Foreword We are only three years away from 2015 ~ the year when we reckon together with other 188 nations worldwide our achievements ofthe 8 Millennium Development Goals (MDGs) that were aimed to fee people from the bondage of extreme poverty and ather multiple deprivation suchas hunger and poor health. | would ike to believe thatthe completion and issuance of ths Reference Manual on Cervical Cancer Prevention and Controls just but one ofthe manifestations ofthe Philippine’ commitment to make the MDGs a realty and the health situation of our population, particularly our ‘women ever better than before, ‘This Manual has been developed with the cifferent health care providers nationwide in mind — both those working in the hospitals and outpatient health ae facies (RHUS, health centers/BHSs), both in the publicand private sector. The Manualalsoincludes guidelines onthe overallanagement of Cervical Cancer Prevention and Control which are applicable to program coordinators atthe national, regional and local levels, and to others involved in managing and coordinating the delivery of cervical cancer prevention and control services. Through this Manual, | hope that our women of reproductive age will ave better access to quality health care and services they so deserve, lu Secretary Enrique Ona, M.D. Reference Manual 3Jenuewaruaiajay ‘TW 2up anbuv3 Keranas "a3 enuey ay) aajduo> padjay aney oym yes s9y}0 pue yUeynsuo> ayy Guipnput ‘oxeapua siyy Bulnsind uj sejoqued w uj aseasiq annevzuabag ayy (QgDN) enw) ue woUaKalgaseasi 40} 18}Ua)feuoNEN ayy ayenHeABUO> yay pjnom | ‘KRsey yenuew Suen ay Jo waurdyarap ay u apuerssseyepueuy papanid out afouyYAeaH SuaLIOM axp pue 4H ax Jo Hod ay aquEe>s 01 2x oye pynom | paureqo aam fenueyy Hod aA ul saunparaid ue souyapin6 ayy Jo sou ypiya wou enuey Bure seDUe) JDM} ayy Jo UOIIAR JNU! axQ aUOp sey YpiAY eudsOH fesBUDD aud -sourddqg apo Ausanun-a¥p3) a4 Bpapsoupe Kyeyoeds 0 2q pjom | Yenuew ayy Buzyeuypue Guypa‘Guuyep ul voy pue awn at ojonapaney oyM yo aseasig annesouatiog Hod an Aq paysigese dnox Guppoy fenuypa ay yo siaquiauaipysoueI0 EIN 03 pInom | “yenuew ayy 6unaydlue> ut snd 2}qenjenu paseys pue astyadxe sayy painquyuo>Assaylasaney oy siapIOUDyEYS 40 sdnou6auatayip ay jo anuersisse ay) nowy ajqissod uaeq akey JOU pynoM jor}UOy pue UoQUARaLyJ2>UE) [eA UO JenueyY >U=LaJOY IY) quawabpajmowpyTable of Contents Foreword Acknowledgment Acronyms and Abbreviation Introduction Chapter 1. Cervical Cancer Prevention and Control ‘A Introduction 8 Status of Cervical Cancer Development of Cervical Cancer Prevention and Control . Goal, Objectives and Target Groups Strategies Strategy 1. Promotion of Healthy Lifestyle Strategy 2 Attain High HPV immunization Coverage Strategy 3 hance Screning and Diagnosis Services Strategy 4 Improve the Delivery of Quality Treatment d and Service Strategy 5. Strengthen Rehabilitation and Palliative Care Services Strategy 6. Strengthen Health Information System on Cervical Cancer Strategy 7. Strategic Planning and Investment ‘Strategy 8. Cancer Epidemiology and Clinical Research F_ Package of Ser for the Prevention and Control of Cervical Cancer Chapter 2. The Epidemiology of Cervical Cancer A. Cancerin General B. Gynecologic Cancers C Cervical Cancer D. Prevalence of PV Chapter 3. Prevention, Screening and Diagnosing Cervical Cancer A. Introduction 8, Prevention of Cervical Cancer G Glent Assessment D. Screening of Cervical Cancer E Diagnosing Cervical Cancer - Cervical Biopsy F Staging the Cervical Cancer 6. Special Precaution and Considerations for Women