 60%; Specificity- 79%; PPV-10-20%; NPV -92-97 %
• False positive rate is high -high number of referral

VIA POSITIVE
• Referral for colposcopy & cervical biopsy &
treatment
• Screen -see- treat
• Immediate treatment depends on VIA report screen & treat
• Referral for VIA with magnification VIAM followed by biopsy & treatment
• VIAM-After acetic acid application handheld magnification lens is used for
reducing false positive cases .

VISUAL INSPECTION AFTER LUGOL'S IODINE
• On application of iodine, the normal cervical epithelium which is reach in
glycogen stains mahogany brown (Schiller's test).
• The abnormal areas, columnar epithelium and areas lined by immature
metaplastic epithelium do not contain iodine and appear mustard yellow
• The test has the same specificity and similar advantage and disadvantage as
VIA

POINT OF CARE ( RAPID RESULT) HPV TESTING
• Point of care or rapid result HPV test is a rapid test that identifies
high risk HPV and is less expensive.
• The results are available in 2.5 hours
• The test is superior to VIA, and comparable to standard HPV testing.
• Self collected sample by using vaginal tampon, cotton swab or
cytobrush can be used for HPV testing in low resource sitting
• No significant difference in self collected [provider collected samples
• Xpert HPV testing using PCR, similal to Gene Xpert for
tuberculosis is also available in some countries
• Combining VIA & HPV testing performed together or sequentially
improves sensitivity & reduces false positive

COLPOSCOPY
• Visualization of Cervix vagina &vulva under magnification to detect premalignant
lesions of vulva , vagina and cervix
• Place the patient in dorso lithotomy position
• Place colposcopy one foot from vulva
• Insert bivalve speculum
• Focus colposcope on the cervix
• Use low power for overall visualization initially
• Shift to high power for closer visualization
• Clean with saline, remove mucus and note findings
• Apply 3% acetic acid note findings
• Apply Lugol's iodine and note findings
• Document colposcopic findings
• Biopsy if indicated

COLPOSCOPY FINDING
• See for adequacy - no inflammation, bleeding or
scarring
• Typical appearance of CIN
• Mosaic & punctation- abnormal capillary distribution
grade 1 or grade 2
• Inner border sign - sharp acetowhite demarcation with
in a les opaque acetowhite area
• Ridge sign- thick opaque ridges of acetowhite
epithelium growing irregularly in the SCJ,

DOC-20241220-WA0005[1].pptx screening of breast cancer

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