Cervical Cancer Screening Updates Dr Arun Shahi MD

Cervical Cancer Screening Updates -Dr. Arun Shahi MD, Medical Oncology(Thesis) NICRH, Dhaka 1

Dedicated to all those Innocent mothers, daughters, sisters who have lost their life with cervical cancer and who are fighting with Cervical cancer. 2

For you & your daughter …. . a wonderful gift Guard Yourself Protect yourself and Beat cervical cancer. 3

Sad but True… In Bangladesh, 18 women die each day due to Cervical cancer ICO (Institut Català d‘ Oncolo gia) Information Centre on HPV and Cancer Epidemiology and Registration Unit. Human Papillomavirus and related cancers, fact sheet 2017(09/04/017) 4

Cervical Cancer – Disease Burden New Cervical Cancer Cases Deaths due to Cervical cancer Bangladesh ~11, 956 World ~ 4, 93, 000 Bangladesh ~ 6582 World ~ 2, 73, 000 BD ~2. 4% India - 27% BD~2. 4% Rest of World - 73% Rest of World – 97. 6% Bangladesh ~2. 4% of new Cervical Cancer cases in world Rest of World – 97. 6% Bangladesh ~2. 4% of deaths due to Cervical Cancer in world 5

Who is responsible for Ca Cervix burden? The cause of nearly all cervical cancer is HPV– Cancer causing Types HPV 99. 7% Non-cancer causing types HPV 16 HPV 18 HPV 11 • >75% of Cervical Cancer • >50% of Vaginal & Vulvar Cancer 90% of Anogenital warts 6

Is it possible to get protect/prevent against cervical cancer Burden? Educational Program 2009 7

BUT HOW? ? Ø Discourage childhood marriage/early age sexual exposure. Ø Early HPV Vaccination. Ø Timely Cervical Cancer Screening!!!

What is Cervical Cancer Screening ? 1. Cervical cancer screening is used to find changes in the cells of the cervix that could lead to cancer. 2. Screening includes cervical cytology (also called the Pap test or Pap smear) and, for some women, testing for human papillomavirus (HPV). 11

Why is cervical cancer screening important? 1. helps to detect cervical cell changes before they become cancer. usually takes 3– 7 years for high-grade changes in cervical cells to become cancer. 2. high-grade cell changes can be removed. 3. low-grade changes can be tested more frequently to see if their cells go back to normal. Due to Cervical cancer screening, it’s prevalence Declined by 50% since 1950 12

Benifit of Cervical cancer screening Normal cervix/ Sub-clinical HPV infection 1 HPV vaccines: Primary prevention CIN 12 CIN 22 Cervical screening CIN 33 ICC 3 Treatment ( Pap smear, HPV testing): Secondary prevention Treatment 1. Image used with permission from Professor Achim Schneider; 2. Image used with permission from Professor Muhieddine Seoud; 3. GSK Image Library

Visual Inspection VIA VILI Pap Smear**** Conventional LBC HPV DNA Testing*** Cervicography Polar Probe Community low resource settings Still Experimental

How is cervical cancer screening done? • Cervical cancer screening includes: 1. Pap test : here sample is examined to see if abnormal cells are present. 2. HPV DNA test(for some woman). here the sample is tested for the presence of 13– 14 of the most common high-risk HPV types Both tests use cells taken from the cervix. 16

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How often should I have cervical cancer screening and which tests should I have? § depend on age and health history: 1. Women aged 21– 29 years should have a Pap test alone every 3 years. HPV testing is not recommended. 2. Women aged 30– 65 years should have a Pap test and an HPV test (co-testing) every 5 years (preferred). also acceptable to have a Pap test alone every 3 years. 18

If I have had a hysterectomy, do I still need cervical cancer screening? The decision is based on: why the hysterectomy was needed: ü Cervical cancer: then continue screening for 20 years after the time of surgery. ü Benign Condition : Presence of moderate or severe cervical cell changes. Note: Even if cervix is removed at the time of hysterectomy, cervical cells can still be present at the top of the vagina. 19

Does Having an HPV Vaccination Change screening recommendation? üHaving an HPV vaccination does not change screening recommendations. üWomen who have been vaccinated against HPV still need to follow the screening recommendations for their age group. 20

