VIA Technique for cervical cancer screening Prof. Dr. Tasneem Ashraf By President Society of Obstetricians & Gynecologists of Pakistan (SOGP) Councilor South Asian Federation of Obstetricians & Gynecologists (SAFOG) Councilor Asia Oceania Federation of Obstetricians & Gynecologists (AOFOG) Provincial Coordinator National Committee for Maternal & Neonatal Health (NCMNH) Head of Gynae Unit-II Bolan Medical College Complex Hospital, Quetta

CERVICAL CANCER Cervical cancer is 2nd most common female cancer . one of the leading causes of cancer deaths in developing countries. 510,000 new cases / year & more than 288,000 deaths worldwide. 80% of cervical cancer occurs in developing countries. ⅔ of the cervical cancer diagnosed are found at an advanced stage with a poor prognosis for survival.

Importance of cervical cancer screening in Pakistan Pakistan has 59.04 million women between 16-69 years at risk of developing cervical cancer. Current estimate indicate that 5233 women are diagnosed and 2876 die of this disease every year2 . Only 3.4 % of urban women between 16- 69 years are screened every 3 years (WHS Pakistan). It is completely preventable, if precancerous lesions are identified and treated early. Globally > 280,000 women die of cervical cancer and 85% of them are from developing countries. Cx cancer is the leading cause of cancer deaths after breast cancer. Sensitivity : is the ability of the test to correctly identify those having disease.(TP/TP+FN)). Specificity is the ability of the test to correctly identify those without disease( true –ve)( TN/FP+TN).

Cervical cancer screening Methods 1: Conventional cytology (Paps smear) (sensitivity44-  86% specificity62- 98%). False –ve 50%. 2: Liquid-based monolayer cytology (sensitivity 61% - 86%, specificity 82%).↓ inadequate rate 9 to1.6%. 3: Human Papilloma virus(HPV DNA) testing (sensitivity 88% to 91% specificity 73% to 97%).It is of value in the triage of low grade smear abnormalities. 4: Visual inspection of the cervix, using acetic acid (VIA) (sensitivity30%- 95% specificity 64-97%). 5 : Visual inspection with Lugol's iodine (VILI).

What is the best method of cervical cancer screening in low resource countries? Test having maximum coverage & sensitivity, affordability and feasibility

VIA: an alternative method of cervical screening in low resource setting. VIA is simple accurate, inexpensive and acceptable method. based on naked-eye inspection of the cervix under bright light at least 1 minute after swabbing the cervix with 3% to 5% acetic acid solution (ordinary table vinegar).

Advantages of screening by VIA method VIA have better results than cervical cytology. It eliminates the need for labs, cytologists and transport of specimens. Require very little equipment. provides the women with immediate test results making it possible to screen and treat women during the same visit. A range of medical professionals—doctors, nurses, or midwives—can effectively perform the procedure, provided they receive adequate training and supervision.

Advantages of VIA As fewer specialized personnel, less infrastructure, training, and equipment are required ,so VIA screening can be implemented in remote public health care settings with more coverage. Results and follow-up care can be provided on the spot so reduces the number of women who may miss out .

Limitations VIA may be less effective for older women in their 50s or 60s because of the tendency of the transformation zone to recede into the endocervical canal. Like cytology, one of the limitations of VIA is that results are highly dependent on the accuracy of an individual's interpretation. This means that initial training and on-going quality control are of paramount importance

When to Perform VIA VIA is indicated on any sexually active woman age 25- 50 and those complaining of excessive vaginal discharge or postcoital bleeding.  VIA can be performed at anytime during the menstrual cycle, including during menses (providing flow is not too heavy), during pregnancy, at a postpartum examination, or during a post abortion checkup or at STI clinic. Women between 25 and 49 years should be screened every 3 yrs, 50- 64 Years are screened every 5 years

Preparing the Woman for VIA Health care providers need to council the woman about explanation of the procedure, why it is being done, what the possible findings might be, as well as what follow-up care might be necessary. A brief history should also be taken including menstrual history, bleeding pattern (irregular or postcoital bleeding), parity, age, current pregnancy status . contraceptive method. family history of cancer especially in mother or sister.

