Transcript Cervical Cancer Screening… “Would we ever have a nation wide

Cervical Cancer Screening…
“Would we ever have a nation wide program?”
Amr Nadim, MD
Professor of Obstetrics & Gynecology
Ain Shams Faculty of Medicine
Cervical Carcinoma
• Second in frequency among women cancers.
• It is still the most frequent cancer in the developing
countries.
• 400,000 new cases identified each year
– 80% of new cases in developing countries
• At least 200,000 women die each year
• Screening programs reduced the mortality from
cancer cervix in developed countries by 70%.
Incidence And Mortality For Cervical
Cancer Vs Breast Cancer, [US, 2000]
192 000
200 000
150 000
100 000
40 200
50 000
12 900
4 400
0
Breast
Cervical
New Cases Per Year
Source: American Cancer Society, 2000
Breast
Cervical
Deaths Per Year
Cancer Cervix…
A Screenable Preventable Disease
Pre - requisites For Successful Screening
• After Wilson and Jugner (1968):
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The condition should be an important health problem.
There should be an accepted treatment .
Facilities for treatment and diagnosis should be available.
There should be a recognizable latent or early
symptomatic stage.
– There should be a suitable method of examination.
– The test should be acceptable to the population.
– The natural history of the disease should be adequately
understood
Pre - requisites, cont....
– There should be an agreed policy on whom to treat
as patients.
– The cost should be economically balanced with the
expenditure of medical care as a whole.
– Case finding should be a continuing process.
They apply reasonably well for screening of
Cervical Carcinoma
The Good and The Evil
Screening Tools for Cancer Cervix
Molecular Biology
Methods
Cytological Methods
•Traditional Pap smear
•Thin layer prep
HPV-DNA genotyping
Visual Inspection Methods
•Unaided Naked Eye visualization
•Acetic Acid enhanced Naked eye Visualization
•Cervicography
•Colposcopy
Risk Factors for Cervix Cancer
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No prior smear screening
History of cervical dysplasia or genital warts
Young age at first coitus
Multiple sex partners
High-risk male partner (e.g., multiple female
partners)
• Sexually transmitted diseases
• Increasing age
Smoking - Nutritional Deficiencies - Immunosuppression
What Makes the Cervix
Vulnerable?
The HPV-cervical cancer link
• Human papillomavirus (HPV) is a very
common infection (more than 50% of adults get it,
in most it is a transitory infection).
• 99.7% of cervical cancer cases are
associated with HPV.
• Progression from HPV infection to cancer
usually takes 20-30 years.
E6
E7
P53
RTS
Immortality
Global distribution of HPV types in
cervical cancer
14%
3%
6%
53%
9%
15%
HPV 16
HPV 18
HPV 45
HPV 31
HPV 33
HPV others
Natural History Of Cervical Cancer
HPV
Infection
years
57%
11%
LSIL
HSIL
Invasive
Cancer
35%
1%
Source: PATH, 2001
>10%
The Papanicolaou Smear:
False Negative Results
• Precancerous cells or cancer cells do not shed in
small percentage of cases.
• Less predictable time course for development of
serious glandular lesion.
• The lesion is missed on sampling.
• The cells are not transferred to the slide or from
the sampled liquid media.
• Human error in cytopathologic analysis.
• Invasive cancer at the time of initial evaluation
These lead to a false negative rate of 20% for cytology.
Cervix Cancer Screening:
Current Controversies
• How often should Pap tests be performed?
• Should a woman who has had a
hysterectomy continue to have periodic Pap
tests?
• When should the Pap test be repeated if
endocervical cells are not present?
• Should Pap tests be performed in patients
older than age 60?
Advances in Cervical Cancer Screening
•New American Cancer Society (ACS)
guidelines
•New Technologies:
- Hybrid Capture II HPV test as part of
primary screening and triage
- Liquid based cytology
- Computer assisted Pap smear
interpretation
ACS Guidelines for Screening
• When to Start Screening
– Initiate cervical cancer screening about 3
years after the onset of vaginal intercourse.
– Screening should begin no later than 21 years
of age.
– The need for cervical cancer screening should
not be the basis for the onset of gynecologic
care.
(CA: A Cancer Journal for Clinicians 53(1):27-43, 2003)
ACS Guidelines for Screening
• When to Stop Screening:
– Women aged >70 years with an intact cervix with
>3 documented, consecutive, technically
satisfactory/normal/negative cervical cytology tests
and no abnormal/positive cytology tests within the
10 years prior to age 70 may stop cervical cancer
screening.
• Screening is recommended for 70+ year old women not
previously screened and for whom information about
previously screening is unavailable and for whom past
screening is unlikely.
CA: A Cancer Journal for Clinicians 53(1):27-43, 2003)
ACS Guidelines for Screening
• Screening After Hysterectomy
– Vaginal cytology screening tests are not
indicated after total hysterectomy for benign
gynecologic disease.
– Hysterectomy for CIN2 or greater is not
considered benign.
CA: A Cancer Journal for Clinicians 53(1):27-43, 2003)
ACS Guidelines for Screening
• Screening Interval:
– After initiation of cervical screening, perform
annually with conventional cervical cytology smears
or every 2 years using liquid-based cytology.
– Women >30 years of age with 3 consecutive,
technically satisfactory normal/negative cytology
results may be screened every 2 to 3 years unless
they have a history of in utero DES exposure, HIV+,
or are immunocompromised.
