SCREENING STRATEGY WITH VIA AND TREAT

AND
SCREENING STRATEGY WITH AN HPV TEST
FOLLOWED BY VIA AND TREAT

Fitriyadi Kusuma, M.D., Ph.D.

Oncology Division, Obstetrics and Gyneacology Department

Faculty of Medicine, Universitas Indonesia
Curriculum Vitae
DATA PERSONAL
• Nama : DR. Dr. Fitriyadi Kusuma, Sp.OG(K)
• Tempat/Tanggal Lahir : Jakarta, 22 Januari 1966
• Email : fitriyadikusuma@gmail.com
RIWAYAT PENDIDIKAN
• 1971-1990 : SD –SMP-SMA di Jakarta Selatan
• 1984-1990 : Universitas Indonesia, S1 Kedokteran Umu
• 1994-1999 : Universitas Indonesia, Sp1 Spesialis Obstetri Ginekologi
• 2008-2011 : Universitas Indonesia, Sp2 Sub Spesialis Ginekologi Onkologi
• 2012-2017 : Universitas Indonesia S3 Ilmu Kedokteran
RIWAYAT PEKERJAAN
• Puskesmas Ujan Mas Bengkulu, 1991-1994
• Staff Pengajar Divisi Sitopatologi Obstetri Ginekologi FKUI 1999-2008
• Staff Pengajar Divisi Ginekologi Onkologi FKUI 2008-Sekarang
• Koordinator Penelitian dan Pengembangan Departemen Obstetri Ginekologi FKUI
PELATIHAN
• Kursus kolposkopi Departemen Obstetri Ginekologi FKUI (1999)
• Colposcopy course Kandang Kerbau Hospital (Singapore, 1999)
• Thin Prep Cytology Course (Sidney, Australia, 2003)
• Laparoscopy Course (Shanghai, 2008)
• Fellow Laparoscopy Oncology Surgery (Seoul, South Korea, 2013)
 Disclosure Slide

I have no actual or potential conflict of interest

in relation to this program presentation
 Outline
• Mengapa IVA?
• Mengenal SSK
• Prosedur IVA
• Menilai hasil IVA
• See and Treat
• Conclusion
 Secondary Prevention
Available Screening Methods in Indonesia
METHODS STUDY URBAN RURAL
Pap Smear ++ +++ +
VIA ++ ++ ++
Gynescopy + + -
Colposcopy + ++ -
Cervicography + +/- -
Liquid base Cytology + + -
(Thin Prep)
Computed Cytology + + -
(Pap Net)
HPV Testing + + -

Jakarta, Bandung,Surabaya
Cervical Cancer Prevention in Developing Country (Indonesian Perspective)
 Perbandingan TES PAP dan IVA
PERBANDINGAN SKRINING TES PAP DAN IVA

Uraian / Metode Skrining TES PAP IVA

Petugas kesehatan Sample takers Bidan

(Bidan/perawat/dokter Perawat
umum/Dr. Spesialis ) Dokter umum
Dr. Spesialis

Skrinner / Sitologist /
Patologist
Sensitivitas 70%--80% 65%-- 96%
Spesifisitas 90%-- 95% 54%-- 98%
Hasil 1 hari–1 bulan Langsung
Waktu periksa Diluar waktu haid, Kapan saja
Malam sebelumnya tidak (sebaiknya tidak saat haid
sanggama banyak)
Sarana Spekulum Spekulum
Lampu sorot Lampu sorot
Kaca benda Asam asetat
Laboratorium
Biaya Rp50.000,00–Rp.125.000,00 Rp 25.000,00
Dokumentasi Ada (dapat dinilai ulang) Dulu tidak ada /
Sekarang dapat dg kamera
digital/HPDOVIA
 Outline
• Mengapa IVA?
• Mengenal SSK
• Prosedur IVA
• Menilai hasil IVA
• See and Treat
• Conclusion
Anatomi serviks,
Mengenal SSK (Sambungan Skuamo Kolumnar)

Transformation
Zone

New SCJ

New SCJ

Transformation Original
zone SCJ
 Daerah Transformasi
Area awal Karsinogenesis

• Daerah antara “original squamocolumnar

junction dan new squamocolumnar
junction”
• Kista Naboti (ovula Naboti) dapat
diidentifikasi pada daerah transformasi
Mengenal Leher Rahim

Sambungan
Zona Transformasi SCJ barukolumnar=
Skuamo
SSK
SCJ lama

Daerah columnar
epithelium

Daerah metaplasti
squamos epithelium

Daerah epithelium
asli
 LOKASI SQUAMO COLUMNAR JUNCTION (SSK)
DAN ZONA TRANSFORMASI

ANAK-ANAK REMAJA PEREMPUAN PEREMPUAN

PASCA REMAJA/ PASCA
DEWASA MENOPAUSE
Alternatif skrining ?
INSPEKSI VISUAL dengan
ASAM ASETAT (IVA )

 Non –invasif
 Mudah-murah
 Di Puskesmas
 Hasil LANGSUNG
 Sensitivitas,spesifisitas memadai

MEMADAI UNTUK
NEGARA BERKEMBANG

Bercak putih
 SCREENING STRATEGY

•  VIA and See and Treat

• sensitivity 31.6-82.14%,
• specificity 50.0 -87.0 %*
• (PPV) was 67.64%, and (NPV) was 68.75%. *

• Cancer Nurs. 2011 Mar-Apr;34(2):158-63

^ PLoS One. 2010 Oct 28;5(10
 Outline
• Mengapa IVA?
• Mengenal SSK
• Prosedur IVA
• Menilai hasil IVA
• See and Treat
• Conclusion
CARA MEMBUAT ASAM ASETAT

• CUKA DAPUR (mengandung

asam asetat 20%)

• ASAM ASETAT (3-5%)

• Untuk membuat asam asetat 5%

dengan cara mengambil
1 bag. cuka dapur + 4 bag. air

• Untuk membuat asam asetat 3%

dengan cara mengambil
1 bag. cuka dapur + 7 bag. air
ALAT / BAHAN IVA
Meja ginekologi
(atau MEJA TULIS)
Sumber cahaya yang
cukup
Asam asetat 3 - 5 %
Kapas lidi
Sarung tangan bersih
( lebih baik steril)
Spekulum vagina
ALAT / BAHAN IVA
 Meja ginekologi
(atau MEJA TULIS)
 Sumber cahaya
yang cukup
 Asam asetat 3 - 5 %
 Kapas lidi
 Sarung tangan
bersih ( lebih baik
steril)
 Spekulum vagina
 Outline
• Mengapa IVA?
• Mengenal SSK
• Prosedur IVA
• Menilai hasil IVA
• See and Treat
• Conclusion
 Teknik IVA
Posisi litotomi,
tampilkan serviks, nilai:

4 langkah
1. Mencurigakan kanker, tidak
perlu IVA

2. SSK tampak seluruhnya?

(Jika tidak  IVA, beri
catatan, sebaiknya  tes
Pap)

3. Lakukan IVA  tunggu 1

menit, timbul epitel putih?
 IVA (+)
KASIVO 4. Kandidat krioterapi ?
 VIA
• Using table vinegar with 5x dilution factor (5% acetic acid)
• Highly available, can be done by midwives, can be done
in low resource setting
• No absolute contraindications
• Except during early stage of pregnancy
• Requirements:
• No mucus / blood clogging the cervix
• Cervix can be visualized
• Ectocervix
• Original SquamoColumnar Junction
• Transformation Zone
• New SquamoColumnar Junction
• Endocervix
 VIA assessment criteria

• Normal
• Cervicitis
• Mild
• Moderate
• Severe
• VIA Positive
• White epithelium
• Cervical Cancer
VIA Approach

Cryotherapy
 Screen and Treat
• See & Treat
• Single Visit Approach

• We can do at the primary Health Care ( Puskesmas)

• Can be done as single visit
• By GP , Midwife or Trained Nurse
• Using Cryotherapy, w/ goof effective for pre cancer lesion
Hospital and Private
 See & Treat Program

• Improving screening coverage, downstaging and therapy

• Reduce the incidence of Lost of follow up, improve access
to health services, and reduce costs
Follow-up Compliance or
Follow Up After 6 months
VIA (+) Attend to Follow up %

68 10 14.8
Nuranna L. Penanggulangan Kanker Serviks. Proactif-VO, 2005

VIA / Cyto Follow up %

(+)
Phase 1 750 362 48.3 %
Phase 2 273 178 65.2 %
Female Cancer Program, Jakarta, 2004-2006
Cryotherapy Effectiveness
 6 Months after Cryotherapy

Neg LSIL HSIL Sembuh

LSIL 208 26 88.1 %
HSIL 23 6 2 74.2 %
CIN I 90.9 -100.0%
CIN II 75.0 - 95.9%
CIN III 71.0 - 91.7%

Ferenczy ‘85, Kwikkel ‘85, Berget ‘91

 Problem Solve Alternatif
See & Treat Program

• See & Treat in single visit.

• Team. ( Doctor , Midwife , Nurse, Social
Worker ) PHC Primary
• See & Treat : Health Center
• Direct Visual ,
• VIA  Cryotherapy
• Colposcopy  LEEP or LLETZ

Hospital
 Outpatient Medical Treatment

Comparison of treatment options

Cryotherapy Laser LEEP

(n=139) (n=121) (n=130)
Effectiveness (1 year)
• Persisten 76% 83% 84%
• Residif 7% 4% 4%
19% 13% 13%

Complications 2% 4% 8%
Bleeding after 0% 1% 3%
Treatment

Sumber: Mitchell et al. 1998.

See  VIA

Treat  Cryotherapy
 In Single VISIT
Counseling
VIA (+)

KRIOTE
RAPI

31
Cryotherapy
 Conclusion
• Screening See and Treat still important

• Pemeriksaan IVA ( Inspeksi Visual Asam Asetat) lebih

menjanjikan untuk skrining alternatif karena prosedur lebih
mudah dan relatif murah.
Terima kasih
Buku Panduan Diagnosis dan
Tatalaksana Terkini di Bidang
Obstetri dan Ginekologi

Bisa didapatkan di booth no. 14,

selama simposium KOGI
 DEPARTMENT OF OBSTETRICS & GYNECOLOGY
FACULTY OF MEDICINE UNIVERSITAS INDONESIA
CIPTO MANGUNKUSUMO GENERAL HOSPITAL
3 International Speakers

PRESENTS

Jeong Yeol Park Jimmy Nomura Wachyu Hadisaputra

(South Korea) (Japan) (Indonesia)
Symposium and more national renowned speakers

Special price for KOGI XVII

Workshop Dry Symposium:
Lab and Video
Session JAKARTA Rp 3.000.000 Rp 2.700.000

Workshop Live
LAPAROSCOPIC
Symposium and Workshop:
Surgery and
Hands on
UPDATE
Rp 6.000.000 Rp 5.500.000

Register during KOGI symposium at

Cipto Mangunkusumo General Hospital | Double Tree Hotel Booth no. 14
Jakarta, 10 – 13 September 2018