Screening for Cervical Cancer by Visual Inspection Techniques

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Screening forCervical CancerbyVisual
Inspection Techniques

• Dr Aruna Batra
• VMMC SJH

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Cervical Cancer- Facts

• A significant public health problem
• 2nd commonest cancer in ? worldwide
• Annually 3,70,000 new cases of cervical cancer,
  80 in developing countries
• Leading cause of death in developing countries,
  often killing women at young ages

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Cervical Cancer- Facts

• Cause virtually all cases of cervical cancer are
  caused by persistent cervical infection with some
  types of Human Papilloma Virus (STI)
• Develops slowly, has a detectable and treatable
  precancerous stage
• Preventable disease

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Cervical Cancer- Why preventable?
Easy accessibility of Cx TZ
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Natural History of Cervical Cancer
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Cervical Cancer- Risk Factors

• Early age at marriage
• Multiple sexual partners
• Sexually transmitted infections
• Poor socio-economic status
• Smoking
• Immunological factors

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Prevention of Cervical Cancer

• Primary prevention
• Education to ? high risk sexual behaviour
• Measures to avoid exposure to HPV STIs
• Secondary prevention
• Detection Treatment of precancerous lesions
  before they progress to cervical cancer

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Cervical Cancer Screening
Methods available

• Papanicolou smear (cytology)
• Visual Inspection techniques
• Colposcopy, Cervicography
• Molecular (HPV DNA) tests

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Limitations of Pap Smears for National Screening
Programs

• Primary screening is repetitive, labour
  intensive, time consuming
• Subject to errors of interpretation
• Sensitivity 60-70
• Complex logistics, advanced training, good
  program implementation required

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Limitations of Pap Smears for National Screening
Programs

• Pap Smear as a screening methods may not be
  appropriate or adequate for many low-resource
  settings
• Even in large cities, quality Pap smears possible
  but require ongoing supervision, refresher
  training continued supplies.

Cytology is not viable as a nationally accessible
screening method in many developing countries
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Visual Inspection Techniques
Unaided Visual Inspection Visual inspection
with acetic acid (VIA) Visual inspection with
acetic acid and magnification (VIAM) Visual
inspection with Lugols Iodine (VILI)
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Unaided Visual Inspection of Cervix

• - Dx at stage III IV ?from 85 to 55
• - Dx at stage I II ? from 15 to 45
• Kerala Study 1977-87

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Unaided Visual Inspection of Cervix

• 60 of Early disease could be identified
• 11 were false positive
• Only 15-20 of pre-cancerous lesions could be
  detected
• Singh V et al 1992

Good for Clinical Down staging Misses
Precancerous lesions
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Visual inspection with acetic acid VIA

• Looking at the cervix to detect abnormalities
  after applying acetic acid
• Acetic acid is used to enhance and mark the
  aceto-white change of a pre-cancerous lesion or
  actual cancer

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VIA- Basis

• Produced due to osmolar changes after acetic acid
  application, causing water of the cell to leave
• Collapse of the cell membrane around the abnormal
  and enlarged nucleus
• Altered lesion appears white due to reflection of
  the incidental light

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VIA positive
HPV lesion
Dysplastic lesion
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VIA Negative
Normal Cervix
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VIAM (Visual Inspection with Acetic Acid Using
Magnification)

• VIAM is visualization of cervix after application
  of acetic acid using low power magnification
  (2.5x to 4x)
• Magnascope (4X)

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VILI
Negative
Positive
Columnar epithelium
Normal squamous epithelium
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Comparison of Screening Methods
Method Sensitivity () Specificity ()
Cytology 45-85 80-98
VIA 60-90 66-96
HPV DNA 65-95 70-96
NEJM Nov17,2005
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Screening Costs
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Ca Cx prevention in Thailand Single visit VIA
Cryosurgery

• 5999 women tested by VIA
• -13.3 VIA counseled for immediate Cryo
• - Accepted by 98.5
• - Minor side effects 2.2, Major Cp nil
• - 83.2 came for follow up, gt 95 satisfied

Safe, acceptable, feasible
RTCOG Lancet 2003 361 814-820
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Visual Inspection Techniques in Low
resource setting

• Noninvasive, easy to perform, inexpensive
• All requirements are available locally
• Can be performed by all levels of healthcare
  workers, in almost any setting
• Results are available immediately
• Initial treatment can be provided at the time of
  the examination

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Conclusion
RCH program can act as a powerful tool in
preventing Cervical cancer Creating
Awareness Using Simple Screening methods