Equipment Needed for VIA Examination Table Light Source Bivalve speculum Instrumental tray Cotton swabs & sponge holding forceps. Examination gloves 4% acetic acid (or white vinegar) 0.5 % chlorine solution Report form for the result

Procedure Assemble equipment and arrange on the tray. Ensure that the light source is working. Assist woman onto the examination table after she has emptied her bladder. Put on gloves. Inspect the external genitalia for the presence of lesions, papules, vesicles, ulcerations, condylomata, discharge, redness, swelling, excoriation.

Procedure Normal cervix Lubricate the speculum with clean, preferably warm, water. Slowly and carefully insert the speculum without scraping the cervix. Adjust the speculum, so the entire cervix is in view and adjust the light as needed. Observe the size and shape of the cervix and the external os. Identify the anterior and posterior lip of the cervix, red columnar epithelium, pink squamous epithelium, the squamo- columnar junction, and the transformation zone. Normal cervix

Inspection Inspect the cervix for cervicitis, discharge ectopy, nabothian cysts, ulcers, warts, polyps, leukoplakia (thickened, white patches), or tumors. Is there any bleeding from the cervix, especially after you touch it? Use a dry cotton swab to wipe away any discharge, blood, or mucus from the cervix. Observe all four vaginal fornices to make sure they are free from any growth. Record any abnormal visual findings. Polyp &Nabothian cysts

Procedure Soak a clean swab in 3% to 5% acetic acid and apply to the cervix . Wait at least 1 full minute for the acetic acid to be absorbed (use a watch). Tell the woman that she might feel a slight burning sensation. Check the transformation zone carefully, especially near the squamo-columnar junction, for any dense, non-movable acetowhite areas in the epithelium.

Look around the entire transformation zone for any raised and thickened white plaques or acetowhite lesions. If acetowhite areas are identified, note the location, extension, intensity of whiteness, borders and demarcations, as well as size. Larger, thicker, more opaque lesions with clearly defined borders next to the squamocolumnar junction suggest more severe cervical disease. Acetowhite area

Reporting VIA test results VIA negative or normal (-) VIA positive (+) VIA positive, invasive cancer

VIA positive (+) Is scored when there are distinct, well defined, dense, opaque or dull white , acetowhite areas, touching the squamocolumnar junction (SCJ) or touching the external os (if SCJ not seen) Circumferential white lesion surrounding the os or the whole cervix turns white after application of acetic acid.

VIA positive. Well defined opaque acetowhite area with digitating margins on ant. and posterior lip abutting SCJ and extending into cervical canal.

VIA positive VIA positive Well defined aceto white area Aceto whitening on posterior lip abutting abutting SCJ and bleeding on touch. SCJ

VIA positive VIA positive Well-defined aceto whitening in anterior lip abutting SCJ with satellite lesion on posterior lip.

Before application of acetic acid VIA positive Bleeding on touching the cervix Aceto whitening in anterior and posterior lip.

VIA positive Dense aceto whitening in col. Epithelium in ant. Lip.

VIA negative or normal Is scored when any of the following occur: No acetowhite lesions; Blush white lesions or faint patchy lesions or doubtful lesions without definite margins; Polyp protruding from the os taking up acetowhitening; Nabothian cysts taking up acetowhitening and appearing as whitish acne (pimples); Faint line-like acetowhitening at the junction of columnar and squamous epithelium;

VIA negative or normal Acetowhite lesions far away from the transformation zone; Streak like acetowhitening; Dot like areas in the endocervix, which are due to grape-like columnar epithelium staining with acetic acid; When there are shiny or cloudy white lesions with ill-defined, indefinite margins.

VIA Negative SCJ with advancing edges of metaplasia Large ectropion

VIA negative Nabothian cysts after application of Acetic acid. Ill defined pinkish white hue.

