Title: Cervical Cancer Screening
1Cervical Cancer ScreeningWould we ever have a
nation wide program?
- Amr Nadim, MD
- Professor of Obstetrics Gynecology
- Ain Shams Faculty of Medicine
2Cervical Carcinoma
- 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.
3Incidence And Mortality For Cervical Cancer Vs
Breast Cancer, US, 2000
4Cancer CervixA Screenable Preventable
Disease
5Pre - requisites For Successful Screening
- After Wilson and Jugner (1968)
- The condition should be an important health
problem. - There should be an accepted treatment .
- Facilities for treatment and diagnosis should be
available. - There should be a recognizable latent or early
symptomatic stage. - There should be a suitable method of examination.
- The test should be acceptable to the population.
- The natural history of the disease should be
adequately understood
6Pre - requisites, cont....
- There should be an agreed policy on whom to treat
as patients. - The cost should be economically balanced with the
expenditure of medical care as a whole. - Case finding should be a continuing process.
They apply reasonably well for screening of
Cervical Carcinoma
7and
8Screening Tools for Cancer Cervix
9Risk Factors for Cervix Cancer
- No prior smear screening
- History of cervical dysplasia or genital warts
- Young age at first coitus
- Multiple sex partners
- High-risk male partner (e.g., multiple female
partners) - Sexually transmitted diseases
- Increasing age
Smoking - Nutritional Deficiencies -
Immunosuppression
10What Makes the Cervix Vulnerable?
11The HPV-cervical cancer link
- Human papillomavirus (HPV) is a very common
infection (more than 50 of adults get it, in
most it is a transitory infection). - 99.7 of cervical cancer cases are associated
with HPV. - Progression from HPV infection to cancer usually
takes 20-30 years.
12P53
RTS
Immortality
13Global distribution of HPV types in cervical
cancer
14Natural History Of Cervical Cancer
HPV Infection
Source PATH, 2001
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17The Papanicolaou Smear False
Negative Results
- Precancerous cells or cancer cells do not shed in
small percentage of cases. - Less predictable time course for development of
serious glandular lesion. - The lesion is missed on sampling.
- The cells are not transferred to the slide or
from the sampled liquid media. - Human error in cytopathologic analysis.
- Invasive cancer at the time of initial evaluation
These lead to a false negative rate of 20 for
cytology.
18Cervix Cancer Screening
Current Controversies
- How often should Pap tests be performed?
- Should a woman who has had a hysterectomy
continue to have periodic Pap tests? - When should the Pap test be repeated if
endocervical cells are not present? - Should Pap tests be performed in patients older
than age 60?
19Advances in Cervical Cancer Screening
- New American Cancer Society (ACS) guidelines
- New Technologies
- Hybrid Capture II HPV test as part of primary
screening and triage - Liquid based cytology
- Computer assisted Pap smear interpretation
20ACS 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)
21ACS Guidelines for Screening
- When to Stop Screening
- Women aged gt70 years with an intact cervix with
gt3 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)
22ACS 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)
23ACS 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 gt30 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)
24FDA Approval of Hybrid Capture II Test in
Conjunction with Pap Test
- Testing combination brings improved sensitivity
to screening and has the potential to benefit the
more than 30 million women age 30 and older who
are screened in the U.S. each year. - Helps physicians determine which patients are at
extremely low risk for cervical cancer and which
patients may be monitored more closely.
25FDA Approval of Hybrid Capture II Test in
Conjunction with Pap Test
- Studies show the testing combination provides a
very high certainty that a woman with a
satisfactory and negative Pap result who is
HPV-negative is at low risk for having or
developing high-grade cervical disease or cancer
in the near term. - Combined screening interval should be no more
often than once every three years. - Screen for high risk HPV types only.
26Abnormal PAP smear Colposcopy
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28Cervical Cancer Have We Decreased the Incidence?
- The curve has been stable for the past decade in
part because we are not reaching the unscreened
population.
- With the advent of the Pap smear, the incidence
of cervical cancer has dramatically declined.
29Cervical Cancer Screening Who Is Not Getting a
Pap Smear?
- Uninsured or Underinsured
- Low socioeconomic status
- Residents in rural locations
- Minorities, especially Hispanic, Asian Pacific
Islander, African-American and American-Indian
women - Residents in developing countries
- Elderly
30Cervical Cancer Screening Who Is Not Getting a
Pap Smear?
