1. Early Detection of Breast & Genital Tract Malignancies

2. Screening…? Organized identification Of a pre - clinical disease state
High coverage of a target population
Continuous quality assessment.
Feasibility of treatment & follow up
Of a pre - clinical disease state
By a test that is repeated at a given interval

3. OR… Screening can be defined as
The application of diagnostic tests or procedures
To asymptomatic people
For the purpose of dividing them into two groups:
those who have a condition that would benefit from early intervention
and those who do not.

4. Early diagnosis alone does not justify a screening program
Early diagnosis alone does not justify a screening program. The only justification is early diagnosis that leads to a measurable improvement in outcome.
The Number Needed to Screen(NNS) is the number of asymptomatic women who must be enrolled in a screening program over a given period of time to prevent one death from the disease in question.
The NNS reflects both the prevalence of the disease and the effectiveness of therapy, and has the advantage of being easy to calculate and intuitively useful to clinicians and patients

5. An Ideal Screening Program…
Features of the disease
Significant impact on public health
Asymptomatic period during which detection is possible
Outcomes improved by treatment during asymptomatic period
Features of the test
Sufficiently sensitive to detect disease during asymptomatic period
Sufficiently specific to minimize false-positive test results
Acceptable to patients
Features of the screened population
Sufficiently high prevalence of the disease to justify screening
Relevant medical care is accessible
Patients willing to comply with further work-up and treatment

6. To screen or To screen not ?
Recommended Screening
Cervical Carcinoma
Breast Carcinoma
Colorectal Carcinoma
Not yet , for…
Ovarian Cancer
Bronchogenic Carcinoma
Skin cancer
Oral Cancer
Endometrial Cancer

7. Effective Screening Program
Should be tailored to suit the principles for national cancer control programs. We Should NOT copy other’s programs...
Otherwise…
Too much money & effort will be spent with minimal impact on the incidence & mortality from the disease.

8. Cervical Carcinoma 400,000 new cases identified each year
Second in frequency among women cancers.
It is still the most frequent cancer in the developing countries.
400,000 new cases identified each year
80% of new cases in developing countries
At least 200,000 women die each year
Screening programs reduced the mortality from cancer cervix in developed countries by 70%.

9. Incidence And Mortality For Cervical Cancer Vs Breast Cancer, [United States, 2000]
Source: American Cancer Society, 2000
Why…
As can be seen in the graph, compared with breast cancer, new cases of and deaths from cervical cancer in the U.S. population are relatively low.
However, there are important differences between cervical cancer and other cancers.
The Pap test, in contrast to mammography, detects cervical changes before they become cancerous to a high degree, when they are still highly curable.
Cervical cancer, unlike many other kinds of cancer, including breast cancer, can in most instances be prevented.
Treating high-grade preinvasive cervical lesions appropriately will lead to fewer new cases and deaths from cervical cancer.
Source: American Cancer Society (ACS). Cancer facts and figures—2000. Atlanta, GA: ACS; 2000.

10. Natural History Of Cervical Cancer
HPV Infection
years 1%
35%
11%
57%
>10%
LSIL
HSIL
Invasive Cancer
In the majority of cervical cancers, the disease develops through a series of gradual, well-defined, precancerous lesions, usually beginning with human papillomavirus (HPV) infection and progressing through several stages over a long period of time.
Precancerous lesions can persist, regress, or progress to an invasive malignancy.
During this lengthy, steady progression, abnormal tissue can be detected by the Pap test and removed.
On the left side of this continuum, we have infection with HPV. Although HPV appears to be necessary for the development of cervical cancer, not all HPV infections develop into cancer. It is not unusual for HPV to cause low-grade dysplasia within months of an infection.
Low-grade cervical dysplasia is usually temporary and disappears over time. At least 70 percent of low-grade dysplasia regresses spontaneously or does not progress.1 Some cases, however, progress to high-grade dysplasia.
High-grade cervical dysplasia, a precursor to cervical cancer, is much less common than low-grade cervical dysplasia. The development from high-grade dysplasia to invasive cancer usually occurs slowly, over a period of several years.
Progression to detectable, precancerous lesions can take as long as 10 years or more.
1The ALTS Group. Human papillomavirus testing for triage of women with cytologic evidence of low-grade squamous intraepithelial lesions: baseline data from a randomized trial. J Natl Cancer Inst 92: 397–402; 2000.
Overall source for graphic: Program for Applied Technology in Health (PATH). Natural history of cervical cancer: even infrequent screening of older women saves lives. Seattle, WA: PATH; 2001.
Source: PATH, 2001

