visual screening
TRANSCRIPT
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Screening for Cancer Cervix
by Visual Technique
Professor .Surendra Nath Panda,M.S.of Obstetrics and Gynecology
M.K.C.G.Medical College
Berhampur, 760004, Orissa, India
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Cervical Cancer
500,000 new cases identified each year
80% of the new cases occur in developing
countries
At least 200,000 women die of cervical cancer
each yearCervical cancer is the third most common
cancer worldwide
Magnitude of the Problem: -
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Natural History of Cervical Cancer:
Source: PATH 1997.
HPV-related Changes
Normal Cervix
Low-Grade SIL (Atypia, CIN I)
High-Grade SIL (CIN II, III/CIS)
Invasive Cancer
HPV Infection
CofactorsHigh-Risk HPV
(Types 16, 18, etc.)
About 60%regresswithin2-3 yrs
About 15% progress within 3-4 yrs
30% - 70% progress within 10 yrs
Current Understanding
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Prevention of Cervical Cancer
Cervical cancer is a preventable disease
Primary prevention:
Education to reduce high risk sexual behaviour
Measures to reduce/avoid exposure to HPV andother STIs
Secondary prevention:
Treatment of precancerous lesions before theyprogress to cervical cancer (implies practicalscreening test)
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Secondary Prevention of Ca.Cx.
Key Point is to detect precancerous lesionsDown staging
Answer: - A good screening method
PAP smear test is considered to be the goldstandard Has limitations ?
Alternatives to Pap Smear What are they?
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Qualities of a Good Screening Test?
Safe
Practical
AffordableAvailable
Effective
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Limitations of Pap Smears for NationalScreening Programs
Pap smear-based programs require complex logistics,advanced training, and well managed program
implementation for adequate testing to occur.
These elements are not available outside large cities
in many low-resource settings.
Even in large cities, quality pap smears are possible
but ongoing supervision, refresher training and
continued supplies are necessary.
Cytology is not viable as a nationally accessible
screening method in many developing countries in
Low Resource Settings.
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Alternatives to Pap Smear Screening
Cervical cancer is a significant public health problem
in many countries.
Cervical cancer is a sexually transmitted disease.
Cervical cancer is preventable (i.e., Methods of
screening and treatment for precancerous lesions
exist).
Pap Smear as a screening methods may not be
appropriate or adequate for many low-resource
settings.
Why?
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Cervical Cancer Screening
Visual inspection with acetic acid (VIA)
Visual inspection with acetic acid and
magnification (VIAM): Gynescope or Aviscope
Colposcopy
Cervicography
Automated pap smears
Molecular (HPV/DNA) tests
Other Options: -
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Approaches to Cervical CancerPrevention in Low-resource Settings
Source-Program for Appropriate Technology in Health [PATH] 1997.
Effective Safe Practical Affordable Available
VisualInspection:AA
Yes Yes Yes Yes Yes
VisualScreening:Unaided
No Yes Yes Yes Yes
AutomatedPap Screening
Yes? Yes ? No No
HPVScreening
Yes Yes ? ? Yes
Cervicography Yes? Yes ? ? Yes
HPV Vaccine ? ? Yes ? No
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What Is VIA / Cervicoscopy ?
Looking at the cervix to detect abnormalities after
applying acetic acid
Acetic acid is used to enhance and mark the
acetowhite change of a precancerous lesion or actual
cancer
Sensitivity and specificity of VIA - 70-92%
Positive Predictive Value - 15-20%
Visual Inspection after Acetic Acid Also known as Aided Visual Inspection of Cervix, or
Acid Acetic Test
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History of Research on Visual Inspection
Historically, before the advent of Pap smears andprogrammatic screening, healthcare providers relied
on looking at the cervix to detect abnormalities.
Schiller test has been used for many years(to aid in
differentiating "mature" normal from "immature" abnormalepithelium).
After the 1950s, when the Pap smear became the
standard for cervical cancer screening-.
