Screening for Female Genital Tract Malignancy

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


2. Endo cxLike endometrial C.

AgeObesity D.M. Hypertension Nulligravida & Virgin Low parityTamoxifen


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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Screening for Female Genital Tract Malignancy