11. HPV infection Condyloma Accuminata Exophytic Frond like surface
Lesion may be single or multiple
Located within or outside the transformation zone

12. HPV infection Subclinical HPV Flat lesions undetectable naked eye
Best assessed after acetic acid application
Shinny, snow-white lesions
Irregular outline
Satellite lesions beyond the transformation zone
Strong or partial uptake of Lugol’s iodine

13. What Makes the Cervix Vulnerable?

14. HPV and Genital Cancer Normal Cx Mild Dysplasia(CIN I)
Moderate Dysplasia(CIN II)
Severe Dysplasia (CIN III / CIS)
Invasive Disease

15. Elements of Screening of Cervical Cancer

16. History Taking
Ask the client if she has experienced any of the following symptoms:
Abnormal vaginal discharge
Contact bleeding
Irregular vaginal bleeding
Ask about risk factors.
Start of sexual intercourse at a young age
Multiple sexual partners (ask in special circumstances: need extra skills).
Male sexual partner having other partners (ask in special circumstances: need extra skills)
Clinical history of infection by human papilloma virus or the presence of condylomata acuminate
Note all findings in the medical record

19. Acetic Acid –enhanced Visual Inspection of the Cervix “VIA”
1. Acetic acid coagulates mucus, which becomes easier to remove.
-allows a better view of the cervix
2. Acetic acid constricts the superficial vessels and blows up the columnar papillae so that they become pale.
allows a better view of the squamocolumnar junction
3. Acetic acid causes dehydration of the cells and coagulation of cellular proteins, thereby reducing the transparency of the epithelium
allows a better recognition of dysplastic epithelium

20. Abnormalities Seen After Acetic Acid
Aceto-white
Margins and surface
White gland openings
Mosaic & punctation
Abnormal vessels

21. What May Be Acetowhite NOT All acetowhite lesions are cancer
Any of these epithelial changes can become acetowhite
Healing or regenerating epithelium
Congenital transformation zone
Inflammation
Immature squamous metaplasia
HPV infection
SIL
Adenocarcinoma
Invasive squamous cell carcinoma

45. VIA: Conclusions Alternative to cytology or HPV testing
Effective in identifying precancerous disease
Identify cancers
Effective in ruling out disease
Specificity of VIA is likely to depend on:
training intervention
presence of STDs in population screened
importance placed on picking up diseased cases
Positive predictive value of VIA can be increased through sequential or risk-based triage screening
What does all this mean? The evidence clearly supports that VIA is a viable alternative to the Pap smear as a primary screening test in service delivery settings where quality cytology is unreliable and identifying disease is a priority. This was the conclusion drawn at the end of a International Network on the Control of Gynecological Cancers consensus meeting meeting held in Tunisia last year.
VIA also confers the added advantage in that test results are available immediately. Given that VIA is rater-dependent, standardized training and close post-training supervision is critical to maintaining high levels of test performance with routine clinical application. For those concerned with relatively high false positive rate, there are ways of reducing this rate through adjunctive or triage based testing, which I will talk about in another presentation later this week

46. Visual inspection with Lugol’s iodine (VILI)
Slide overview: This presentation provides a summary of the latest evidence, as of 2003, on visual inspection with Lugol’s iodine (VILI) as a test for cervical cancer.
Original source: Alliance for Cervical Cancer Prevention (ACCP)

47. What does VILI involve?
Performing a vaginal speculum exam during which a health care provider applies Lugol’s iodine solution to the cervix.
Viewing the cervix with the naked eye to identify color changes on the cervix.
Determining whether the test result is positive or negative for possible precancerous lesions or cancer.
Slide overview: VILI is simple to administer, and a range of types of health care providers can perform the procedure with appropriate training.
Note fur bullet 3: Results of the test are available immediately and do not require laboratory support.

48. How VILI works:
Squamous epithelium contains glycogen, whereas precancerous lesions and invasive cancer contain little or no glycogen.
Iodine is glycophilic and is taken up by the squamous epithelium, staining it mahogany brown or black.
Columnar epithelium does not change color, as it has no glycogen.
Immature metaplasia and inflammatory lesions are at most only partially glycogenated and, when stained, appear as scattered, ill-defined uptake areas.
Precancerous lesions and invasive cancer do not take up iodine (as they lack glycogen) and appear as well-defined, thick, mustard or saffron yellow areas.
Slide overview: Application of iodine results in brown or black color staining in areas containing glycogen. In areas lacking glycogen, iodine is not absorbed and such areas remain colorless or turn yellow.
Note for bullet 1: Glycogen is a sugar stored by normal cells.
Note after the last bullet: Gross cancerous lesions are usually apparent before the application of iodine.