Are there any women who should not follow routine cervical cancer screening guidelines? Yes. Women who have a 1. 2. 3. 4. history of cervical cancer, are infected with human immunodeficiency virus (HIV), have a weakened immune system, or who were exposed to diethylstilbestrol (DES) before birth. require more frequent screening and should not follow these routine guidelines. 21

What does it mean of having an abnormal cervical cancer screening test result? An abnormal test result does not mean that you have cancer. 1. Most of the time cervical cell changes often go back to normal on their own. And if they do not, it often takes several years for even high-grade changes to become cancer. 2. additional testing is needed to find out whether high-grade changes or cancer actually are present. 3. i. e colposcopy and cervical biopsy is recommended to find out how severe the changes really are & conform the diagnosis. 22

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The entire new SCJ is visible colposcopic examination is satisfactory. the TZ is fully visualized. The metaplastic squamous epithelium is pinkish-white compared to the pink original squamous epithelium Post Menopausal Cervix: Epithelium is pale, brittle, lacks lusture, shows sub-epithelial petichiae, SCJ not visualized

Inflammatory lesions of the Uterine Cervix Reddish “angry-looking”, inflamed columnar epithelium with loss of the villous structure & with inflammatory exudate (before application of 5% AA) Chronic cervicitis: This cervix is extensively inflammed with a reddish appearance & bleeding on touch, there are illdefined, patchy acetowhite areas scattered all over the cervix after the application of AA

CIN (CERVICAL INTRAEPITHELIAL NEOPLASIA) as Seen in Colposcopy findings confirmed by histology 1 CIN 1 Photo courtesy of Dr. J. Monsonego CIN 2 Photo courtesy of Dr. J. Monsonego CIN 3 From IARC, 2003. 4 1. Wright TC Jr, Cox JT, Massad LS, et al, for the ASCCP-Sponsored Consensus Congress. JAMA. 2002; 287: 2120– 2129. 2. Bonnez W. In: Richman DD, Whitley RJ, Hayden FJ, eds. Washington, DC: American Society for Microbiology Press; 2002: 557– 596. 3. Canadian Cancer Society. Cervical Cancer: What you need to know. Available at: http: //www. cancer. ca/vgn/images/portal/cit_86751114/63/40/151140772 cw_library_wyntk_cervical_en. pdf. Accessed March 13, 2006. 4. Reprinted with permission from Sellors JW, Sankaranarayanan R, eds. Colposcopy and Treatment of Cervical Intraepithelial Neoplasia. A Beginner’s 27 Manual. Lyon, France: International Agency for Research on Cancer; 2003.

Carcinoma in Situ

Preclinical invasive Carcinoma Early invasive cancer: note the raised irregular mosaics with umbilication (a), breaking mosaics (b), surface irregularity & the atypical vessels after the application of 5% AA

How accurate are cervical cancer screening test results? Cervical cancer screening results are not always accurate. • Sometimes “false-positive” result. (i. e. the results show abnormal cells when the cells are normal) • Sometimes “false-negative” result. ( also may not detect abnormal cells when they are present. ) To help prevent false-negative or false-positive results, one should avoid: 1. 2. 3. 4. douching, sexual intercourse, and using vaginal medications or hygiene products for 2 days before the test. Avoid cervical cancer screening when you have your menstrual period. 30

When should I stop having cervical cancer screening? after age 65 years if: 1. no history of moderate or severe abnormal cervical cells or cervical cancer, and 2. have/had either three negative Pap test results in a row or two negative co-test results in a row within the past 10 years, with the most recent test performed within the past 5 years. 31

Aim: To Make a Cervical Cancer Free Society… Screening and identification of High Risk groups Education – Discourage marriage at early age. Think of Cervical Cancer as an extension of STD Behavioral changes Avoid multiple sexual partners. Delay early age of sexual intercourse Avoid STD – Use of Condoms. Avoid Smoking HPV Vaccines to be promoted at the right age

Lets fight against cancer …. . join hands…… …. . take preventive measures……. …. . update yourself…. . take care…. . 33