VIA negative Ill defined pinkish white hue.SCJ fully visible. Dot like acetowhitening. Ill defined pinkish white hue.SCJ fully visible.

VIA negative, cervix unhealthy, inflamed, SCJ prominent with acetic acid. Ulceration, necrosis,.

VIA positive, invasive cancer Is scored if there is clinically visible ulcero-proliferative growth on the cervix that bleeds on touch.

VIA positive invasive cervical cancer Dense acetowhitening with raised areas Abnormal vascular pattern bleeding

Acto-whitening and ulcero-proliferative growth

Management of pt after VIA test. VIA –ve :Advised follow-up after five years; Cervicitis : Advised medication for Cervicitis and follow-up after six months. VIA +ve :Referred for colposcopy. VIA + ve :Referred for immediate treatment. VIA + invasive :Referred for staging and treatment of invasive cancer.

Management of VIA positive Women with acetowhite lesions are usually treated with cryotherapy or loop electrical excision procedure (LEEP). Cryotherapy is a simpler and less expensive outpatient procedure that requires a steady supply of compressed refrigerant gases (N2O or CO2). Cryotherapy is effective in treating 90% of suitable patients and can often be done during the screening visit. It is less effective when lesions extend into the endocervix or are larger than the probe tip.  LEEP is 90% to 95% effective in treating high-grade precancerous lesions. However, in developing countries this may only be available at regional centers. Both LEEP and cryotherapy have failure rates of 10% to 15%; therefore, post-treatment follow-up within 1 year is recommended. Women with very early stage invasive cervical cancer may be offered hysterectomy at the regional hospital

Result reporting form Pt ‘s Biodata Clinic/Serial/Hospital number ________ Date of testing [ ][ ]-[ ][ ]-[ ][ ] Name: _________________________ Address: _______________________ Age (in years) [ ][ ]

Education (1: Nil; 2: Primary; 3: Middle; 4: High school; 5: College; 6: Not known) [ ] When did you have your last menstruation? (1: Less than 12 months ago; 2: More than 12 months ago) [ ] Marital status: (1: Married; 2: Widowed; 3: Separated; [ ] Age at marriage or first sexual intercourse[ ] Total number of pregnancies/miscarriages:[ ]

Result form Pts symptoms Do you suffer from the following? (use to indicate if the response is yes; otherwise, leave blank): Excessive vaginal discharge Itching in the external anogenitalia Ulcers in the external anogenitalia Lower abdominal pain Pain during sexual intercourse Bleeding after intercourse Intermenstrual bleeding Low back ache

Result form Visual examination findings (use  to indicate if the response is ‘Yes’, otherwise, leave blank): Squamocolumnar junction fully seen Cervical polyp Nabothian follicles Cervicitis Leukoplakia Condyloma Growth

Result form Findings one minute after application of 5% acetic acid (VIA) (1: Negative; 2: Positive; 3: Positive, invasive cancer) [ ] If VIA positive, does the acetowhite lesion extend into the endocervical canal? (1: Yes; 2: No) [ ] If VIA positive, how many quadrants are involved in the acetowhite lesion(s)? (1: Two or less; 2: Three; 3: Four quadrants) [ ]

Diagram (Draw the location of the squamocolumnar junction with a dotted line and the acetowhite area(s) as a continuous line)

Result form If invasive cancer, stage (1: IA; 2: IB; 3: IIA; 4: IIB; 5: IIIA; 6: IIIB; 7: IVA; 8: IVB; 9: Not known) [ ] Biopsy taken? (1: Yes; 2: No) (If yes, indicate the biopsy site(s) in the diagram with ‘x’ mark) [ ]

Result form Action taken: Advised follow-up after five years; Advised medication for cervicitis and follow-up after six months; Referred for colposcopy; Referred for immediate treatment; Referred for staging and treatment of invasive cancer; Other, specify______________) [ ]

Thank you