Screening for Cancer Cervix

by Visual Technique

University Sriwijaya Palembang

Dept. Obstetrics and Gynaecology
 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
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 Cervical Cancer: Aetiology

Cause: HPV -a sexually transmitted infection

Women are generally infected with HPV in their
teens, 20s, 30s
Cervical cancer can develop up to 20 years after
HPV infection

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 Natural History of Cervical Cancer:
Current Understanding
Normal Cervix

About 60% HPV Infection

regress
within HPV-related Changes
2-3 yrs

Low-Grade SIL (Atypia, CIN I)

Cofactors
About 15% progress within 3-4 yrs High-Risk HPV
(Types 16, 18, etc.)
High-Grade SIL (CIN II, III/CIS)

30% - 70% progress within 10 yrs

Invasive Cancer Source: PATH 1997.

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 Prevention of Cervical Cancer

Cervical cancer is a preventable disease

Primary prevention:
Education to reduce high risk sexual behaviour
Measures to reduce/avoid exposure to HPV and
other STIs
Secondary prevention:
Treatment of precancerous lesions before they
progress to cervical cancer (implies practical
screening test)

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 Secondary Prevention of Ca.Cx.

Key Point is to detect precancerous lesions

Down staging
Answer: - A good screening method
PAP smear test is considered to be the gold
standard Has limitations ?
Alternatives to Pap Smear What are they?

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Qualities of a Good Screening Test?

Effective
Safe
Practical
Affordable
Available

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Limitations of Pap Smears for National
Screening Programs
Pap smear-based programs require complex logistics,
advanced training, and well managed program
implementation for adequate testing to occur.
These elements are not available outside large cities
in many low-resource settings.
Even in large cities, quality pap smears are possible
but ongoing supervision, refresher training and
continued supplies are necessary.
Cytology is not viable as a nationally accessible
screening method in many developing countries in
Low Resource Settings.
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Alternatives to Pap Smear Screening
Why?
Cervical cancer is a significant public health problem
in many countries.
Cervical cancer is a sexually transmitted disease.
Cervical cancer is preventable (i.e., Methods of
screening and treatment for precancerous lesions
exist).
Pap Smear as a screening methods may not be
appropriate or adequate for many low-resource
settings.

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 Cervical Cancer Screening
Other Options: -
Visual inspection with acetic acid (VIA)
Visual inspection with acetic acid and
magnification (VIAM): Gynescope or Aviscope
Colposcopy
Cervicography
Automated pap smears
Molecular (HPV/DNA) tests
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 Approaches to Cervical Cancer
Prevention in Low-resource Settings
Effective Safe Practical Affordable Available
Visual Yes Yes Yes Yes Yes
Inspection:
AA
Visual No Yes Yes Yes Yes
Screening:
Unaided
Automated Yes? Yes ? No No
Pap Screening
HPV Yes Yes ? ? Yes
Screening
Cervicography Yes? Yes ? ? Yes
HPV Vaccine ? ? Yes ? No
Source-Program for Appropriate Technology in Health [PATH] 1997.

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 What Is VIA / Cervicoscopy ?
Visual Inspection after Acetic Acid
Also known as Aided Visual Inspection of Cervix, or
Acid Acetic Test
Looking at the cervix to detect abnormalities after
applying acetic acid
Acetic acid is used to enhance and mark the
acetowhite change of a precancerous lesion or actual
cancer
Sensitivity and specificity of VIA - 70-92%
Positive Predictive Value - 15-20%

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History of Research on Visual Inspection

Historically, before the advent of Pap smears and

programmatic screening, healthcare providers relied
on looking at the cervix to detect abnormalities.
Schiller test has been used for many years(to aid in
differentiating "mature" normal from "immature" abnormal
epithelium).
After the 1950s, when the Pap smear became the
standard for cervical cancer screening-.
Increasing numbers of women undergoing this test led to
increased utilization of the colposcope (initially developed in
the 1930s) to confirm screening findings.