49. What infrastructure does VILI require?
Private exam room
Examination table
Trained health professionals
Adequate light source
Sterile vaginal speculum
New examination gloves, or HLD surgical gloves
Large cotton swabs
Lugol’s iodine solution and a small bowl
Containers with 0.5% chlorine solution
A plastic bucket with a plastic bag
Quality assurance system to maximize accuracy
Slide overview: The supplies and equipment required to provide VILI testing are listed here. Most of these supplies are available at even the most basic levels of the health care system in low-resource countries, although not always.
Note for bullet 4: Preferably, a bright halogen lamp that can be easily directed at the cervix. The light source needs to be something other than daylight. It can be a flashlight or torch, or a gooseneck lamp. The stronger and more consistent the light source, the easier it will be for health care providers to identify abnormalities.
Note for bullet 7: Cotton swabs can be handmade using cotton batting and broomsticks or ring forceps.
Note for bullet 9: For decontamination, an aluminium/steel/plastic container is used for immersing the gloves, and a plastic bucket or container for decontamination of instruments.
Note for bullet 10 (second to last): A bucket is used to dispose of contaminated swabs and other waste items.
Note for last bullet: Elements of a quality assurance system include (but are not limited to) supervision, periodic refresher trainings, evaluation of on-going program activities and long-term impact, a mechanism for constructive feedback from women and health care providers, and an effective information system.
Note at the end: Other necessary supplies that should be available at any clinic setting include cotton balls, gauze, and rubber or plastic sheets for the table.

50. Categories for VILI test results:
VILI Category
Clinical Findings
Test-negative
Squamous epithelium turns brown and columnar epithelium does not change color; or irregular, partial or non-iodine uptake areas appear.
Test-positive
Well-defined, bright yellow iodine non-uptake areas touching the squamo-columnar junction (SCJ) or close to the os if SCJ is not seen.
Suspicious for cancer
Clinically visible ulcerative, cauliflower- like growth or ulcer; oozing and/or bleeding on touch.
Slide overview: There are three categories of test results. Each is described in more detail on the following slides.

51. VILI: test-negative
The squamous epithelium turns brown and columnar epithelium does not change color.
There are scattered and irregular, partial or non-iodine uptake areas associated with immature squamous metaplasia or inflammation.
Slide overview: Patterns associated with a normal or inflamed cervix are visible during VILI.
Note for bullet 1 and photo: In the top photo, squamous epithelium turns black in color (due to presence of glycogen) and the columnar epithelium does not change color (due to lack of glycogen). No well-defined yellow areas are observed in the transformation zone.
Note for bullet 2 and photo: In the bottom photo, scattered, discontinuous yellow spots are seen all over the cervix and the vaginal fornices due to localized thinning caused by inflammation.
Photo source: IARC

52. VILI: test-positive
Well-defined, bright yellow iodine non-uptake areas touching the squamocolumnar junction (SCJ).
Well-defined, bright yellow iodine non-uptake areas close to the os if SCJ is not seen, or covering the entire cervix.
Slide overview: The well-defined, mustard-yellow lesions in the transformation zone indicate cervical intraepithelial neoplasia.
Note for bullet 1: The squamocolumnar junction (SCJ) is the point at which columnar cells meet ectocervical squamous cells on the cervix. This junction marks the furthest extent of the transformation zone towards or, in the case of post-menopausal women, into the cervical canal.
Photo source: IARC

53. VILI: Suspicious for cancer
Clinically visible ulcerative, cauliflower-like growth or ulcer; oozing and/or bleeding on touch.
Slide overview: Because invasive cervical cancer lacks glycogen, the growth does not stain with iodine and turns yellow. Gross cancerous lesions can be apparent before the application of iodine.
Photo source: IARC

54. Management options if the VILI result is positive:
Offer to treat immediately, (without colposcopy or biopsy, known as the “test-and-treat” or “single-visit” approach).
Refer for colposcopy and biopsy and then offer treatment if a precancerous lesion is confirmed.
Slide overview: Women testing positive may be offered further testing (colposcopy or biopsy) or treatment, or both, immediately after testing.
Note after bullet 2: The different approaches to screening, diagnosis, and treatment, based on VILI, are being evaluated in terms of safety, acceptability to women, and effectiveness in preventing invasive cancer.

