CERVICAL CANCER

SCREENING
TLOTLO NTHIBO

OUTLINE

Objectives
Significance
Definition of terms
About Cervical Ca.
HPV and HIV
Primary prevention
Secondary prevention
Summary
References

OBJECTIVES
To learn about the impact of Cervical
cancer in Botswana
To find out the different prevention
types and examples
To fully understand the basis of
screening

Cervical cancer significance

Globally it is the second most
common cancer in women
Botswana: leading cancer
Cervical>skin>breast (2010)
AIDS defining illness

Cervical cancer
Caused by HPV infection
>100 types only small number cause cervical cancer
16 & 18 (70%)
45, 31, 33, 52, 58, 35, 59, 56, 39, 51, 73, 68, 66

Others lead to genital warts (so called low risk HPV)

Most common being 6 & 11 (90%)

Transient infection very common - 8 in 10 people infected in

lifetime
Infection persists in 20-30% of women

Cervical ca cont....
Women or their partners may have HPV for
many years without knowing it
Sexually Transmitted disease
skin-to-skin contact

Condoms help but dont provide full

protection

So what happens is
Initial infection (starts at the basal
layer)
HPV oncogenes (E6 & E7) are
expressed
HPV DNA integrates into the host
genome
Cytogenetic instability results
Genetic changes allow controlled cell
growth
Malignant transformation to cervical

Disease progression
For every 1 mil women infected with
HPV
100 000 develop precancerous lesion
8000 develop CIS
1600 develop invasive cervical cancer if
above not detected or treated

Cervical cancer symptoms

Abnormal bleeding; post coital, post
douching, in between menses
Unusual heavy discharge; foul
smelling, watery, thick or mucoid
Pelvic pain
Pain during urination; advanced
disease

HPV & HIV

risk of infection with multiple strains of HPV
risk of progression to cancer
Onset of cancer 10 years younger
Overall poor prognosis
recurrence rates of treated lesions

PRIMARY PREVENTION
Goal: prevention of HPV infection
Education and awareness to reduce
high risk sexual behaviour
Biological measures such as HPV
vaccine
Quadrivalent- Gardasil
Bivalent- Cervarix
nanovalent

SECONDARY PREVENTION
AIM
To reduce mortality and morbidity
associated with cervical cancer by
identifying and treating pre-cancerous
changes (NCCPP, 2012)
Screening can prevent >70% of cervical
cancers

 According to MoH
Target age range: 30-49
Screening frequency: once in 3-5yrs

SCREENING METHODS
Cytology aka Pap smear
VIA; visual inspection with acetic acid
HPV DNA testing

Screening method
Diagnosis
Treatment

Pelvic Exam
Findings

Normal

Perform VIA

VIA

Abnormal

Vulvar
lesion

Heavy
menses

Return after
menses for
VIA

Discharge

Rx for infection
Return in two
weeks for VIA

Clinical
cancer

Refer
urgently to
COLP

PAP TEST

PAP SMEAR CONT.

PROCEDURE
Place patient in lithotomy position
Insert speculum
surface anatomy of the cervix must be
fully visualized, including the squamous
epithelium of the ectocervix,
squamocolumnar junction, and the
external os
sampling the cells at the transformation
zone to adequately detect the presence
of dysplasia

 cervical broom or cervical spatula is applied to the

surface of the cervix and turned in a single direction
to achieve an adequate sample for cytology, making
sure to rotate it at least 360 for the spatula and 5
rotations for the broom
protocol for specimen transfer varies depending on
the test used
SurePath, after the cervical broom or cervical
spatula and cytobrush are removed from the cervix,
they are placed specimen side down into the liquid
cytology vial, each removable head is snapped off,
and the vial is labeled and sent to pathology

 ThinPrep; the spatula and brush are to be swirled

vigorously in the vial 10 times to release the
specimen and then discarded
if the broom is used, it is to be pushed into the
bottom of the vial 10 times and then swirled
vigorously and discarded
Conventional; the specimens are smeared on a
glass slide and subsequently sprayed with
fixative or placed in 90% alcohol solution

 Abnormal results are reported according to the

Bethesda system
Squamous cell abnormalities (SIL)
Atypical squamous cells of undetermined significance
(ASC-US)
Atypical squamous cells cannot exclude HSIL (ASC-H)
Low-grade squamous intraepithelial lesion (LGSIL or LSIL)
High-grade squamous intraepithelial lesion (HGSIL or HSIL)
Squamous cell carcinoma

Glandular epithelial cell abnormalities

Atypical Glandular Cells not otherwise specified (AGC or
AGC-NOS)

