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1、Screening for Cancer Cervix by Visual Technique,Professor.Surendra Nath Panda,M.S.of Obstetrics and GynecologyM.K.C.G.Medical CollegeBerhampur,760004,Orissa,India,2,17 February 2023,Screenig For Cancer Cervix by Visual Technique,Cervical Cancer,500,000 new cases identified each year80%of the new cas
2、es 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 Problem:-,3,17 February 2023,Screenig For Cancer Cervix by Visual Technique,Cervical Cancer:Aetiology,Cause:HPV-a sexually transmitted in
3、fectionWomen are generally infected with HPV in their teens,20s,30s Cervical cancer can develop up to 20 years after HPV infection,4,17 February 2023,Screenig For Cancer Cervix by Visual Technique,Natural History of Cervical Cancer:,Source:PATH 1997.,Current Understanding,5,17 February 2023,Screenig
4、 For Cancer Cervix by Visual Technique,Prevention of Cervical Cancer,Cervical cancer is a preventable disease Primary prevention:Education to reduce high risk sexual behaviourMeasures to reduce/avoid exposure to HPV and other STIsSecondary prevention:Treatment of precancerous lesions before they pro
5、gress to cervical cancer(implies practical screening test),6,17 February 2023,Screenig For Cancer Cervix by Visual Technique,Secondary Prevention of Ca.Cx.,Key Point is to detect precancerous lesions“Down staging”Answer:-A good screening methodPAP smear test is considered to be the gold standard Has
6、 limitations?Alternatives to Pap Smear What are they?,7,17 February 2023,Screenig For Cancer Cervix by Visual Technique,Qualities of a Good Screening Test?,Safe,Practical,Affordable,Available,Effective,8,17 February 2023,Screenig For Cancer Cervix by Visual Technique,Limitations of Pap Smears for Na
7、tional 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 possibl
8、e 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.,9,17 February 2023,Screenig For Cancer Cervix by Visual Technique,Alternatives to Pap Smear Scre
9、ening,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
10、for many low-resource settings.,Why?,10,17 February 2023,Screenig For Cancer Cervix by Visual Technique,Cervical Cancer Screening,Visual inspection with acetic acid(VIA)Visual inspection with acetic acid and magnification(VIAM):Gynescope or AviscopeColposcopyCervicographyAutomated pap smearsMolecula
11、r(HPV/DNA)tests,Other Options:-,11,17 February 2023,Screenig For Cancer Cervix by Visual Technique,Approaches to Cervical Cancer Prevention in Low-resource Settings,Source-Program for Appropriate Technology in Health PATH 1997.,12,17 February 2023,Screenig For Cancer Cervix by Visual Technique,What
12、Is VIA/Cervicoscopy?,Looking at the cervix to detect abnormalities after applying acetic acidAcetic 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%,Also known as“Aided Visual In
13、spection of Cervix”,or“Acid Acetic Test”,13,17 February 2023,Screenig For Cancer Cervix by Visual Technique,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.Sc
14、hiller 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(in
15、itially developed in the 1930s)to confirm screening findings.,14,17 February 2023,Screenig For Cancer Cervix by Visual Technique,History of Research on Visual Inspection,Years later,given the expense and inconvenience of colposcopy services,clinicians began to explore whether unmagnified visualizati
16、on 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 aci
17、d(VIA)for purposes of identifying a normal transformation zone or detecting precancerous lesions of the cervix(i.e.,primary screening).,15,17 February 2023,Screenig For Cancer Cervix by Visual Technique,History of Research on Visual Inspection,Then,in 1982,Ottaviano and La Torre published an importa
18、nt 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 auth
19、ors concluded that colposcopic magnification is not essential in clinical practice for the identification of the cervix at risk.,16,17 February 2023,Screenig For Cancer Cervix by Visual Technique,History of Research on Visual Inspection,In 1990,Abrams published his experience with the Gynoscope,a mo
20、nocular 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
21、 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.,17,17 February 2023,Screenig For Cancer Cervix by Visual Technique,History of Research on Visual
22、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 Papanico
23、laou smear for cervical cancer screening”and can be helpful in reducing referrals for colposcopy without compromising quality of care.,18,17 February 2023,Screenig For Cancer Cervix by Visual Technique,Needed Equipment and Supplies for VIA,VIA can be performed in any clinical setting when the follow
24、ing are available:Examination table,preferably with stirrups or leg supports Sterile speculum,preferably Cuscos 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,19,17 Februar
25、y 2023,Screenig For Cancer Cervix by Visual Technique,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(i