in Special Conditions Chapter 4. Management and Treatment of CIN and Cervical Cancer AA. Introduction B. Treatment Modalities Referral System . Palliative Care Page B 5 15 8 19 20 20 20 a n n a n 2 n 4 m4 4 2% 8 30 30 31 35 37 31 52 SERRE Reference Manual 5enue auaaay 9 sepuarayay ‘waists VQSaHI3@ LOZ au, "2 XouNY quawa6paymoupy “Lxeuuy suo 6uuaans tol s2aue} jen soy payable) vawoy Jorspaysen) zoL ‘wuo4 Bupyoday sa2uey e"N9) 3 ool apioig san1s9§ 120Ue)fe1A8) Jo BupIODay “) 96 Uwoyeuyu feng 30} aay“ 96 worpnponuy “y 86 wayshs juawaBeuey uopeuoyuy g s2ydey) i uatuabieuey sayddns pue uous +6 Uoqenjeg pue 6uuowuoyy % uawoytyo ypeay ayy Gulwapia"9 6 Spying Agigede 6 ‘spouses uonezIIgoW 3 88 fyuueyg wesbog 9 8 ues foog anguoddns 8 aumpni woddns euoneziuebig'g 8 vuownponuy “y 8 quaurabeuey wesboag 7 12dey) woueay, a ue stsoubeg jo sabers snouea yeuawoy Gujpsuno) 3 Is swy6y way “a 08 Gupsuno) u“ uonowiog yreaH “a ul ‘uononponuy "y “a Suyjsunoy pue uonoworg yyeay 9 s23dey) ‘Adereyjohs s0/pue Gunso yiq.u samnparong 9L Luoljeulweyuorag pue jesodsig ayseq4 jo uonedt|ddy °y u ‘quowinsjsuy Butssapo.g ul sainparoig “q u Jox}uo) uon>9ju) ul papaan sjeuarew pue sayddns >) ow jonuoy pue uonuandig uomDayu yo suaWaR, “g ou uonpnponuy *¥ o Joxqu0) wonrayuy *¢ 42dey)List of Tables Number 1 10 u n B 4 15 16 v7 18 19 Title Number of Cervical Cancer Deaths and Matemal Deaths 2002 Ferlay eta.2004, AbouZahr and WardLaw 2004 Incidence of Cervical Cancerin the Philippines, South Eastern Asia and the World, 208, IARC, GLOBOCAN “Mortality of Cervical Cancer in te Philippines, South-Eastern Asia and the World, 2008, ARC, GLOBOCAN Targets by Component and Package of Cervical Cancer Services by Level of Prevention Requitements fo the Prevention and Control of Cervical Cancer by Level of Health Care Facilities Cssification of HPY infection HPV Routine Immunization Schedule Reduction in Cumulative Cervical Cancer Rate With Diferent Frequencies of Screening, IARC 1986 Comparative Features ofthe Different Diagnostic Test of Cervical Cancer ‘VIA Classification Relative to Clinical Findings FIGO STAGING OF GYNECOLOGIC CANCERS ~ CERVICAL CANCER, 2009 Advantages and Disadvantages of reatment Modalities for CIN Comprehensive Cervical Cancer Control A Guide to Essential Practice, WHO, 2006 Side Effects of Cyotherapy and Management Management and Treatment Modalities of ON ‘Management and Treatment Modalities for Malignant Lesions Indications for Referal, Service Required and Level of Referral Facility Management and Other Interventions (Pain Syndromes in Cervical Cancer ands Management Recommended Dosage er Type of Drug For Cancer Patients Expected Side Effects of Cryotherapy Reference Manual 7lenuew anuaiajay ‘@2UeUO}2g [ENpIAPUl Jo} sIO}e>IpuUl a2UEULOYag ajdweS @ 3 pue yy Aemyreg ped aworing-inding-andu ay u ‘sasino) Bujurey, Aq quedouseg payabuey, wz seoyvo5 49) Jo Along pue juawa6euey aly ul padonuy Buuosiag yeaH Jo MOMIAN wList of Figures ‘Number Title Common Cancer Sites in Both Sexes, 1983-2010, Philipines, Source: 2010 Cancer Facts and Estimates, PCS! Common Cancer Sites Among Females, 1983-2010, Philippines, Source: 2010 Cancer Facts and Estimates, PCS! The Female Reproductive Organ The Cervix Development of Cancer Cells, adapted from Woodman et al. Nature Reviews Cancer 7, 11-22 January 2007 Progress in HPV Infection (Adapted from Cervical Cancer Screening, Lyon, IARC Press, 2008, (IARC Handbooks of Cancer Prevention Vol, 10), Flow of Cervical Cancer Preventive and Control Services ‘Atlas of Negative Cervix (Adopted from WHO) Atlas of