1. Screening for Cervical Cancer by Visual Inspection Techniques Dr Aruna Batra VMMC & SJH

2. Cervical Cancer- Facts A significant public health problem 2 nd commonest cancer in ώ worldwide Annually 3,70,000 new cases of cervical cancer, 80% in developing countries Leading cause of death in developing countries, often killing women at young ages

3. Cervical Cancer- Facts Cause: virtually all cases of cervical cancer are caused by persistent cervical infection with some types of Human Papilloma Virus (STI) Develops slowly, has a detectable and treatable precancerous stage Preventable disease

4. Cervical Cancer- Why preventable? Easy accessibility of Cx & TZ

5. Natural History of Cervical Cancer HPV-related Changes Normal Cervix Low-Grade SIL High-Grade SIL Invasive Cancer HPV Infection Cofactors High-Risk HPV About 60% regress within 2-3 yrs 15% progress êin 3-4 yrs 30 - 70% progress êin 10 yrs

6. Cervical Cancer- Risk Factors Early age at marriage Multiple sexual partners Sexually transmitted infections Poor socio-economic status Smoking Immunological factors

7. Prevention of Cervical Cancer Primary prevention: –Education to ↓ high risk sexual behaviour –Measures to avoid exposure to HPV & STIs Secondary prevention: –Detection & Treatment of precancerous lesions before they progress to cervical cancer

8. Cervical Cancer Screening Papanicolou smear (cytology) Visual Inspection techniques Colposcopy, Cervicography Molecular (HPV DNA) tests Methods available

9. Limitations of Pap Smears for National Screening Programs Primary screening is repetitive, labour intensive, time consuming Subject to errors of interpretation Sensitivity 60-70% Complex logistics, advanced training, good program implementation required

10. Limitations of Pap Smears for National Screening Programs Pap Smear as a screening methods may not be appropriate or adequate for many low-resource settings Even in large cities, quality Pap smears possible but require ongoing supervision, refresher training & continued supplies. Cytology is not viable as a nationally accessible screening method in many developing countries

11. Visual Inspection Techniques * Unaided Visual Inspection * Visual inspection with acetic acid (VIA) * Visual inspection with acetic acid and magnification (VIAM) * Visual inspection with Lugol’s Iodine (VILI)

12. Unaided Visual Inspection of Cervix - Dx at stage III & IV ↓from 85% to 55% - Dx at stage I & II: ↑ from 15% to 45% Kerala Study 1977-87

13. Unaided Visual Inspection of Cervix -60% of Early disease could be identified -11% were false positive -Only 15-20% of pre-cancerous lesions could be detected Singh V et al 1992 Good for Clinical Down staging Misses Precancerous lesions

14. Visual inspection with acetic acid VIA Looking at the cervix to detect abnormalities after applying acetic acid Acetic acid is used to enhance and “mark” the aceto-white change of a pre- cancerous lesion or actual cancer

15. VIA- Basis Produced due to osmolar changes after acetic acid application, causing water of the cell to leave Collapse of the cell membrane around the abnormal and enlarged nucleus Altered lesion appears white due to reflection of the incidental light

16. VIA positive Dysplastic lesion HPV lesion

17. VIA Negative Normal Cervix

18. VIAM (Visual Inspection with Acetic Acid Using Magnification) VIAM is visualization of cervix after application of acetic acid using low power magnification (2.5x to 4x) Magnascope (4X)

19. VILI Positive Negative Normal squamous epithelium Columnar epithelium

20. Comparison of Screening Methods MethodSensitivity (%)Specificity (%) Cytology45-8580-98 VIA60-9066-96 HPV DNA65-9570-96 NEJM Nov17,2005

21. Screening Costs

22. Ca Cx prevention in Thailand: Single visit: VIA & Cryosurgery 5999 women tested by VIA -13.3% VIA + counseled for immediate Cryo - Accepted by 98.5% - Minor side effects: 2.2%, Major Cp: nil - 83.2% came for follow up, > 95% satisfied RTCOG: Lancet 2003; 361: 814-820 Safe, acceptable, feasible

23. Visual Inspection Techniques in Low resource setting Noninvasive, easy to perform, inexpensive All requirements are available locally Can be performed by all levels of healthcare workers, in almost any setting Results are available immediately Initial treatment can be provided at the time of the examination

24. RCH program can act as a powerful tool in preventing Cervical cancer: * Creating Awareness * Using Simple Screening methods Conclusion