Screening for Female Screening for Female Genital Tract MalignancyGenital Tract Malignancy
BY
Prof.Mohammad Ahmed EmamM.D OB & GYN
Director of Early Cancer Detection Unit
OB & GYN Dept.
Mansoura Faculty of Medicine
Screening GenerallyScreening Generally
Is to seek about certain problem in certain high risk gp.
Validity of Screening TestValidity of Screening Test
Validity of test determined by ability to correctly categorise subjects to test-positive or test-negative
Disease status
Test
result Positive Negative Total
Positive a b a+b Negative c d c+d
Total a+c b+d
Validity of Screening Test Validity of Screening Test contcont......
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
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
Validity of Screening Test Validity of Screening Test contcont......
When to 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
When to Suspect Gynecologic Cancer cont….
Premenopausal woman with:Premenopausal woman with: Irregular menses
Women older than 35 or with long history of irregular menses
Postmenopausal woman with: Vaginal bleeding Abnormal vaginal discharge
ConceptConcept
Prevention is better than cure. Cancer cx. Screening programs
are in adulthood But ov. cancer programs are
still in relative infancy, why?
Phases of TumourgenesisPhases of Tumourgenesis
Dysplasia Invasiveasymptomatic
Invasivesymptomati
Cancer cx. End. C.
As cancer ovary
Normal cells
Most Cancers Develop In The Unscreened
And The Underscreened.
CRITERIA FOR SCREENINGCRITERIA FOR SCREENING
Disease: Must be serious enough Must be widespread enough Must be fairly reliably diagnosable Must be treatable Must be affordable Hopefully legally defensible
Criteria for Screening TestCriteria for Screening Test
11. Simple & quick. Simple & quick
2. 2. Capable of being performed by paramedicsCapable of being performed by paramedics
33. Inexpensive. Inexpensive
44. Acceptable to population. Acceptable to population
5. 5. AccurateAccurate
6. 6. RepeatableRepeatable
7. Sensitive7. Sensitive
8. 8. SpecificSpecific
Incidence of Gynecologic Incidence of Gynecologic Cancers in Egyptian Women with Cancers in Egyptian Women with
cancercancer
00
55
1010
1515
2020
2525
Breast Breast CancerCancer
Cervical Cervical CancerCancer
Ovarian Ovarian CancerCancer
UterineUterineCancerCancer
PercentPercent
Source: GLOBOCAN 2000.Source: GLOBOCAN 2000.
Epidemiology of Cervical Epidemiology of Cervical CancerCancer
500,000 new cases identified each year80% of the new cases occur in developing countriesAt least 200,000 women die of cervical cancer each year Cervical cancer is the third most common cancer worldwide
Magnitude of the ProblemMagnitude of the Problem: -: -
Epidemiology of Cervical Epidemiology of Cervical Cancer Cancer contcont.….…
Most common female cancer in Most common female cancer in developing countries:developing countries:
• leading cause of cancer death in women.
• 80-85% cases seen at late incurable stages.
High risk patients:High risk patients:
1)Exo cx:High parity?!!Multiple partner Genital infectionsHPV & HSV IISmokingSexual behaviour of women’s partner
Epidemiology of Cervical Epidemiology of Cervical Cancer Cancer contcont.….…
2. Endo cxLike endometrial C.
AgeObesity D.M. Hypertension Nulligravida & Virgin Low parityTamoxifen
Epidemiology of Cervical Epidemiology of Cervical Cancer Cancer contcont.….…
Pathogenesis of CIN
•Columner epith.St.sq. epith.
CIN
Metaplasia
Dysplasia
•Dysplasia by oncogen
Micro-organism.
Sperm Ptn.
Chlamydia – H.S.V. - H.P.V- TV.
Histones & protamines
Morphological Changes of Morphological Changes of Cervical CancerCervical Cancer
Prevention of Cervical CancerPrevention of Cervical Cancer
Cervical cancer is a preventable diseaseCervical 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: Secondary prevention: 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 – Has limitations ?
Alternatives to Pap Smear – What are they?
Why screening for cervical cancer?
1. Is relatively common in unscreened women.
2. Has a relatively good prognosis if found early stage in its natural course of disease.
3.Has a characteristic natural course that is a slow progression through a premalignant stage.
Why screening for cervical cancer? Cont…
4. A premalignant stage can be detected by noninvasive means (the Pap smear , cervicography&VIA).
5. There are effective treatment modalities to eradicate premalignant lesions and early invasive cervical cancer.
Screening by Pap. Cx. Smear unscreened female have ten fold
risk > screened female
- Every sexually active female (18-35 y)- Specially, high risk group.