26、f 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.,20,17 February 2023
27、,Screenig For Cancer Cervix by Visual Technique,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
28、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.,21,17 February 2023,Screenig For Cancer Cervix by Visual Technique,The Examination,Do not perform the examination
29、 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.,Important,22,17 Februa
30、ry 2023,Screenig For Cancer Cervix by Visual Technique,Objectives Of Acetic Acid Examination,Locate the squamocolumnar junctionIdentify any lesion&its limitsDecide whether the lesion is CINDetermine whether invasion is possibleSelect a site or sites for biopsy if appropriate,23,17 February 2023,Scre
31、enig For Cancer Cervix by Visual Technique,What does Acetic Acid do?,Acetic acid Dissolves mucusInduces intracellular dehydrationCauses coagulation of proteinAs a result cells with increased Nuclear/Cytoplasmic ratio ratio Nuclear density Chromosomal aneuploidy Become opaque acetowhite area test pos
32、itive,24,17 February 2023,Screenig For Cancer Cervix by Visual Technique,Abnormalities Seen After Acetic Acid,Aceto-whiteMargins and surfaceWhite gland openingsMosaic&punctationAbnormal vessels,25,17 February 2023,Screenig For Cancer Cervix by Visual Technique,What May Be Acetowhite,All acetowhite p
33、atches are not cancerAny of these epithelial changes can become acetowhiteHealing or regenerating epitheliumCongenital transformation zoneInflammationImmature squamous metaplasiaHPV infectionCIN/CGINAdenocarcinomaInvasive squamous cell carcinoma,26,17 February 2023,Screenig For Cancer Cervix by Visu
34、al Technique,Reporting Visual Inspection Findings,Smooth,pink Clear mucoid secretion Central hole-external osNulliparours-roundMultiparous-slit or cruciateCervix in postmenopausal women is atrophic,Normal Cervix,NORMAL:-,27,17 February 2023,Screenig For Cancer Cervix by Visual Technique,Reporting Vi
35、sual Inspection Findings,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,ABNORMAL:-,28,17 February
36、2023,Screenig For Cancer Cervix by Visual Technique,Reporting Visual Inspection Findings,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,ABNORMAL:-,29,17 February
37、 2023,Screenig For Cancer Cervix by Visual Technique,Reporting Visual Inspection Findings,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.,30,17 February 2023,Screenig For Cancer
38、 Cervix by Visual Technique,Action Plan,VIA,Negative,Positive,Follow-up after 3-5 years according to the decided policy.Advise to come back if develops symptoms.,Treat/Refer to an appropriate center-PHC/Secondary/Tertiary/Oncology Centre,31,17 February 2023,Screenig For Cancer Cervix by Visual Techn
39、ique,Action Plan,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:Pap-smear/Colposcopy negative:re call for follow-up in 6-12 months.Pap-smear/Colposcopy positive
40、:call the patient for appropriate treatment,Management of VIA Positive Cases:-,32,17 February 2023,Screenig For Cancer Cervix by Visual Technique,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 Me
41、morial 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.,33,17 February 2023,Screenig For Cancer Cervix by Visual Technique,Why VIA as an Alternative inLow-resource Settings?,Non-invas
42、ive,easy to perform and inexpensiveCan be performed by all levels of healthcare workers,in almost any settingSkills consistent with service delivery tasks performed by nurses/midwives in MCH/FP clinic settingsResults are available immediately,34,17 February 2023,Screenig For Cancer Cervix by Visual
43、Technique,Why VIA as an Alternative inLow-resource Settings?,Initial treatment can be provided at the time of the examinationAll system requirements are available locallyPotential for immediate link to treatmentApproach suitable for lowest-resource settings*,35,17 February 2023,Screenig For Cancer C
44、ervix by Visual Technique,THANK YOU,A,At the service of women,V I A,MajpjMVcyzj21HLfrvy96dv02lPPfYgxUS7IYmZkyEmZ0kGeYZS3bpLCkYH1lt4EK7CxmUX3ijoYSOer7ZuaVWYgz4EpZrUirVpMzzvNtf1XZw5oswSXOtFaejnOcmfE1lZgnN1RSXg8wLCG8CVQ3XPJMvodPFWcpiYJgZazNSEPNIaklYSu7qSd1UpaxmZDlpN9zW7kljfsLCLi26Yv109ffbnDH8LbUN1G6ACU
45、RQ39eG12KHL9tXsZ1jzgoCK8g1kuNOh5eFvcmVT5ZYVQt9zk3rp3qLnf02FovEXxVRxjCcFRNppiJljNiOuk6fONnyX7fyGg7sXZ49BmCN5oy9VesHpKzdjTKwjrkCEQCFDehVmGax3lrOEbw63VscA3YSijtUKoCyiLzAlVRp7l4QgPNHxvJFFDyjUVN3oHlMah0XBd4uTbkfPIhHtw0evPmYOrdhEDoPwvYhzlGplU1AU9mpyiCXH8gpPCBRYjq77VcnbXumNE1yGfyTsbSj89J63kRTKDkKUg3mdS5sJ4
46、X5cQ8dK7oW9IkScssECQdz2O9UTlpRjAFPChjhLdzopQzwxQf8ozdzOhogwAooXpUF83BX4C3jRgjDJiiXEUDMaNz4vQ4n164vspddHvOIVuBBdMA4xp1YhiHk0vOJ8TL1BxogzVlMpmod6ianYGmksQq6NWCEd56hZF4wfaNyZcrGfNxnPiG6ZAxSkfmhJAKtNmCqbRmppeXp8inz4eq3HkWCMSORyMMX522xpHG6basNr6KQfbZsFbHjzyNlJrruLolKFcC84dqfijBO5Dy2NaBcNEBPgQrT12PgpcKx2or2YChN5DPjs80zzdtdAdTKuW4uVv9bbZu3K2SZ2aEhTlIC1UqrIWibkzwHh6p8gLv26zr01mJybfOzFc4T7kQH1IpPwOzMDnAKPLsLrznXGjFNIA9bSWWms6ibKZwQIKrMzalwbFrQJvOP1rPH8rx2KkyYqrtQk5VRwM1HSX,