Increasing numbers of women undergoing this test led toincreased utilization of the colposcope (initially developed inthe 1930s) to confirm screening findings.
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History of Research on Visual Inspection
Years later, given the expense and inconvenience ofcolposcopy services, clinicians began to explore
whether unmagnified visualization of the cervix (with
acetic acid) could be used as an adjunct to cytology
so that patients in need of colposcopy could beidentified more effectively and efficiently.
However few studies were conducted, that examined
the value of unmagnified inspection of the cervix after
the application of acetic acid (VIA) for purposes ofidentifying a normal "transformation zone" or
detecting precancerous lesions of the cervix (i.e.,
primary screening).
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History of Research on Visual Inspection
Then, in 1982, Ottaviano and La Torre published animportant study involving 2,400 women who were
examined visually and colposcopically after a cervical
wash with acetic acid.
"naked-eye" (unmagnified) inspection detected abnormalitiesin 98.4% of the cases (i.e., in 307 of 312 patients assessedcolposcopically as having an abnormal transformation zone).
These authors concluded that "colposcopic magnification isnot essential in clinical practice for the identification of thecervix at risk."
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History of Research on Visual Inspection
In 1990, Abrams published his experience with the"Gynoscope," a monocular telescope with a
magnifying power of 2.5,
high correlation between the (visual) Gynoscope examination
and cytology. should be considered as a practical adjunct that willencourage better sampling by the clinician.
World Health Organization (WHO) supported a study
in India between 1988 and 1991 in which unmagnified
visual inspection with acetic acid washing wasevaluated as a "down staging" technique.
VIA was found to be effective in identifying women withcancer at an earlier, more treatable stage.
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History of Research on Visual Inspection
Several other comparative studies in Kenya,Zimbabwe and South Africa suggest that visual
inspection with acetic acid performs comparably to
the Pap smear and/or other screening tests.
More recent studies have also demonstrated that "VIA
is a safe, simple and effective adjunct to the
Papanicolaou smear for cervical cancer screening
and can be helpful in reducing referrals forcolposcopy without compromising quality of care.
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Needed Equipment andSupplies for VIA
VIA can be performed in any clinical settingwhen the following are available:
Examination table, preferably with stirrups or legsupports
Sterile speculum, preferably Cusco'sSterile glovesSource of light, a lamp or a torchCotton swabs
ForcepsSyringe for acetic acid lavageAcetic acid in dilutions of 3-5%Stationary, to record examination findings
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The Examination
The procedure and the reason for it should be carefullyexplained to the woman to be examined and she should be made
as comfortable as possible. Take into consideration the privacy
of the patient.
Put patient in lithotomy position (if possible) or suppine with
legs bent at knees.
Good visualization is essential. Direct the light source to the
genital area.
Observe and record any abnormal findings in the external
genitalia.
Lubricate the speculum with warm water and insert into the
vagina with the speculum closed.
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The Examination
Open the speculum and adjust the light source so as to get aclear view of the cervix.
If there is excess mucus or discharge, clean it with a cotton
swab soaked in boiled water or normal saline solution.
Observe any abnormal findings.
Wash the cervix with the acetic acid (3-5%) with the help of the
syringe. Alternatively can be applied with a cotton swab.
Wait for approximately 1 minute.
Inspect the cervix for acetowhite areas.
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The Examination
Do not perform the examination if the woman
is having menstrual period or is using
intravaginal medication. Advise her to comeback when the mensus or the treatment is
over.
Do not apply acetic acid if there is a grosslesion suspicious of malignancy, refer patient
directly to oncology / tertiary care facility.
Important
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Objectives Of Acetic Acid Examination
Locate the squamocolumnar junction
Identify any lesion & its limits
Decide whether the lesion is CIN
Determine whether invasion is possible
Select a site or sites for biopsy if appropriate
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What does Acetic Acid do?