Positive Cervix (Adopted from WHO) Atlas of Cervix With Suspect Cancer (Adopted from WHO) ‘ample Flow Diagram For Cervical Cancer Prevention Referral Algorithm for Cervical Cancer Services Reference Manual 9enueyyaovasajsy OL abenpiy joyuay-0p0 By) ‘aeayropey weag eq 1488 ‘Adeouiopey peu papuang 14 rosy waunesy poe soubeg wld ‘wieeH jo weunsedog Hoo “apg waunsedag 00 pe repnu-oquhtoag wa Tay aseoig annerouabog 00 ‘ydesbowo,paynduioy D ‘SPuIppINg Dye FIND 30 -5r35q eqvoUnaug BND NSG 2UOH) 7) 0009 jeqouy deny iA) «ND sedan ree FEW) aTapOHT co) es doay jeyauadeenu ina) ND ‘wea, YaeBH AUTO) Ww wo NeeH AD ow Tonwoy a5e251q 10) 1208) 0 wig engay 20ue) jem) 3 ‘weaBorg jon} pue wonwanaigabue) ed wesBorg uonuaralg DUE) |W) aD Tonu03 pue uoquaralg DUE) EIN) 5) aque paseg Ovaiadwoy 1») "wouneay pue ssouberg SuaaDs WaUSSISY OID ic) ‘au pue ager ave aaxdwo) ww) 04 WaUISSSSY AND wD favor3voyd09 bus aI 058 ‘woqpassg 2p04 Dg BEN ane ones ueaH KeBueIeg ‘#8 saq fbojouypa pue wie} jo neaIng 1048 ‘xn a 9pUN EBAY ony io WoUSsaSsy iY ‘spuesyiis pausojepunjo5je) snowenbs jordy sm 8) snowenbsyerdhag sims un] apeD YB sp sToWeNs oy Host ‘Bojigegjeansaypue dossodj) 0} anos uuu ‘Dw -2pi0 aNTenSTUPY ov Ts uj eWoupeDoUapY siv ‘aucputs(ovapyag oun amy saw Si) 22mnpueID edAay ov suiAuosy pue suonernaqqytH Eta facial Hysterectomy FDA Food and rug Administration FSIS Field Health Service Information System Figo International Federation of Gynecology and Obstetrics PNA Fine-Needle Aspiration FSIS Field Healt Service information System Hal Healthcare Associate infections Hey Hepatitis BVius HOR High Dose Rate EPO Health Education and Promotion Officer HAROB Health Human Resource Development Bureau HAROU Health Human Resource and Development Unit HW. Human Immunodeficiency Virus Hu High Level Disinfection HEV Human Papilloma Virus Ht High-grade Squamous inta-ephitheial Lesion ARC International Agency for Research on Cancer lec Information, Education and Communication i Immunization For Women IMs Internal Management Service W Inta-Yenous KAS: Knowledge, Attude and Skis UB Liquid based cytology oR Low Dose Rate LeeP Loop Electrosurgical Excision Procedure wet Lage Loop Excision ofthe Transformation Zone ou Local Government Unit isi Low-Grade Squamous intraepithelial Lesion Ws! lympho -Vasular Space invasion Mw Notifiable Disease Report MB Mortality Report Mande Monitoring and Evaluation MHO Municipal Health Ofce MR Modified Radical Hysterectomy MRI Magnetic Resonance Imaging Neo Non-Communicable Disease NcoPC National Center for Disease Prevention and Control NAD National Center for Health and Facility Development NCHP National Center for Health Promation NCPAM National Center for Pharmaceutical Acess and Management NEC National Epidemiology Center Reference Manual uyenuew2ouaiayay ZL anu) KSoNpY ERM aNDpOEEY SUEWON ay oe EH HOH Co ‘epseydoay reyaqnide-enuy jenny Cy au son Bus von>adsu sin TA OY NaDy gM UoRDadsu esp vA pone mn dno Gupoy EIUPAL OM ‘sed [e20) at wap wb DL uon>ayu pans Aemas us 35r05g PANNUSUE AeMIAS as Wo ea RaenU snoUeNDs Ws ‘Saudia 39 J ssI60}>u0 oy0D9uk 0 KaDOS 4098 ora euuino)-ourenbs 0s spsrewoqideg Kojendsoy wang a wun wea My on woRpassIq apoy YELL IN KuopAISH ENpey avsks Rao aris empey He ‘Wun uejanmns pueMBo|owap euobey 1s ‘25060 pueAbojoyig ea) yo apes aurddnua 245d ‘ap0seaojoauN pu eames auddys sB0d SIV/AIH Wu Bua ajdo5g wwnttd yO HERH eDURONg ond “ydesBowo, wos uonysog Ba ‘poy 0 ue URI eUDRNATTADARDUREDS Haina twevorg jue pu uonuaraig wove, auddn ‘DM Toeonuedeg deg anndazenu9) (29 0 Paypads saMDION son ‘eH 30} sONN>a/GQ UREN HON Burbewy s5veu0rey snaubeyJeapAN a ‘WneZUebig WaLNUINOD - UN ONIntroduction This Reference Manual on Cervical Cancer Prevention and Control (CPC) isintended forthe use ofthe diferent heath cae provider in both the out- patient health care facilities - Rural Health Units (RHUS), Barangay Health tations, (BHSs) health centers, clinics and the hospitals, who in one way or another ar involved in the prevention and control of cervical cance. tis also targeted to the regional and local Non-Communicable Disease (NCD) Coordinators responsible in its overall management and implementation in ther respective offices and localities, The Manual consists of eight (8) chaptersas described below. Any use ofthis Manuals highly encouraged to begin with Chapter 1 o appreciate the lbal and national status of cervical cancer and seque way to Chapter 2- the Epidemiology of Cervical Cancer. However, the users ofthis Manual an also refer to any chapter appropiate to meet his/her needs for guides, standards and procedures to follow. It mut be noted that there are sections especially in Chapter 3 (Prevention, Screening and Diagnosing Cervical Cancer) and Chapter 4 (Management and Treatment of CIN and Cervical Cancer which are only applicable to the hospital staff as they provide higher level of health cae to women found pasitive with cervical cancer. Chapter Brief Description - Chapter 1. Presents briefly the status of cervical cancer in the county and around the world in order to appreciate the need for Cervical Cancer Prevention | more vigilant and cohesive design and implementation of preventive and control measures against the disease. and Control It also summarizes the historical development of efforts on CCPC which the Department of Health (OOH), has now integrated in the National Policy on Strengthening the Prevention and Control of Chronic Lifestyle-Related Non- ‘Communicable Diseases. Chapter 1 describes the goal, objectives and targets of CCP, the strategic approaches to be pursued in achieving them and the package of services tobe offered at various eves of healthcare. Ghapter2, Hopes that health managers and service providers will havea clear understanding ofthe epidemiology of cervical The Epidemiology of cancer. The Chapter begins with the presentation of the basic information on cancer in general followed by Cewviel Cancer aymecologic cancers, of which cervical cancer is one. The epidemiology of cervical cance is introduced with the description of the female reproductive system which the ervs part of, and then segues way to how the cervical cancer develops a a disease by identifying the risk factors involved with focus to the Human Ppiloma Virus (HP). Chapter 3. Provides the guideline in preventing, screening and diagnosing women with cervical cancer. This Chapter begins Prevention, Screening and | with the presentation ofthe overall process which the woman must undergo from primary prevention to screening, Diagnosing Cervical Cancer| diagnosis and treatment for cervical cancer, if indicated. It discusses the specific measures that woman can | do to prevent herself from developing cervical cancer, and presents next the steps indent assessment and the corresponding forms tobe used. then outines the diferent tool for screening andthe detailed procedures how each s to be performed, The last section discusses briefly the biopsy procedures in diagnosing cervical cancer. It is hoped that through this chapter, service providers at varius levels of health care will be quided how to help women prevent cervical cancer