 Endocervical and endometrial

abnormalities can also be detected &
infectious processes, including yeast,
HSV and trichomoniasis
But not very good at detecting above
If done regularly and with good follow
up can help reduce cervical cancer
deaths by 80%

 Pap Tests commonly look for epithelial

abnormalities/ metaplasia/ dysplasia/ borderline
changes
Nuclei will stain dark blue, squamous cells will stain
green and keratinised cells will stain pink/ orange.
Koilocytes may be observed where there is some
dyskaryosis
The nucleus in koilocytes is typically irregular, ratio
of nucleus to cytoplasm changed, less cytoplasm
bigger nucleus

PAP SMEAR RESULTS

NORMAL

LSIL/ASCU
S

HIV +

HIV-

Repeat
PAP
SMEAR
3yrs

Repeat
PAP
SMEAR
5yrs

ASC-H

Repeat
PAP
SMEAR
after 1yr

HSIL

Refer for
COLPOSCOPY

AGC/AGCFN/AIS

Abnormal
endometrial
cells

Endo
Sampling

Cancer

Refer for
urgent
COLPOSCOPY

VIA
Position the patient
Insert a speculum into the vagina and
visualize the cervix
Inspect the cervix and note any lesions
Apply acetic acid using a cotton swab,
wait for one minute
Inspect the cervix again and note any
lesions or color changes
Document the findings

 positive test; opaque, dense, well-defined

acetowhite areas that touch the
squamocolumnar junction or are close to
the external os or by the presence of a
cervical lesion that turns acetowhite
Acetic acid dehydrates cells so that
squamous cells with relatively large or
dense nuclei reflect light and therefore
appear white

 Visual inspection of the cervix after

application of acetic acid(VIA) or
Lugol's iodine (VILI)

VIA impression

Negative

HIV f/u
in 5yrs

Positive

Uncertain

Inadequat
e

Suspicious for
cancer

Lesion
outside TZ

HIV + f/u
in 3yrs

Eligible
cryo

Not eligible
cryo

Cryo
performed?

Defer cryo to
specified date

f/u at VIA
clinic in 1yr

Refer to COLP
clinic

Not eligible for cryo if

lesion covers >75% of
cervix, extends into
cervical os, lesion too
thick for cryo, atypical
vessels, suspicious for
cancer, lesion outside
TX, previous cryo*2

COLPOSCOPY
Colposcope is used to provide an illuminated,
magnified view of the cervix
Based on the finding that malignant and
premalignant epithelium have specific macroscopic
characteristics relating to contour, color, and
vascular pattern
Cervix is first viewed before application of additional
solutions, to look for areas of erosion, true
leukoplakia, pigmented lesions, or areas of obvious
ulceration or exophytic growth

 acetic acid solution is used to improve visualization of

abnormal areas
identifies the squamocolumnar junction or transformation
(TZ) zone
smooth grey-pink appearing ectocervix and the pink-red
cobblestone appearing endocervix
ability to see the transformation zone dictates whether the
colposcopic examination is adequate (ie, the entire
squamocolumnar junction is visible circumferentially around
the os) or inadequate
white epithelium are further evaluated for abnormal
vascular patterns such as punctation, mosaicism, or
abnormal appearing vessels

HPV DNA TESTING

Better sensitivity than cytology and
visual tests
Can be coupled with same day
outpatient treatment
Vision: to be used in 2017

CRYOTHERAPY
Eliminates precancerous lesions by
freezing them
Lasts =15mins
Highly cooled metallic disc
(cryopobe) applied to the cervix
Surface frozen using carbon dioxide
or nitrous oxide gas

LEEP
Loop electrosurgical excision
procedure

LEEP
Procedure
Consent
Place in lithotomy position
Insert speculum
Use iodine or acetic acid to identify
lesions
Consider paracervical block
Introduce loop 3-5mm lateral to os at 90
degree angle to cervix. Activate current
prior to tissue contact

 Draw loop to surface until opposite side

of os is reached
Withdraw at 90 degree angle and stop
electrical current
Obtain haemostasis by using
electrocautery
Tag specimen for orientation and send to
pathology

SUMMARY
Cervical cancer is the leading cause of
cancer in Botswana
Even worse with HIV situation
Caused by HPV persistent infection
Can be tackled through primary and
secondary prevention
Secondary prevention involves screening
with VIA, PAP SMEAR & HPV DNA testing
HPV DNA testing to be implemented by 2017

REFERENCES
Human papillomavirus Vaccination to
prevent cervical cancer, Department of
Public Health, 2014, Botswana, MoH
National Cervical Cancer Prevention
Programme, Five year comprehensive
prevention and control strategy, 2012,
Botswana, MoH
Medscape
Merck manual