- Annually up to the age of 35y- No need to extend screening > 35y if smear is N.- At each pregnancy- If new risk factors appear after 35y.
d- If + ve smear colposcopy
c. When:
b. To whom :
a. Importance:
Alternatives to CytologyAlternatives to Cytology Visual Inspection of the cervix:Visual Inspection of the cervix:
Unaided: Downstaging. Aided with acetic acid: VIA:
Naked eye Aided with acetic a and magnification( VIAM)
Cervicography Colposcopy Speculoscopy
Automated pap smear HPV DNA test Infrared Spectroscopy & Laser Fluorescence
Limitations of Pap SmearLimitations of Pap Smear
• Complex laboratory test • Requires trained cytotechnician for reading and
pathologist for review• Continuous monitoring needed to maintain high-
quality results• Reports often take minimum 1-2 weeks to obtain• Follow-up of women is difficult• Usually available only in large cities in many
countries
COMPARISON BETWEEN COMPARISON BETWEEN SCREENING METHODSSCREENING METHODS
Source-Program for Appropriate Technology in Health [PATH] 1997.
Effective Safe Practical Affordable Available
Visual Inspection: AA
Yes Yes Yes Yes Yes
Visual Screening: Unaided
No Yes Yes Yes Yes
Automated Pap Screening
Yes? Yes ? No No
HPV Screening
Yes Yes ? ? Yes
Cervicography Yes? Yes ? ? Yes
HPV Vaccine ? ? Yes ? No
““VIA ..represents a proven, VIA ..represents a proven, simple means of identifying simple means of identifying
cervical intraepithelial cervical intraepithelial neoplasia in developing neoplasia in developing
countriescountries”.”.
Commentary: P. Blumenthal. Detection of cervical intraepithelial neoplasia in developing countries. The Lancet March 13, 1999
Comparison between : Comparison between : VIA and CytologyVIA and Cytology
Sensitivity(%)Sensitivity(%) Specificity (%) Specificity (%)
Cytology 47--62 60-95
VIA 76-84 79-83
VIA& PAP SMEARVIA& PAP SMEAR
Recent studies have 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.
MEANING OF AcetowhiteMEANING OF AcetowhiteAll acetowhite patches are not cancer: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
MEANING OF MEANING OF Acetowhite Acetowhite contcont.….…
HPV infection CIN / CGIN Adenocarcinoma Invasive squamous cell
carcinoma
Endometrial Cancer Endometrial Cancer ScreeningScreening
• Screening of unproven benefit• Transvaginal ultrasound
examinations Helpful in evaluating vaginal bleeding
• Endometrial sampling Risks include discomfort, bleeding,
infection, uterine perforation (rare)
PRE-INVASIVE LESIONS OF END.PathologyPathology Malig. Malig.
Potential Potential
MetaplasiaMetaplasia Replacement of usual gland cell by cells having cilia, sq. cells
Little or none
Simle Simle hyperplasia hyperplasia
Irregular glands, minor budding or out pouching
1-3% over 15y
Complex Complex hyperplasiahyperplasia
Back to back glands, budding, papillary process, minor stratification
3-4% over 13y
Atypical Atypical hyperplasiahyperplasia
Atypisim + back to back + budding
23% over 10y
Early Cancer Detection of Early Cancer Detection of ENDOENDO..
• Fractional curettage • Isaac Aspiration curette• Aspiration cannula (cytology)• Manual Vacum aspirator(MVA).
Ovarian Cancer Ovarian Cancer ScreeningScreening
• 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 Screening For Early Diagnosis Ovarian MalignancyOvarian Malignancy
Modalities:Modalities:1- Clinical.2- Cul-de-sac aspiration.3- Imaging techniques.4- Tumour markers.5- Radio immuno scientography.6- Multimodels.
PRE-INVASIVE LESIONS OF PRE-INVASIVE LESIONS OF VULVAVULVA
Risk factor:Postmenopausal +
Vulva dystrophy VIN
Vulval infectious disease.Chronic granulomatous.
VIN: I, II & IIIPaget`s: may be associated with paget`s of breast.
Dermatoses LeukoplekiaKrausons vulva Lichen simplex
Early Cancer Detection Early Cancer Detection of Vulvaof Vulva
Colposcopy Taulidine blue VIN Biopsy Acetic Acid
BreastBreast• Population - women, age 20 +Population - women, age 20 +
Breast self-examination Monthly, starting at age 20
Clinical breast examination Every three years, age 20-39
Annual, starting at age 40 *
Mammography Annually, starting at age 40 *
Beginning at age 40, annual clinical breast examination should be performed prior to mammography. Most other affluent countries recommend mammography every other year between ages 50 and 70.
OB& GYN, Mansoura Faculty of Medicine
Mansoura Integrated Fertility Center (MIFC) EGYPT
Telfax 0020502319922 & 0020502312299
Email. [email protected]
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