Acetic acidDissolves mucus
Induces intracellular dehydration
Causes coagulation of protein
As a result cells with increased
Nuclear / Cytoplasmic ratio ratio
Nuclear density
Chromosomal aneuploidy
Become opaqueacetowhite areatest positive
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Abnormalities Seen After Acetic Acid
Aceto-white
Margins and surface
White gland openings
Mosaic & punctation
Abnormal vessels
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What May Be Acetowhite
All acetowhite patches are not cancerAny of these epithelial changes can become
acetowhite
Healing or regenerating epitheliumCongenital transformation zone Inflammation Immature squamous metaplasia
HPV infectionCIN / CGINAdenocarcinoma Invasive squamous cell carcinoma
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Reporting Visual Inspection Findings
Smooth, pink
Clear mucoid secretion
Central hole-'external os'
Nulliparours-roundMultiparous-slit or cruciate
Cervix in postmenopausalwomen is atrophic
BEFORE ACETIC ACID APPLICATION- Unaided visualinspection of Cx Clinical Down staging
Normal Cervix
NORMAL: -
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Reporting Visual Inspection Findings
Hypertrophy
Redness or congestion Irregular surface
Distortion
Simple erosions (do not bleed on touch)
Cervical polyps (with smooth surface)
Abnormal discharge: foul smelling, dirty / greenish, cheesy white,blood stained
Nabothian follicles
Prolapsed uterus
BEFORE ACETIC ACID APPLICATION- Unaided visualinspection of Cx Clinical Down staging
ABNORMAL: -
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Reporting Visual Inspection Findings
Clinical interpretation can be:
Infection
Ectopy (Erythroplasia)
Benign tumour
SUSPICIOUS OF MALIGNANCY: - Erosion that bleeds on touch or friable
Growth, with an irregular surface or friable
BEFORE ACETIC ACID APPLICATION- Unaided visualinspection of Cx Clinical Down staging
ABNORMAL: -
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Reporting Visual Inspection Findings
AFTER ACETIC ACID APPLICATION- Aided visualinspection of Cx Acid Acetic Test
Acetic Acid Test-
Negative
Aceto-white area(s) not
presentAcetic Acid Test-
Positive
Aceto-white area(s)
present
Important: All findings, normal or abnormal, should becarefully recorded in a printed form. The patient should
be informed and explained the follow-up procedure
accordingly.
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Action Plan
VIANegative Positive
Follow-up after 3-5
years according tothe decided policy.
Advise to come
back if develops
symptoms.
Treat / Refer to an
appropriate center-
PHC/ Secondary /
Tertiary / Oncology
Centre
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Action Plan
If infection is suspected /present take a swab
and send for analysis.Treat the patient
accordingly. Re-examine after six weeks. If no signs of infection: - perform Pap-smear
and / or Colposcopy:
I. Pap-smear / Colposcopy negative: re call
for follow-up in 6-12 months.
II. Pap-smear / Colposcopy positive: call the
patient for appropriate treatment
Management of VIA Positive Cases: -
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VIA - The Status To-Day
A randomised trial of early detection of breastand cervical cancers using low cost
technology approaches - Professor I. Mittra,
Tata Memorial Hospital, Mumbai.The study is now in its 3rd year and 110,000 women
have so far been randomised.
VIA appears to be more sensitive but less specific
than the PAP smear.
Why VIA as an Alternative in
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Why VIA as an Alternative inLow-resource Settings?
Non-invasive, easy to perform and inexpensiveCan be performed by all levels of healthcare workers,
in almost any setting
Skills consistent with service delivery tasksperformed by nurses/midwives in MCH/FP clinic
settings
Results are available immediately
Why VIA as an Alternative in
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Why VIA as an Alternative inLow-resource Settings?
Initial treatment can be provided at the time ofthe examination
All system requirements are available locally
Potential for immediate link to treatment
Approach suitable for lowest-resource
settings
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A
At the service of women
V I A