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History of Research on Visual Inspection
Years later, given the expense and inconvenience of
colposcopy services, clinicians began to explore
whether unmagnified visualization of the cervix (with
acetic acid) could be used as an adjunct to cytology
so that patients in need of colposcopy could be
identified more effectively and efficiently.
However few studies were conducted, that examined
the value of unmagnified inspection of the cervix after
the application of acetic acid (VIA) for purposes of
identifying a normal "transformation zone" or
detecting precancerous lesions of the cervix (i.e.,
primary screening).
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History of Research on Visual Inspection

Then, in 1982, Ottaviano and La Torre published an

important study involving 2,400 women who were
examined visually and colposcopically after a cervical
wash with acetic acid.
"naked-eye" (unmagnified) inspection detected abnormalities
in 98.4% of the cases (i.e., in 307 of 312 patients assessed
colposcopically as having an abnormal transformation zone).
These authors concluded that "colposcopic magnification is
not essential in clinical practice for the identification of the
cervix at risk."

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History of Research on Visual Inspection
In 1990, Abrams published his experience with the
"Gynoscope," a monocular telescope with a
magnifying power of 2.5,
high correlation between the (visual) Gynoscope examination
and cytology.
should be considered as a practical adjunct that will
encourage better sampling by the clinician.
World Health Organization (WHO) supported a study
in India between 1988 and 1991 in which unmagnified
visual inspection with acetic acid washing was
evaluated as a "down staging" technique.
VIA was found to be effective in identifying women with
cancer at an earlier, more treatable stage.

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History of Research on Visual Inspection

Several other comparative studies in Kenya,

Zimbabwe and South Africa suggest that visual
inspection with acetic acid performs comparably to
the Pap smear and/or other screening tests.
More recent studies have also demonstrated that "VIA
is a safe, simple and effective adjunct to the
Papanicolaou smear for cervical cancer screening
and can be helpful in reducing referrals for
colposcopy without compromising quality of care.

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 Needed Equipment and
Supplies for VIA
VIA can be performed in any clinical setting
when the following are available:
Examination table, preferably with stirrups or leg
supports
Sterile speculum, preferably Cusco's
Sterile gloves
Source of light, a lamp or a torch
Cotton swabs
Forceps
Syringe for acetic acid lavage
Acetic acid in dilutions of 3-5%
Stationary, to record examination findings

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 The Examination
The procedure and the reason for it should be carefully
explained to the woman to be examined and she should be made
as comfortable as possible. Take into consideration the privacy
of the patient.
Put patient in lithotomy position (if possible) or suppine with
legs bent at knees.
Good visualization is essential. Direct the light source to the
genital area.
Observe and record any abnormal findings in the external
genitalia.
Lubricate the speculum with warm water and insert into the
vagina with the speculum closed.

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 The Examination
Open the speculum and adjust the light source so as to get a
clear view of the cervix.
If there is excess mucus or discharge, clean it with a cotton
swab soaked in boiled water or normal saline solution.
Observe any abnormal findings.
Wash the cervix with the acetic acid (3-5%) with the help of the
syringe. Alternatively can be applied with a cotton swab.
Wait for approximately 1 minute.
Inspect the cervix for acetowhite areas.

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 The Examination

Important
Do not perform the examination if the woman
is having menstrual period or is using
intravaginal medication. Advise her to come
back when the mensus or the treatment is
over.
Do not apply acetic acid if there is a gross
lesion suspicious of malignancy, refer patient
directly to oncology / tertiary care facility.

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Objectives Of Acetic Acid Examination

Locate the squamocolumnar junction

Identify any lesion & its limits
Decide whether the lesion is CIN
Determine whether invasion is possible
Select a site or sites for biopsy if appropriate

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 What does Acetic Acid do?

