ss 2017: prevention of cervical cancer

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  1. 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
  2. 2. Father of Gynae- Oncology in Sri Lanka
  3. 3. 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
  4. 4. Cervical Cancer
  5. 5. 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.
  6. 6. Common early symptoms Inter-menstrual bleeding post-menopausal bleeding Post-coital bleeding Abnormal vaginal bleeding An unusual vaginal discharge Excessive sero-purulent discharge
  7. 7. 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
  8. 8. HPV types and disease association
  9. 9. 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
  10. 10. 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
  11. 11. Prevention Primary prevention - Lifestyle factors HPV vaccine
  12. 12. 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.
  13. 13. 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
  14. 14. After vaccination
  15. 15. 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%
  16. 16. 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.
  17. 17. Conventional cytology: Pap smear . a) Combined spatula b) Endocervical brush c) Cervical broom
  18. 18. Cyto brush
  19. 19. 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
  20. 20. Cervical changes
  21. 21. Normal variations-colposcopic view Post menopausal Cervical ectropion
  23. 23. Pre malignant lesions- Cervix LGSIL HGSIL
  24. 24. Abnormal cervix
  25. 25. 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.
  26. 26. 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.
  27. 27. 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.
  28. 28. 2.Loop excision(LLETZ)
  29. 29. 3.Cone biopsy
  30. 30. Where we are
  31. 31. 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.
  32. 32. National Cancer Institute Sri Lanka Annually 8000 new cancer patients registered 1200 oral cancer 1100 breast cancer 500-600 cervical cancer
  33. 33. 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
  34. 34. 41Source: National Cancer Control Programme Cervical Cancer : age distribution in Sri Lanka - 2009
  35. 35. 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)
  36. 36. Number of Well Woman Clinics
  37. 37. Percentage of women attending Well Woman Clinics
  38. 38. Percentage of 35 year age cohort screened with Pap smear
  39. 39. 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
  40. 40. 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
  41. 41. 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
  42. 42. 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
  43. 43. HPV vaccine was Introduced under EPI programme in 2017
  44. 44. A woman should not die or suffer from cervical cancer when it is preventable! 54
  45. 45. Dr. Deepa Gamage- Community Medicine Consultant
  46. 46. 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.
  47. 47. 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.
  48. 48. HPV test of cure CGIN treated patients are a


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