and in performing client assessment, screening and diagnosis of clients. It is aso hoped | that the health managers in each health cre facility wil be able to appreciate the need for essential equipment, | supplies and forms and availabilty of appropratly-trained personnel to be able to provide quality services on | conical ance. Chapter Brief Description Chapter 4. Provides basic information on the clinical aspects of cervical cancer treatment and palliative care, It hopes to | Management and improve the access of women to treatment and palliative care services and to establish and maintain effective Treatment of IN and | linkages between prevention and treatment services and the information system asin cancer registries. It presents Cervical Cancer the different modalities of treatment appropriate for specific stages of cervical cancer as classified in the previous section It also outlines the steps in providing paliatve cre to patient in advanced stage. Reference Manual 13,(000) ayo aseasg anesauabag~ (40DN) nua pue vonvanaig asso} aU8) evOReN a AUN enueyya>uaiajay pL ‘yo pue sayoe} anyradsay su ur Yenuey si asm Kay se pega Aue unuoD 0 pasupe ae pu ‘sa16oxd uu om e se mau 0 pase ave yenuey sip Jo suas “awn 0} AWN Woy paepdn ave sprepueys ayy se GuUa.ABuENS 10 UeUADUEYLD JOY amb ys few suaquo> 90 awos Joquo> pue 3raudJapue> > A¥8> Bulwian¥0> sjo0jud ay QUaLuNDop avO Und oY Hoya SHY UN St SHY “Aauno> ay uy 2pue jem go smyeys aly Jo aumpid sa}j2q 104 suoquandaqu jo syjnsau pue aseasip ayy Uo evep azluoWUeY 0 Japuo UI JaydeU) sy) 0 2 0 paBeunosva ave uonensiuupe J jar snoven ye repaid an/2s pue siaBeuew weiboigpaniuigns ue paedaid ag 01 suodasAessanau ayy pue paysdcove aq 0 suoy Suporal ay tap ul Saqunsap 34D) J0 _uawa6euew 2340 ay} Hoddns w pauresnspue paysyqeysaaq o waystsjuaueBeueW VoneuLowulayystuasoig wayshs quauiaBeuew vopewoyyy guaydey) uonev0q@j0> jeuopas-nynw pue saunas ypeasino Buztue6vo uaua6euew soto) ‘ayray uonewvawaydu pue Surwued ‘ywauidojanap Ayygede>‘wonequawa/diy pue quawaBevew sy 0} voddns w amnas jeuonezuebi0 ay sassedwiooua pue weibord ai yo yuawaBeuew 24 ur seuypin6 jexauab sapivoud 3 san195 yo AaMap aut Ul 349) at Jo yUauodwo> ueyodus axp Soquoseg wawaGevey weifoig “Laardey) “swap sey 0) sanuvas Buyjasuno>apioud oy oy opin 40} uoNDes iy oy 9} «0 paBesnonua ave sapuoid ave yyeay a6ers paduenpe u pease aso oj axe>aneyjed jo uoneStuUpe ay) UL ara pueaseaip ayy yum anysod puno} aso oy santas yuaunean Buypmcd uayp weyodw| es 'seunpapeud stsouBexp of1apun oy pe pau2a.s aq 0 Buyin vawiom gu requ paup u axe oym ssapinod ale uyeay ay Aq Ajjepadsa pausea| aq 0} js [2D ads e st puey 1240 ayp Uo BuYjasuno-sad4J9s 0} syuaIp Jo ssan2e BuIseaDUt UL Jequassa 5} uonowoly yyeay TuaUiean pue ssoubieip ‘Suuaans ‘uauissasse BuloSiapun uaWom BuyasuneD W ‘yerypads ow pue‘er2u26 u2>ue> jes) Jo yonuos pue uoquaraid ayy Bunowoxd uy seUyEpIn6 a swasald Buyesuno ue vonoworg neeH “guaydeyy jouuo> woR>aju uo sainseau Axeuonnexaid prepues 0 aiaypesapinud pue ssabeuew Ape yea ayy Saeua sardeup sty Yeu padoy st] aasem Jo esodsp pue abso sadoud“sainseaw ‘anqpaqoud jeuosiad uo sautjapin6 aig aauay ‘siapiaosd axe> yyeay ayy pue Syualp YjOq 104 JUaLWUOWLAUa ayes pue ‘yenb 6uunsua jo puepodu ty sazubo>aysoinseau yuauiean pue anquanaidJ>ue> [22> Jo Lanlap ayy "usrapnci ae yyeay ye A panasqo aq oy paau yey jonUED uoMDayU! Uo sanpanoid puesauyapin6 aly swasaig foxquoy uor>ayu ‘gaadey)Chapter 1 Cervical Cancer Prevention and Control A. Introduction Cervical cancer remains a public health concern that continues to threaten