CA: A Cancer Journal for Clinicians 53(1): 27-43, 2003)
FDA Approval of Hybrid Capture II Test
in Conjunction with Pap Test
• Testing combination brings improved
sensitivity to screening and has the potential
to benefit the more than 30 million women
age 30 and older who are screened in the
U.S. each year.
• Helps physicians determine which patients
are at extremely low risk for cervical cancer
and which patients may be monitored more
closely.
FDA Approval of Hybrid Capture II Test
in Conjunction with Pap Test
• Studies show the testing combination provides a very
high certainty that a woman with a satisfactory and
negative Pap result who is HPV-negative is at low risk
for having or developing high-grade cervical disease
or cancer in the near term.
• Combined screening interval should be no more often
than once every three years.
• Screen for high risk HPV types only.
Abnormal PAP smear: Colposcopy
Cervical Cancer: Have We Decreased the
Incidence?
• With the advent of the
• The curve has been
Pap smear, the incidence stable for the past
of cervical cancer has
decade in part because
dramatically declined.
we are not reaching the
unscreened population.
Cervical Cancer Screening:
Who Is Not Getting a Pap Smear?
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Uninsured or Underinsured
Low socioeconomic status
Residents in rural locations
Minorities, especially Hispanic, Asian Pacific
Islander, African-American and AmericanIndian women
• Residents in developing countries
• Elderly
Cervical Cancer Screening:
Who Is Not Getting a Pap Smear?
• Reasons for Lack of Screening:
– Cultural barriers
– Financial barriers
– Access
– Poor education, myths
Barriers to Screening
• Embarrassment, unpleasantness
• Lack of knowledge of recommended
screening interval
• Financial barriers
• Lack of knowledge concerning the
importance of screening
IN EGYPT...
• Only sporadic attempts of screening.
• Lack of screening of the older women : the
priority target group.
• Lack of appreciation by the women of the
relevance of the disease
• Lack of availability of health care in the rural
areas.
• Fatalism
• ‫الخـــوف من المجـــــهــــول‬
Findings of many community based
studies
• Demand for cervical
cancer prevention
services is strong
among women and
communities.
• Organized prevention
programs are feasible
and can be integrated
with existing services.
Role of the Primary Care Physician
in Preventing Cervix Cancer
• Identify patients who should be screened
• Educate patients regarding the importance
and timing of Pap smears
• Conduct Pap smears properly
• Follow up abnormal Pap smear results
Findings
The single-visit
screen-and-treat
approach is safe and
effective in lowresource settings.
This is a major
paradigm shift in
cervical cancer
prevention.
…and if it works in subsaharan Africa, it should work for us!!!
Treatment of Cervix Dysplasia
Treatment Modality
Cure Rate (5-year)
Overall
• Destructive Methods
– Cryotherapy
– Laser ablation
85-95%
85-95%
• Excision
– Cervical conization
– LEEP
>90%
>90%
More Education Needed for All!
• Public awareness
– TV commercials
– Magazines
• Physician Education
– Primary Care Providers
– FP’s who work with
adolescents
• Physician to Patient
What kinds of Education?
• Disease awareness in general for all
• Link of HPV to Cervical Cancer
• Perfect opportunity for physicians to
combine with discussions of adolescent
sexuality and risk-taking behaviors
• Do we limit discussions and education to
female patients only? Probably not.
Family Barriers
• HPV is a sexually transmitted
disease
• Adolescents are invulnerable
(so they think)
• The home will protect fully
Cervical Cancer: How Do We
Eradicate Cervical Cancer?
• Optimal screening with 100% participation
• Better detection of glandular precancer
lesions
• Early detection of invasive cancers
followed by adequate evaluation and
treatment
• HPV vaccines
HPV vaccine
Evolution of Molecular-based Therapies
Cervical Cancer: Vaccines
• Prophylactic Vaccines
– Vaccinate young people before exposure to HPV
– Polyvalent HPV vaccines are being studied
– Decreased incidence of dysplasia and cancer may
not be seen for several generations
• Therapeutic vaccines
– Under evaluation for treatment of CIN and cancer
– Many different technologies
– Participants needed for clinical trials
HPV vaccine news headlines
• “Vaccine prevents most cervical cancers.” - New
York Times, October 7, 2005.
• Vaccine proves 100 percent effective in
preventing cervical cancer – Seattle Times,
October 6, 2005.
• “Promising new vaccines could wipe out cervical
cancer. But they must be administered to
preteens, and some groups oppose that.” –
Philadelphia Inquirer, July 4, 2005.
• “OK Roll up your sleeve; new vaccines are
arriving but the economics are still a challenge”
–Business Week, July 25, 2005.
HPV vaccine opportunity
• 2 vaccines protecting against HPV 16 and 18
are nearing licensure.
• Both have high efficacy in Phase II trials and
appear very safe.
• Phase III trials will involve over 50,000
women worldwide.
• Both manufacturers express interest in
serving developing country markets.
Effective Screening Program
Should be tailored to suit the principles for
national cancer control programs. We Should
NOT copy other’s programs...
Otherwise
Too much money & effort will be spent with
minimal impact on the incidence & mortality
from the disease.
Coming to an end…
• Cervical cancer is a preventable disease.
• Cervical screening is one of the most successful
public health measures ever introduced for the
prevention of cancer.
• Successful screening strategy should be coupled
with an effective treating policy to eradicate premalignant lesions
• Still, many of the world's, most vulnerable
women are not being screened.
• Implementation of comprehensive,
organized, and quality cervical screening
programs demand our energies and
attention as health professionals,
policymakers, governments, and citizens.
Thank you !!!