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CERVICAL CANCER and ITS PREVENTION PowerPoint Presentation

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Description : Check out this medical presentation on cancer titled "CERVICAL CANCER & ITS PREVENTION" to find important information on cervical cancer and ways to prevent it.

Tags : Cancer, cervical cancer, prevention, cervix, Human Papillomavirus, HPV, Virus, Infection, Cervical Carcinogenesis, symptoms, screening, Vaccination, Secondary Prevention, Pap smear, Cytology, HPV Test, COLPOSCOPY, Preclinical invasive Carcinoma, Inflammatory lesions, Uterine Cervix, Primary Prevention, HPV Vaccine

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1 CERVICAL CANCER & ITS PREVENTION -Dr.MEETA AGRAWAL, Obs & Gynae., Bhopal Educational Program 2009 1
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2 Sad but True… In India, 200 women die each day due to Cervical cancer
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3
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4 For you & your daughter …..a wonderful gift Guard Yourself means Protect yourself very special programme to prevent cervical cancer.
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5 where is cervix in woman? Educational Program 2015 5 CERVIX
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6 What is cancer? Uncontrolled growth of abnormal cells in any part of the body. Generally due to 1. chemicals (e.g. From smoking ) 2. radiation 3. micro-organisms (e.g. Bacteria, viruses)
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7 India ~1,32,000 World ~ 4,93,000 India ~27% of new Cervical Cancer cases in world India ~ 74,000 World ~ 2,73,000 India ~27% Rest of World - 73% India ~27% of deaths due to Cervical Cancer in world Rest of World - 73% India - 27% Cervical Cancer – Disease Burden New Cervical Cancer Cases Deaths due to Cervical cancer India ~27% Rest of World - 73%
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8 Incidence ( Women of all ages) – Cervical Cancer vs. other Cancers 2. X. Castellsagué, S. de Sanjose, T. Aguado, K. S. Louie, L. Bruni, J.Muñoz, M. Diaz, K. Irwin, M. Gacic, O. Beauvais, G. Albero, E. Ferrer, S. Byrne, F. X. Bosch. HPV and Cervical Cancer in the World. 2007 Report. WHO/ICO Information Centre on HPV and Cervical Cancer (HPV Information Centre). Available at: www.who.int/hpvcentre
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9 HPV 16 HPV 18 HPV 6 HPV 11 Cancer causing Types1,2,4 Non-cancer causing types1,2 >75% of Cervical Cancer5 >50% of Vaginal & Vulvar Cancer5 90% of Anogenital warts5 HPV is a necessary cause of cervical cancer – 99.7%4 HPV 1.Schiffman M, Castle PE. Arch Pathol Lab Med. 2003;127:930–934. 2. Wiley DJ, Douglas J, Beutner K, et al. Clin Infect Dis. 2002;35(suppl 2):S210–S224. 3. Muñoz N, Bosch FX, Castellsagué X, et al. Int J Cancer. 2004;111:278–285. Reprinted from J Virol. 1994;68:4503–4505 with permission from the American Society for Microbiology Journals Department. 4. Walboomers JM, Jacobs MV, Manos MM, et al. J Pathol. 1999;189:12–19. 5. X. Castellsagué, S. de Sanjose, T. Aguado, K. S. Louie, L. Bruni, J.Muñoz, M. Diaz, K. Irwin, M. Gacic, O. Beauvais, G. Albero, E. Ferrer, S. Byrne,F. X. Bosch. HPV and Cervical Cancer in the World. 2007 Report. WHO/ICO Information Centre on HPV and Cervical Cancer (HPV Information Centre). Available at: www.who.int/hpvcentre Human Papillomavirus (HPV)
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Human Papilloma Virus Anogenital Disease: cervix, vulva, vagina, anus, penis Condylomata accuminatum Squamous intraepithelial neoplasia Cancer Head/Neck Disease: Mouth, tongue, tonsils Sinuses Oropharangeal Respiratory mucosa (children; type 6, 11) Cancer: usually HPV 16 Cofactors: Smoking, Alcohol
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Acute (Incident) HPV Infection
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Natural History of HPV Infection HPV Infection Cervical Lesions Normal Development of Precancerous lesions CIN1, CIN2 & CIN3 Invasive Cancer Ranges from Measured by HPV DNA detection in cervical cells Relative frequency increases with severity of lesion
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Cofactors for progression of cervical HPV infection to Cancer Long term use of Hormonal Contraceptive -> 5-9yrs :: 3 times Risk -> 10yrs or more :: 4 times Risk High Parity :: 4 times Risk Early initiation of Sexual Activity Multiple Sex Partners Tobacco Smoking (Both active & passive) HIV Infection Other STI’s ->Chlamydia Trachomatis -> HSV 2 Immune Suppression Low S/E status ; Diet poor in anti oxidants