the welfare and well-being of women and the population as a whole. itaffects relatively the young women and results in many lst years off. In 200, it was estimated that about 2.7 milion age-weighted year of life workwide were lost due tothe disease Cervical cancer deaths have significant economic costs and impact heavily on te families’ resources Many of those who die are breadwinner and caretakers of both children and elders. The affected women ose opportunity to work, preventing other family members to engage inthe same, s they have tobe taken care of, thus resulting to loss f income and even any savings they may have due to the overwhelming cost of medical treatment. The biggest impacts of cervical cancer are on poverty, education, and gender equity -the fst three @) Development Goals (MDGs) the Philipines andthe other 189 countries aimed to achieve by 2015. Cervical cancer perpetuates the je-generational and unending cycle of poor health status to economic lw productivity, poor education and lack f empowerment among affcted ‘women and thei families As poverty increases, more children (especially ils) are kept out of school. Because ofthe disease’ differential economic and socal impact on women and gn, the desired gender equity becomes more dificult to achieve, B. Status of Cervical Cancer 1.Global Situation Cervical cancers the second most common cancer among women worldwideand isthe leading cause of cancer-related deaths among women inthe majority of developing countries. Up tomare than 500,000 new cases are identified each year and causes over 250,000 deaths worldwide (50 percent af those women who develop cervical cance). Women in developing countries account for about 85 percent ofboth the annual cases of cervical Cancer andthe annual deaths from cervical cancer. The majority of cases are squamous cel carcinoma while adenocarcinomas are less common? The incidence and mortality of cervical cancer vary according to age. The incidence of cervical cancer usualy starts to rise at age 30 and peaks between 45-55 years? Estimates of new cases and deaths occurring each year worldwide have been increasing, In 2002, it was estimated that about 493,000 new cases were diagnosed each year wit alittle over a quarter of a milion (274,000) women dying of cervical cance yearly. n 2008, new cases were estimated at 529,409 and deaths at 274,83, About 86 percent of cases occu in developing counties, representing 13 percent of female cancers worldwide. As shown below, cervical cancer remain the principal cause of death among women in the developing countries. In fact, the numberof deaths due to «cervical cancers much higher than matemal mortality as shown in Table 1. Scott Wittet a, Vivien Tsu. Cervical Cancer Prevention and the Millennium Development Goals, WHO. Vaccine 2006, Vol. 24, Supl 3; Vaccine 2008, Vol. 26, Sup! 10; |ARC Monographs 2007, Vol. 90 Parkin etal, 2002, WHO 2001 Reference Manual 15,yenuewyanuaiajey OL ‘002 eTpIEM puE AYeZMOAY "PODT'IE 18 ABHOS «fue you ey wayse3-yInos aup 0} uadiad g UeU) Ss] 2ynqUUED AJuo saseD AajeYoW fenuue saulddluyg 24 14M apHMpHOM syyeaP jenuue [e404 ayy JO (266'28) yyy snoy uew asow saynquuo ews ws2yse3Yanos ‘dod gon‘0OL/E'8 8 elsy wayse]-yanOs UI LEW JBMoI Y>NW YPIYA 0OO‘OOL/E'S 1 pues 120ue>jo1na> 0 np aye AyjeuoU pazipuepuers-abe ain ‘sauiddyug tp U ayes 2uap!su u aDUarayND stp 04 paxedwoo (dod 900 '0OL/8 2) ‘apimpjiom ueyp parunouaid Ajyby axows (dod o9p‘ODL/E"g) st eIsy Wsayse3-UANOS ul ayes AyjeUoUN sa>UeD jeD|AJ—> pazipuepuers-abe aya ¢ aIqe] UI vos'y vor've 878'67s