SS 2017: Prevention of cervical cancer
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Dr. Chintana Hapuachchige discusses the prevention of cervical cancer at the National Cancer Institute of Sri Lanka, emphasizing the role of HPV as a major cause and the importance of vaccination and screening. The document highlights the low screening coverage and the need for increased public awareness and better follow-up systems for early detection and treatment of cervical cancer. It outlines various screening methods, treatment options for CIN, and global cervical cancer statistics, urging urgent action to combat rising mortality rates associated with the disease.
![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](https://image.slidesharecdn.com/9-171009071140/85/SS-2017-Prevention-of-cervical-cancer-10-320.jpg)
![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](https://image.slidesharecdn.com/9-171009071140/85/SS-2017-Prevention-of-cervical-cancer-47-320.jpg)
![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](https://image.slidesharecdn.com/9-171009071140/85/SS-2017-Prevention-of-cervical-cancer-48-320.jpg)
SS 2017: Prevention of cervical cancer
- 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
- 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
- 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.
- 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