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Cervical Carcinogenesis
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Natural History of HPV & Cervical Cancer
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16 CIN (CERVICAL INTRAEPITHELIAL NEOPLASIA) as Seen in Colposcopy CIN 1 CIN 2 CIN 3 1. Wright TC Jr, Cox JT, Massad LS, et al, for the ASCCP-Sponsored Consensus Congress. JAMA. 2002;287:2120–2129. 2. Bonnez W. In: Richman DD, Whitley RJ, Hayden FJ, eds. Washington, DC: American Society for Microbiology Press; 2002:557–596. 3. Canadian Cancer Society. Cervical Cancer: What you need to know. Available at: http://www.cancer.ca/vgn/images/portal/cit_86751114/63/40/151140772cw_library_wyntk_cervical_en.pdf. Accessed March 13, 2006. 4. Reprinted with permission from Sellors JW, Sankaranarayanan R, eds. Colposcopy and Treatment of Cervical Intraepithelial Neoplasia. A Beginner’s Manual. Lyon, France: International Agency for Research on Cancer; 2003. Photo courtesy of Dr. J. Monsonego Photo courtesy of Dr. J. Monsonego From IARC, 2003.4 Colposcopy findings confirmed by histology1
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17 How HPV infection can occur? Through sexual intercourse, vertical transmission i.e. mother to child & fomites. It is found that in every 10 women 8 women might have HPV infection at anytime in life.* Educational Program 2009 17 *Ref: CDC Factsheet on Genital HPV infection www.cdc.gov/STD/healthcomm/factsheet.html
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18 Beware of this symptoms Consult your doctor immediately if you have Continuous vaginal discharge,inspite of treatment Foul smelling, thick discharge, Repeated vaginitis and UTI Post coital bleeding(bleeding after sex) Non healing or recurrent cervical erosion Irregular or intermenstrual bleeding specially in pre menopausal phase
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19 Cervical cancer screening Chronic pain distension loss of weight Heavy prolong bleeding ,before or during menopausal age Post menopausal bleeding-important Cervical polyp tumor during or before menopause age
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20 Educational Program 2009 20 Is it possible to get protection against cervical cancer?
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Cervical Cancer Cervical Cancer is now a virtually preventable disease due to Early Vaccination Screening strategies Long natural history Cervix is easily accessible
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22 Secondary Prevention Screening may help in early detection of cervical abnormalities
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23 What is the use of screening program? Secondary prevention or screening program are helpful in detecting cancer at the early stage hence useful in saving lives.
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Tests Available Visual Inspection VIA VILI Pap Smear Conventional LBC HPV DNA Testing Cervicography Pap Net Polar Probe Community low resource settings Still Experimental
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USPSTF and ACS/ASCCP/ASCP Guidelines at a Glance
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USPSTF and ACS/ASCCP/ASCP Guidelines at a Glance
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PAP Smear PAP smear sampling of cervix involves scraping of cervical surface and a portion of non visualised cervical canal using various sampling devices
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28 disasters “prevention is better than cure’-holds true for cervical cancer This can be achieved by regular health check up and regular pap smear test Pap- smear is cancer screening which is easy ,painless and reliable method in which the discharge from vagina is taken on slide and sent for examination for presence of abnormal cells Routine pap smear has reduced ca cx by 75% in developed world Repeat pap is advised if it shows abnormal cells & than advised colposcopy & biopsy. It can give early diagnosis of cancer before its sets in and hence early treatment can avoid disease
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Significance of Pap smear Detect precancerous & invasive cancer cervix cases in early stages Positive screeners can be selected for selective tests and management With treatment, progression of disease is halted. Thus morbidity associated with advanced cancer decreases Mortality reduces by 20-60 %. Helps us to study natural history of disease.