55. Management options if the VILI result is suspicious for cancer:
Refer for colposcopy and biopsy and further management. Further management options include:
Surgery
Radiotherapy
Chemotherapy
Palliative care
Slide overview: If a VILI test result is suspicious for cancer, refer for further testing (colposcopy or biopsy) and management.

56. Strengths of VILI:
Simple, easy-to-learn approach that is minimally reliant upon infrastructure.
Low start-up and sustaining costs.
Many types of health care providers can perform the procedure.
High sensitivity results in a low proportion of false negatives.
Test results are available immediately.
Decreased loss to follow-up.
Slide overview: VILI has the following strengths as an alternative test for precancer or cancer in low-resource settings.
Note for bullet 1: Assuming sufficiently trained providers are available, VILI is a simple approach. Health care providers can be trained in a short period of time (1 to 2 weeks).
Note for bullet 2: In most settings, costs associated with launching and sustaining VILI-based programs are lower than other methods (except VIA). VILI can be performed in extremely low-resource settings.
Notes on bullet 3: In situations in which health care providers can receive adequate and ongoing training, VILI has the potential for adequate population coverage.
Note for bullet 4: Therefore, a high proportion of precancerous lesions are detected.
Note for bullet 5: Because results are available immediately, further investigations (such as colposcopy and biopsy), and treatment (such as cryotherapy or LEEP) can occur during the same visit, if appropriate.
Note for bullet 6: This means that additional visits for investigations and treatments are reduced.

57. Limitations of VILI:
Moderate specificity may result in over-referral and over-treatment in a single-visit approach.
Less accurate when used in post-menopausal women.
There is a need for developing standard training methods and quality assurance measures.
Rater dependent.
Slide overview: VILI also has limitations.
Note for bullet 1: The single-visit “test-and-treat” approach results in over-referral and over-treatment of women. Over-referral has important cost implications in settings with scarce resources.
Note for bullet 2: It may be difficult to interpret the color patterns associated with Lugol’s iodine application in post-menopausal women because of the degeneration and atrophy of the epithelium. Menopause reduces the production of glycogen, and the color pattern resulting from iodine application becomes confusing.
Note for bullet 3: The Alliance for Cervical Cancer Prevention (ACCP) is currently investigating these elements.
Note for bullet 4: “Rater dependent” means the test's performance depends on the abilities of the person doing the test (versus a machine, as for HPV testing). This means that even when service providers have training, test performance may vary depending on service delivery conditions and other factors.

58. The Alternative…Downstaging !!!
The detection of the disease at an earlier stage when still curable…
Just
Insert a speculum and look at the cervix

59. Warning signs of early cervical cancer
1. Yellowish and friable epithelium
2. Abnormal contour
3. Ulceration
4. Atypical vessels
5. Very severe colposcopic atypia
6. Large, significant lesion
7. Canal lesion, going out of range
8. Perimenopausal and post radiation

60. Mimics of cervical cancer
1. Severe cervicitis e.g., herpes, syphilis
2. Benign ulceration e.g., trauma
3. Foreign body reaction
4. Granulomatous cervical conditions
5. Granuloma inguinale
6. Lymphogranuloma venereum
7. Schistosomiasis
8. Cervical condylomata
Cololposcopy aids differentiation.
Histology is the gold standard

63. ACCP/ACS Guidelines for Screening
When to Start Screening
Initiate cervical cancer screening about 3 years after the onset of vaginal intercourse.
Screening should begin no later than 21 years of age.
The need for cervical cancer screening should not be the basis for the onset of gynecologic care.
(CA: A Cancer Journal for Clinicians 53(1):27-43, 2003)

64. ACCP/ACS Guidelines for Screening
When to Stop Screening:
Women aged >70 years with an intact cervix with >3 documented, consecutive, technically satisfactory/normal/negative cervical cytology tests and no abnormal/positive cytology tests within the 10 years prior to age 70 may stop cervical cancer screening.
Screening is recommended for 70+ year old women not previously screened and for whom information about previously screening is unavailable and for whom past screening is unlikely.
CA: A Cancer Journal for Clinicians 53(1):27-43, 2003)