- Reasons for Lack of Screening
- Cultural barriers
- Financial barriers
- Access
- Poor education, myths
31Barriers to Screening
- Embarrassment, unpleasantness
- Lack of knowledge of recommended screening
interval - Financial barriers
- Lack of knowledge concerning the importance of
screening
32IN EGYPT...
- Only sporadic attempts of screening.
- Lack of screening of the older women the
priority target group. - Lack of appreciation by the women of the
relevance of the disease - Lack of availability of health care in the rural
areas. - Fatalism
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33Findings of many community based studies
- Demand for cervical cancer prevention services is
strong among women and communities. - Organized prevention programs are feasible and
can be integrated with existing services.
34Role of the Primary Care Physician in Preventing
Cervix Cancer
- Identify patients who should be screened
- Educate patients regarding the importance and
timing of Pap smears - Conduct Pap smears properly
- Follow up abnormal Pap smear results
35Findings
The single-visit screen-and-treat approach is
safe and effective in low-resource settings. This
is a major paradigm shift in cervical cancer
prevention.
and if it works in subsaharan Africa, it should
work for us!!!
36Treatment of Cervix Dysplasia
- Cure Rate (5-year) Overall
- 85-95
- 85-95
- gt90
- gt90
- Treatment Modality
- Destructive Methods
- Cryotherapy
- Laser ablation
- Excision
- Cervical conization
- LEEP
37More Education Needed for All!
- Public awareness
- TV commercials
- Magazines
- Physician Education
- Primary Care Providers
- FPs who work with adolescents
- Physician to Patient
38What kinds of Education?
- Disease awareness in general for all
- Link of HPV to Cervical Cancer
- Perfect opportunity for physicians to combine
with discussions of adolescent sexuality and
risk-taking behaviors - Do we limit discussions and education to female
patients only? Probably not.
39Family Barriers
- HPV is a sexually transmitted disease
- Adolescents are invulnerable (so they think)
- The home will protect fully
40Cervical Cancer How Do We Eradicate Cervical
Cancer?
- Optimal screening with 100 participation
- Better detection of glandular precancer lesions
- Early detection of invasive cancers followed by
adequate evaluation and treatment - HPV vaccines
41HPV vaccine
Evolution of Molecular-based Therapies
42Cervical Cancer Vaccines
- Prophylactic Vaccines
- Vaccinate young people before exposure to HPV
- Polyvalent HPV vaccines are being studied
- Decreased incidence of dysplasia and cancer may
not be seen for several generations - Therapeutic vaccines
- Under evaluation for treatment of CIN and cancer
- Many different technologies
- Participants needed for clinical trials
43HPV vaccine news headlines
- Vaccine prevents most cervical cancers. - New
York Times, October 7, 2005. - Vaccine proves 100 percent effective in
preventing cervical cancer Seattle Times,
October 6, 2005. - Promising new vaccines could wipe out cervical
cancer. But they must be administered to
preteens, and some groups oppose that.
Philadelphia Inquirer, July 4, 2005. - OK Roll up your sleeve new vaccines are
arriving but the economics are still a challenge
Business Week, July 25, 2005.
44HPV vaccine opportunity
- 2 vaccines protecting against HPV 16 and 18 are
nearing licensure. - Both have high efficacy in Phase II trials and
appear very safe. - Phase III trials will involve over 50,000 women
worldwide. - Both manufacturers express interest in serving
developing country markets.
45Effective Screening Program
- Should be tailored to suit the principles for
national cancer control programs. We Should NOT
copy others programs... - Otherwise
- Too much money effort will be spent with
minimal impact on the incidence mortality from
the disease.
46Coming to an end
- Cervical cancer is a preventable disease.
- Cervical screening is one of the most successful
public health measures ever introduced for the
prevention of cancer. - Successful screening strategy should be coupled
with an effective treating policy to eradicate
pre-malignant lesions
47- Still, many of the world's, most vulnerable women
are not being screened. - Implementation of comprehensive, organized, and
quality cervical screening programs demand our
energies and attention as health professionals,
policymakers, governments, and citizens.
48Thank you !!!