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Transformation zone Cervix develops from 2 embryonic sites * from Mullerian duct - lined by columnar epithelium * from urogenital plate - lined by stratified squamous epithelium Point at which columnar and squamous epithelium meet is called as original squamo-columnar junction
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Transformation zone Under influence of estrogen, original SCJ moves onto the portio. Exposure of delicate columnar cells to vaginal environment leads to squamous metaplasia. Transformation zone - - Area of squamous metaplasia - Area between original and new SCJ
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Transformation zone
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Transformation Zone -TZ Exposure of TZ to carcinogens begins the process of intraepithelial neoplasia While exact role of carcinogens in this process remains poorly understood, it is clear that HPV and cigarette smoking can cause dysplasia at the TZ 95% of cervical cancers develop in TZ Important to take sample from TZ
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34 PAP SMEAR The cells are taken from the cervix region by speculum & spatula, then smear is prepared which is then observed under microscope. It is not recommended in virgin females. Recommended in every 3 years to all female aged more than 30 years.
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How to take a Pap Smear ? Spatula is rotated through 360 degrees maintaining contact with ectocervix Do not use too much force [bleeding /pain] Do not use too less force [inadequate sample] Sample is smeared evenly on the slide and fixed immediately Both sides of spatula are to be smeared
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How to take a Pap Smear ? Endocervical sample is collected using an endocervical brush Insert the cytobrush into canal, so that last bristles of brush are visible Rotate the brush through 180 degrees. [more rotations increase the chance of bleeding] Sample is rolled on the slide and fixed.
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Fixation of smear Fixation is done immediately with fixative like 95% alcohol or cytofix spray to avoid air drying Spray should be kept at 10 inches, to avoid destruction of cells by propellent in the spray Smear should monolayer for proper penetration of cell surface by fixative
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Fixation of smear Fixation is done immediately with fixative like 95% alcohol or cytofix spray to avoid air drying Spray should be kept at 10 inches, to avoid destruction of cells by propellent in the spray Smear should monolayer for proper penetration of cell surface by fixative
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Several slides can be prepared from one smear Chlamydia, HPV testing can be done at later date Reduces the incidence of inadequate and repeat smears Liquid Based Cytology
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What is the HPV Test? The HPV test is a very accurate way to tell if high-risk HPV is present in a woman’s cervix. This test can use the same sample of cells taken for the Pap test. A positive test result means a woman has high-risk HPV. A positive HPV test does not mean that a woman has cancer.
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When Should an HPV Test be Done? To see if a woman with a borderline Pap test result (one that shows unusual cells but not dysplasia) needs additional tests. To screen for cervical cancer, along with the Pap test, in women aged 30 or older.
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Preventive Methods
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43 COLPOSCOPY Colposcopy is the examination of the cervix & vagina with a light magnifying instrument colposcope after the application of a vinegar (acetic acid) to the cervix.
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Colposcopy Magnified visual examination of uterine cervix by a low power ,stereoscopic microscope with a powerful light source to help in diagnosis of cervical neoplasia . Key ingradients –observations of features of cervical epithelium after application of normal saline , 3-5% dilute acetic acid and Lugol’s iodine solution .
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INDICATIONS OF COLPOSCOPY Squamous or glandular cell abnormalities Persistence of inflammatory cells despite adequate tt Presence of keratinized cells . VIA +ve and VILLI+ve Evaluation of HPV +ve women . Postcoital ,postmenopausal bleeding . Unhealthy cervix . Treatment and monitoring of women with CIN Anogenital condylomas ,VIN and VAIN. DES exposure in utero.
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Colposcopy - Objectives Determines the presence of invasive cancer Localizes the squamocolumnar junction Identifies the most severe disease for biopsy Evaluates the extent of disease
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A method of identifying outer & inner borders of the transformation zone
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ppt slide no 48 content not found
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Post Menopausal Cervix: Epithelium is pale, brittle, lacks lusture, shows sub-epithelial petichiae, SCJ not visualized The entire new SCJ is visible colposcopic examination is satisfactory. the TZ is fully visualized. The metaplastic squamous epithelium is pinkish-white compared to the pink original squamous epithelium
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Squamous metaplasia Earliest colposcopic changes in immature squamous metaplasia (after 5% AA) in which tips of columnar villi stain white & adjacent villi start fusing together Prominent white line corresponds to the new SCJ & tongues of immature Squamous metaplasia a) with crypt openings at 4-8 o’clock positions b) after application of AA
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Immature squamous metaplastic epithelium (narrow arrow) on the polyp with intervening areas of columnar epithelium a) after application of AA The endocervical polyp & the immature squamous metaplasia surrounding the os partially take up iodine.