65. ACCP/ACS Guidelines for Screening
Screening After Hysterectomy
Vaginal cytology screening tests are not indicated after total hysterectomy for benign gynecologic disease.
Hysterectomy for CIN2 or greater is not considered benign.
CA: A Cancer Journal for Clinicians 53(1):27-43, 2003)

66. ACCP Guidelines for Screening
Screening Interval:
After initiation of cervical screening, perform annually with conventional cervical cytology smears or every 2 years using liquid-based cytology.
Women >30 years of age with 3 consecutive, technically satisfactory normal/negative cytology results may be screened every 2 to 3 years unless they have a history of in utero DES exposure, HIV+, or are immunocompromised.
CA: A Cancer Journal for Clinicians 53(1): 27-43, 2003)

67. Abnormal PAP smear: Colposcopy

70. Multimodal Spectroscopy

71. Recent FIGO Recommendations For the Management of Abnormal Smear
( Benedet,2000)
Persistent inflam., persistent ASCUS, LSIL, HSIL, AGCUS,Invasive
Colposcopy ± Biopsy
Normal or LSIL HSIL Invasive
6 mo smear x LLETZ Appropriate TT
Normal Persistent
Annual screening

72. LLETZ Large Loop Excision of the Transformation Zone

73. Against Breast Cancer

74. Elements of Screening of Breast Cancer

75. Approach to the Client
Explain to the client the importance of breast examination as a tool for early detection of abnormalities especially cancer that results in better prognosis.
Explain and train all clients to perform breast self-examination and instruct them when, how to do it and abnormalities to look for.
Maintain good communication channels with the clients whose screening shows suspicious results to ensure that follow-up can be achieved: note the client’s telephone, address and who to contact.
Respond to all the client Needs and inquiries and provide reassurance while encouraging her to perform extra-necessary procedures

76. History Taking Ask about risk factors: Ask about symptoms:
Family history of breast cancer
Menstruation after age of 55 or before age of 12
Menstrual cycles lasting more than 40 years
Hormone administration
Obesity
Smoking
Previous uterine cancer
First pregnancy after age 30 or no pregnancies
Ask about symptoms:
Pain
Swelling in breast or armpit
Discharge from nipple
Discoloration of the skin
Note all findings in the medical record

78. What changes should She be aware of?
• A change in size – it may be that one breast has become noticeably larger or noticeably lower
• A nipple has become inverted (pulled in) or changed its position or shape
• A rash on or around the nipple
• A discharge from one or both nipples
• A puckering or dimpling of the skin
• A swelling under the armpit or around the collarbone (where the lymph nodes are)
• A lump or thickening in the breast that feels different from the rest of the breast tissue
• Constant pain in one part of the breast or in the armpit.

79. Clinical Breast Examination
Yearly Done
Postmenstrually
Should be part of any gynecologic examination.
Refer client to a MOHP hospital if needed.
Explain the procedures to the client, and ask her to undress to the waist and stand relaxed.
Inspection
Ask the client to put her hands on her waist, and to push inwards to contract the chest muscles.
Inspect both breasts for any puckering, abnormalities of the skin, change in the nipple such as swelling or retraction, asymmetric appearance or nipple discharge.
While the client lies on her back, inspect breasts to detect any abnormalities.
Inspect for any abnormal discoloration of the skin
Note all findings in the medical record.

80. Palpation
Palpate the breast tissue for any breast masses as well as the axilla and supraclavicular area for any enlarged lymph nodes.
Be sure that all parts are felt carefully.
Milk the nipple after massage of the areola medially to identify any fluid discharge.
Describe as none, clear, milky, pinkish or dark-bloody color.
If any abnormality is detected by examination, refer to specialist for mammography.
Note all findings in the medical record.

81. Breast Self Examination
Tell the client to conduct breast self-examination once every month after the end of menstruation starting at the age of 20 years for life.
Palpation of the breasts during bathing is recommended.
Soap and water on the skin facilitates palpation of the breast tissue.
It is important to note the normal consistency of the breasts at the first examination so that she will be aware of any changes in subsequent examinations.

85. Diagnosis Vs Screening ??

86. Mammography…A debate
Before the age of 40 and after 70 there is NO recommendations for routine mammographic screening
Currently, the American Cancer Society and the American College of Radiology encourage mammograms every two years for women ages 40 to 49.
Yearly mammographic examination are done from the age of years.

87. Other tools..
Breast Ultrasonography
MRI
Thermography
BRCA

88. Thank you !!!