Acetic acid
Dissolves mucus
Induces intracellular dehydration
Causes coagulation of protein
As a result cells with increased
Nuclear / Cytoplasmic ratio ratio
Nuclear density
Chromosomal aneuploidy
Become opaque acetowhite area test positive

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Abnormalities Seen After Acetic Acid

Aceto-white
Margins and surface
White gland openings
Mosaic & punctation
Abnormal vessels

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 What May Be Acetowhite

All acetowhite patches are not cancer

Any of these epithelial changes can become
acetowhite
Healing or regenerating epithelium
Congenital transformation zone
Inflammation
Immature squamous metaplasia
HPV infection
CIN / CGIN
Adenocarcinoma
Invasive squamous cell carcinoma

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Reporting Visual Inspection Findings
BEFORE ACETIC ACID APPLICATION- Unaided visual
inspection of Cx Clinical Down staging

NORMAL: -
Smooth, pink
Clear mucoid secretion
Central hole-'external os'
Nulliparours-round
Multiparous-slit or cruciate
Cervix in postmenopausal
women is atrophic Normal Cervix
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Reporting Visual Inspection Findings
BEFORE ACETIC ACID APPLICATION- Unaided visual
inspection of Cx Clinical Down staging

ABNORMAL: -
Hypertrophy
Redness or congestion
Irregular surface
Distortion
Simple erosions (do not bleed on touch)
Cervical polyps (with smooth surface)
Abnormal discharge: foul smelling, dirty / greenish, cheesy white,
blood stained
Nabothian follicles
Prolapsed uterus

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Reporting Visual Inspection Findings
BEFORE ACETIC ACID APPLICATION- Unaided visual
inspection of Cx Clinical Down staging

ABNORMAL: -
Clinical interpretation can be:
Infection
Ectopy (Erythroplasia)
Benign tumour
SUSPICIOUS OF MALIGNANCY: -
Erosion that bleeds on touch or friable
Growth, with an irregular surface or friable

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Reporting Visual Inspection Findings
AFTER ACETIC ACID APPLICATION- Aided visual
inspection of Cx Acid Acetic Test

Acetic Acid Test- Aceto-white area(s) not

Negative present
Acetic Acid Test- Aceto-white area(s)
Positive present
Important: All findings, normal or abnormal, should be
carefully recorded in a printed form. The patient should
be informed and explained the follow-up procedure
accordingly.
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 Action Plan

Negative VIA Positive

Follow-up after 3-5

Treat / Refer to an
years according to
appropriate center-
the decided policy.
PHC/ Secondary /
Advise to come
Tertiary / Oncology
back if develops
Centre
symptoms.

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 Action Plan
Management of VIA Positive Cases: -
If infection is suspected /present take a swab
and send for analysis.Treat the patient
accordingly. Re-examine after six weeks.
If no signs of infection: - perform Pap-smear
and / or Colposcopy:
I. Pap-smear / Colposcopy negative: re call
for follow-up in 6-12 months.
II. Pap-smear / Colposcopy positive: call the
patient for appropriate treatment
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 VIA - The Status To-Day

A randomised trial of early detection of breast

and cervical cancers using low cost
technology approaches - Professor I. Mittra,
Tata Memorial Hospital, Mumbai.
The study is now in its 3rd year and 110,000 women
have so far been randomised.
VIA appears to be more sensitive but less specific
than the PAP smear.

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 Why VIA as an Alternative in
Low-resource Settings?
Non-invasive, easy to perform and inexpensive
Can be performed by all levels of healthcare workers,
in almost any setting
Skills consistent with service delivery tasks
performed by nurses/midwives in MCH/FP clinic
settings
Results are available immediately

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 Why VIA as an Alternative in
Low-resource Settings?
Initial treatment can be provided at the time of
the examination
All system requirements are available locally
Potential for immediate link to treatment
Approach suitable for lowest-resource
settings
***

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 VIA

At the service of women

H
THANK YOU
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