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Cervical Cancer Screening

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Cervical Cancer Screening Would we ever have a nation wide program? Amr Nadim, MD Professor of Obstetrics & Gynecology Ain Shams Faculty of Medicine – PowerPoint PPT presentation

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Title: Cervical Cancer Screening


1
Cervical Cancer ScreeningWould we ever have a
nation wide program?
  • Amr Nadim, MD
  • Professor of Obstetrics Gynecology
  • Ain Shams Faculty of Medicine

2
Cervical 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.

3
Incidence And Mortality For Cervical Cancer Vs
Breast Cancer, US, 2000
4
Cancer CervixA Screenable Preventable
Disease
5
Pre - 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

6
Pre - 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
7
and
8
Screening Tools for Cancer Cervix
9
Risk 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
10
What Makes the Cervix Vulnerable?
11
The 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.

12
P53
RTS
Immortality
13
Global distribution of HPV types in cervical
cancer
14
Natural History Of Cervical Cancer
HPV Infection
Source PATH, 2001
15
(No Transcript)
16
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17
The 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.
18
Cervix 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?

19
Advances 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

20
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)
21
ACS 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)
22
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)
23
ACS 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)
24
FDA 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.

25
FDA 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.

26
Abnormal PAP smear Colposcopy
27
(No Transcript)
28
Cervical 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.

29
Cervical 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

30
Cervical Cancer Screening Who Is Not Getting a
Pap Smear?
  • Reasons for Lack of Screening
  • Cultural barriers
  • Financial barriers
  • Access
  • Poor education, myths

31
Barriers to Screening
  • Embarrassment, unpleasantness
  • Lack of knowledge of recommended screening
    interval
  • Financial barriers
  • Lack of knowledge concerning the importance of
    screening

32
IN 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
  • ???????? ?? ????????????????

33
Findings 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.

34
Role 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

35
Findings
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!!!
36
Treatment 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

37
More Education Needed for All!
  • Public awareness
  • TV commercials
  • Magazines
  • Physician Education
  • Primary Care Providers
  • FPs who work with adolescents
  • Physician to Patient

38
What 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.

39
Family Barriers
  • HPV is a sexually transmitted disease
  • Adolescents are invulnerable (so they think)
  • The home will protect fully

40
Cervical 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

41
HPV vaccine
Evolution of Molecular-based Therapies
42
Cervical 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

43
HPV 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.

44
HPV 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.

45
Effective 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.

46
Coming 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.

48
Thank you !!!
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