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Immature squamous metaplastic epithelium (narrow arrow) on the polyp with intervening areas of columnar epithelium a) after application of AA The endocervical polyp & the immature squamous metaplasia surrounding the os partially take up iodine.
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Leukoplakia Usually benign May obscure an underlying neoplasia Therefore, all patches observed before application of acetic acid must be biopsied Hyperkeratosis ( Leukoplakia)
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54 CIN (CERVICAL INTRAEPITHELIAL NEOPLASIA) as Seen in Colposcopy CIN 1 CIN 2 CIN 3 1. Wright TC Jr, Cox JT, Massad LS, et al, for the ASCCP-Sponsored Consensus Congress. JAMA. 2002;287:2120–2129. 2. Bonnez W. In: Richman DD, Whitley RJ, Hayden FJ, eds. Washington, DC: American Society for Microbiology Press; 2002:557–596. 3. Canadian Cancer Society. Cervical Cancer: What you need to know. Available at: http://www.cancer.ca/vgn/images/portal/cit_86751114/63/40/151140772cw_library_wyntk_cervical_en.pdf. Accessed March 13, 2006. 4. Reprinted with permission from Sellors JW, Sankaranarayanan R, eds. Colposcopy and Treatment of Cervical Intraepithelial Neoplasia. A Beginner’s Manual. Lyon, France: International Agency for Research on Cancer; 2003. Photo courtesy of Dr. J. Monsonego Photo courtesy of Dr. J. Monsonego From IARC, 2003.4 Colposcopy findings confirmed by histology1
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Geographic satellite lesion condyloma low-grade lesion
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Thin acetowhite lesion with geographic margins in the upper lip. Histology indicated CIN 1 Moderately dense acetowhite lesions with irregular margins in the anterior & posterior lips ( CIN 1)
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circumorificial acetowhite CIN 1 lesion with irregular margin & fine mosaics
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Moderately dense acetowhite lesions with well defined margins & coarse punctations in the anterior lip & in 3 o’clock position (CIN 2 lesion Dense well defined acetowhite area with regular margins & coarse mosaic ( CIN 2 lesion )
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A dense acetowhite lesion with varying colour intensity & coarse mosaics (a) in a CIN 2 lesion Acetowhite lesions with coarse punctation (a) & mosaics (b) in a CIN 2 lesion
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A circumoral dense opaque acetowhite area with coarse mosaics ( CIN 3 lesion) A dense acetowhite lesion with regular margin & coarse, irregular punctation in a CIN 3 lesion.
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Carcinoma in Situ
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Early invasive cancer: note the raised irregular mosaics with umbilication (a), breaking mosaics (b), surface irregularity & the atypical vessels after the application of 5% AA Preclinical invasive Carcinoma
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Reddish “angry-looking”, inflamed columnar epithelium with loss of the villous structure & with inflammatory exudate (before application of 5% AA) Inflammatory lesions of the Uterine Cervix Chronic cervicitis: This cervix is extensively inflammed with a reddish appearance & bleeding on touch, there are ill-defined, patchy acetowhite areas scattered all over the cervix after the application of AA
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TV after Acetic acid T.V. After Lugol’s Multiple red spots (a) suggestive of Trichomonas vaginalis colpitis ( strawberry appearance), after application of 5% AA Trichomonas vaginalis colpitis after application of Lugol’s iodine (leopard-skin appearance)
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65 Primary Prevention by HPV Vaccine GARDASIL® [Human Papillomavirus Quadrivalent (Types 6, 11, 16, and 18) Vaccine 0.5ml prefilled syringe] CERVERIX [Human Papillomavirus Bivalent (Types 16 and 18) Vaccine 0.5ml prefilled syringe] 09-2009-GRD-2008-AP-(IN)-1601-SS
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66 HPV Vaccines- made by recombinant DNA technology
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67 INDICATION FOR Gardasil For the prevention of Cervical Cancer Vulvar/ Vaginal Precancers Cervical Dysplasia Genital Warts Cerverix is only indicated for Cervical cancer
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68 Effectiveness Gardasil vaccine’s efficacy is 98 to 100%. Cerverix vaccine’s efficacy is 92 to 94% Educational Program 2009 68
