SCREENING FOR FEMALE GENITAL TRACT MALIGNANCY BY Dr

SCREENING FOR FEMALE GENITAL TRACT MALIGNANCY BY Dr. Ahmed Samir Sanad M. D OB & GYN Early Cancer Detection Unit OB & GYN Dept.

SCREENING GENERALLY Is to seek about certain problem in certain high risk group.

• “The PRESUMPTIVE identification of UNRECOGNIZED disease or defect by the application of tests, exams or other procedures which can be applied RAPIDLY to sort out apparently well persons who PROBABLY have a disease from those who PROBABLY do not”

VALIDITY OF SCREENING TEST Sensitivity = ability of test to give a positive result when disease is present = a / a+c Specificity= ability of test to give a negative result when disease is absent = d / b+d

VALIDITY OF SCREENING TEST Validity of test determined by ability to correctly categorize subjects to testpositive or test-negative

Validity of Screening Test cont. . . • Predictive value is determined by sensitivity & specificity and also by the prevalence of preclinical diseas • Positive predictive value = probability that a person with a positive test actually has the disease = a / a+b • Negative predictive value = probability that a person with a negative test is truly disease-free = d / c+d

CRITERIA FOR SCREENING: Disease: ØMust be serious enough ØMust be widespread enough ØMust be fairly reliably diagnosable ØMust be treatable ØMust be affordable ØHopefully legally defensible

CRITERIA FOR SCREENING TEST: 1. Simple & quick 2. Capable of being performed by paramedics 3. Inexpensive 4. Acceptable to population 5. Accurate 6. Repeatable 7. Sensitive 8. Specific

SUSPECT GYNECOLOGIC CANCER Woman with: • Ovarian mass/cyst • Growth or ulcer of cervix, vagina or vulva • Abdominal mass, increased abdominal girth • Postcoital bleeding • New onset of hematuria or renal failure • New onset of bowel obstruction

Suspect Gynecologic Cancer cont…. ü Premenopausal woman with: Irregular menses ü Women older than 35 or with long history of irregular menses ü Postmenopausal woman with: ü Vaginal bleeding ü Abnormal vaginal discharge

CONCEPT ØPrevention is better than cure. ØCancer cx. Screening programs are in adulthood ØBut ov. cancer programs are still in relative infancy, why?

Most Cancers Develop In The Unscreened And The Underscreened.

INCIDENCE OF GYNECOLOGIC CANCERS IN EGYPTIAN WOMEN WITH CANCER 25 20 Percent 15 10 5 0 Source: GLOBOCAN 2000. Breast Cervical Ovarian Uterine Cancer

EPIDEMIOLOGY OF CERVICAL CANCER Magnitude of the Problem: 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 year Cervical cancer is the third most common cancer worldwide

PREVENTION OF CERVICAL CANCER Cervical cancer is a preventable disease v. Primary prevention: l Education to reduce high risk sexual behaviour l Measures to reduce/avoid exposure to HPV and other STIs v Secondary prevention: l Treatment of precancerous lesions before they progress to cervical cancer (implies practical screening test) Now : HPV vaccines.

SECONDARY PREVENTION OF CA. CX. Key Point is to detect precancerous lesions –BY - A good screening method - PAP smear test is considered to be the gold standard

SCREENING BY PAP. CX. SMEAR Importance unscreened female have ten fold increase risk >screened female To whom - Every sexually active female (18 -70 y) - Specially, high risk group. When - Annually for three years - Every three years thereafter. - If test +ve repeat the test every 6 monthes - If new risk factors appear after 35 y.

Equipment

Ayre’s Spatula & cytobrush

Cervical smear

Preparation of the slide

Smearing of the exocervical sample with a wooden spatula (Ayre's spatula)

Fixation with Alcohol

• Spray fixation: immediate, during a few seconds, with a spray/slide distance around 20 cm.

ALTERNATIVES TO CYTOLOGY § Visual Inspection of the cervix: ü Unaided: Downstaging. ü Aided with acetic acid: VIA: l Naked eye l Aided with acetic a and magnification( VIAM) l. Cervicography l Colposcopy l. Speculoscopy ü Schiller Iodine test § Automated pap smear § HPV DNA test

Normal Colposcopic appearance

LIMITATIONS OF PAP SMEAR • Complex laboratory test • Requires trained cytotechnician for reading and pathologist for review • Continuous monitoring needed to maintain highquality results • Reports often take minimum 1 -2 weeks to obtain • Follow-up of women is difficult • Usually available only in large cities in many

“VIA. . REPRESENTS A PROVEN, SIMPLE MEANS OF IDENTIFYING CERVICAL INTRAEPITHELIAL NEOPLASIA IN DEVELOPING COUNTRIES. ” Commentary: P. Blumenthal. Detection of cervical intraepithelial neoplasia in developing countries. The Lancet March 13, 1999

COMPARISON BETWEEN : VIA AND CYTOLOGY Sensitivity(%) Cytology VIA 47— 62 76 -84 Specificity (%) 60 -95 79 -83

MEANING OF ACETOWHITE All acetowhite patches are not cancer: l Healing or regenerating epithelium l Congenital transformation zone l Inflammation l Immature squamous metaplasia l HPV infection l CIN / CGIN l Adenocarcinoma l Invasive squamous cell carcinoma

ENDOMETRIAL CANCER SCREENING • Screening of unproven benefit • Endometrial sampling Risks include discomfort, bleeding, infection, uterine perforation (rare) • Transvaginal ultrasound examinations Helpful in evaluating vaginal bleeding • Role of office hysteroscopy in evaluation of the endometrium

ENDOMETRIAL CANCER SCREENING v Office endometrial sampling: ü Jet Lavage Aspiration ü Intrauterine brushing ü Suction aspiration canula ü Endometrial biopsy curette ü Manual Vacum aspirator(MVA). v Office endometrial visualization: ü Vaginal ultrasonography ü Doppler examination ü Hysteroscopy ü MRI

OVARIAN CANCER SCREENING • Benefit to screening is unproven • Annual bimanual gynecologic examination • Transvaginal ultrasound • CA 125 serum levels • Screening may result in more unnecessary surgeries than new ovarian cancers

SCREENING FOR EARLY DIAGNOSIS OVARIAN MALIGNANCY Modalities: 1 - Clinical. 2 - Cul-de-sac aspiration. 3 - Imaging techniques. 4 - Tumour markers. 5 - Radio immuno scientography. 6 - Multimodels.

EARLY CANCER DETECTION OF VULVA Colposcopy VIN Biopsy Acetic Acid Taulidine blue

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