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69 When we can give this vaccine? This vaccine can be given to any girl above 9 years. Recommended for women of 9-45 years age group The most effective time to vaccinate girls and young women is before they become sexually active. Educational Program 2009 69
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70 How many dose recommended? Three doses First .(as elected date) Second (after 2 month of first dose) Third (after 6 month of first dose) Cerverix – 0,1 & 6 Educational Program 2009 70 6 months 2 Months 0
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71 Side effects HPV Vaccines demonstrated a favorable safety profile. Following injection-site reactions occurred at a greater incidence in the group that received VACCINE Very common: erythema, pain, and swelling. Common: pruritis. Most injection-site reactions were mild to moderate. Very Common (≥1/10); Common (≥1/100, <1/10); Uncommon (≥1/1,000, <1/100); Rare (≥1/10,000, <1/1,000); Very Rare (<1/10,000) Educational Program 2009 71
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72 Special Population PREGNANT WOMEN Because of insufficient trial there is no recommendation of this vaccine in pregnancy. If woman gets pregnant after first dose ,then remaining dose should be taken after delivery. LACTATING MOTHER Lactating woman can take this vaccine. Cerverix is not indicated during lactation Educational Program 2015 72
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73 Is vaccine costly? No, if we can see the mortality rate of the cervical cancer or its treatment ,vaccine cost is nothing against it. If we see the modern life style of people ,vaccine cost is nothing. People give lacks of rupees of dowry to their daughters ,vaccine cost is nothing against it. It is cost effective Educational Program 2009 73
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74 Screening & Vaccination Pap testing and screening for HPV DNA or HPV antibody are not needed before vaccination at any age. Benefits may be limited to protection against HPV genotypes with which they have not been infected. Women infected with vaccine HPV-type and have cleared the cervical infection appears to have similar protective effects as in HPV naïve to the same vaccine HPV-type.
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75 3 North America: USA Canada Mexico 8 South America: Brazil Bolivia Argentina Uruguay Peru Ecuador Colombia Chile 26 Middle East & Africa: Gabon Congo Kinshasa Israel C.A.R. Morocco Mauritius Kenya Kuwait Mauritania UAE Guinea Eq. Ethiopia Uganda Togo Malawi Congo Brazzaville Jordan Egypt Cote d’Ivoire Burkina Faso Chad Bahrain Saudi Arabia Botswana South Africa Cameroon 13 Asia Pacific: Australia Indonesia Korea Taiwan Hong Kong Singapore New Zealand Macau Malaysia Philippines Thailand India Vietnam 40 Europe: Germany Cyprus Ireland France Czech Republic Latvia UK Denmark Lithuania Spain Estonia Luxembourg Italy Finland Malta Austria Greece Netherlands Belgium Hungary Norway Bulgaria Iceland Poland Portugal Romania Slovakia Slovenia Sweden Serbia Montenegro Switzerland Liechtenstein Turkey Croatia Bosnia Russia Macedonia Belarus Georgia Caribbean & Central America: Costa Rica Trinidad Puerto Rico El Salvador Guatemala Honduras Curaçao Nicaragua Bermuda Panama Bahamas Cayman Islands Barbados Aruba Jamaica Dominican Republic 16 Gardasil Approvals: 156 countries
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76 Is this vaccine is using with another developing country? Yes, this vaccine is available in 156 country. till date 200 million doses already used within 9 years of time. Educational Program 2009 76
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77
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78 But PRIMARY PREVENTION is most important.
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79 Preventing aspects-lifestyle change Social change –avoid early marriages Multiparity_ role of family planning Avoid multiple partners Use of condom to avoid STD,and HPV diseases Improve nutrition and personal hygiene Prevents smoking ,alcoholism ,etc Regular exercise Health awareness-health check up
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Recommendations To produce a Cancer Free Society Screening and identification of High Risk groups Education – Think of Cervical Cancer as an extension of STD Behavioral changes Limit number of sexual partners Delay initial age of sexual intercourse Avoid STD – Use of Condoms/ Spermicidals; Avoid Smoking HPV Vaccines to be promoted at the right age
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81 Lets fight against cancer …..join hands…… …..take preventive measures……. …..update yourself….. …..take care…..
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82 Thank you