ase) Jo Jaquiny jenuuy | sivak p/-0 sabe BLL HLL %9'L “(06) asia aaneinuiny t 000'001/2'LL 000'001/8'SL OO0'0OL/E'SL yey aouapIoul pazipiepueys aby 000'001/1'01 000‘001/r'SL 000'001/8'SL ayey aduap!u) apy ey saurddinud usayseg-yanos 2PIMPHOM 403e21pUy N¥D08079 ‘Du¥I ‘8002 ‘PHO a1p pue eysy wragseg yanog ‘souiddyyiyd ays ul 12Due) jer4a19) Jo a>uappUl Z aIqeL “ey waIse3- nos Ut 595 eyo aly yoquar.ad 01 vey, axow iy syunosyesauiddug at a]4M ‘2pLMpHOM sase Jo Jaquunu feo) ayp yo uadiad gUeUH atOW o saINqUIUOD ‘oye esy uuese3-yanos ‘sase> Jo Jaquiu jenuue au} Jo sway Wy "aBeNaRE sy WyseR-YInOS aly LENA aed JAMO] e pases is sauddyyg _2y a} >uappul paziplepues-abe aiy Buss ‘dod gog'O9L/L‘OL 1 puyag woy 18 OU s sauddyg axp apy (dod goo'oDL/e"SL) apumpHOM pavasiau sem yey ue Jamo] 9 aR st ey UHESe3-)Ns UI JaDUED je1A2> JO (99O'DOL/ySL) aL BuapDUL apnD aIp LA SMOYS 7 2}ge) ozs oz pueyeyr 000'9EL BLI'bL eIpul 000° Los'sz, eulyd 00977 189'e Poy uINOS 00s'z £997 a) 06 Le6 au 002’ 9878 eg 06s 629'L eunuabiy ‘sipeag jewiarew ‘Syye|q 199UeD [eDIA18> ‘Aaunoy ‘syyeag JeWsayeW pur syyeag Ja2Ue) [e>{A19) Jo 1aquINN *La|qeL,Table 3: Mortality of Cervical Cancer in the Philippines, South-Eastern Asia and the World, 2008, IARC, GLOBOCAN Indicator World South Eastern Asia Philippines Crude Mortality Rate 8.2/100,000 7.8/100,000 4.1/100,000 ‘Age-Standardized Mortality Rate 7.8/100,000 '8.3/100,000 5.3/100,000 Cumulative Risk (96), Ages 0-74 years 09% 0.996 0.6% Annual Number of Deaths 27,128 22,497 1,856 2. National Situation The 2010 Cancer Facts and Estimates ofthe Philippine Cancer Society Incorporated (PCS!) based on data from Rizal Province and Manila Cancer Registry showed that cervical cancers the 3d leading cause of mortality inthe general population. Figure 1 shows thatthe top two most common cancer sites for both sexes in the country ae the lungs andthe breasts. Cancer in the colon/rectum, the liver and the cervixshare the third most common site, While cancerin ‘the colon/rectum and liver had shown spikes ofincrease at certain periods, cervical cancer showed slight but continues to decrease over the yeas. Among females, ‘the breast continues to be the most common site and continues to increase over the years (Figure 2). Cervix isthe second most common cancer site and gradually decreases over the years. These data wee sourced from PCS. Figure 1. Common Cancer sites In Both Sexes 4983-2010, Philippines 4g POPPE OER LS Figure 2. Common Cancer sites Among Females 4988-2010, Philippines Source: 2010 Cancer Foes and Estimates PCS! Wn To er aaa aes wer quite isos 7 Reference Manual[enuey apuasajay aL VOVHVO ‘YVO HON "WX-1 GHO Ut sjeNdsoH pauIeiee HOM IV Ul Bulueaiog J90Ue9 |BOIALeD, ‘9814 J0 JONPUOD 944 UI SEUIIEPIND "2100-0102 "ON WNpUELWAW weuedeq OL0z ‘euePUIN 40} GHO pue sexesiA 10) GHO “YOZN7 40} HO "HON Ut SIewASOH PeLIE}eY HOG Pe1D9/95 ul BulueeI9g 180UeD leowsed Jo FonPUED eUN UI SeUIIEPINS “9ZL0-6002 “ON WNpUBJOWIEWY juaUIUedeq —G00z ‘wieiBoig Buluesiog J0U89 [eoIA189 € JO UAWIYSIGEIS3 "9000-S00Z ‘ON JEPIO enHENSIUWPY —G00z ‘yuo; SseusnoDsUOD 18029 leolniag Se J80K Asana Jo AeW Jo YoU au BuIe;ORA “BOE ‘ON ONEWIBjOO‘d E007 4e1UED IPOIPAIN IeHOWAYY CHOS eIUEDIA UI YSEM POY OHEDY JOI0\ld —000z “syau98i0s-ovo se ysiB0}0UY901 eoIpeW Jo UoneUBisep ‘se;noqed Ul ‘WesBoie |ONUOD JeDUeD [eDIAIED elN UI Suuse.05-01A9 Uo forioe IEUONEN eUL. “8661S V-6LON J8PIO ENTENSIUIWIY 9661 “einpeooig (120s ded) sBaUIg Noe|oIUEded UO SeUI]aPIND HOG “L661 ’S E-£°0N JEPIO eANENSIUIWPY —_L66) ‘wesBol [Os U09 J80UD Ould OU “0661'S V-6B'ON JOPIO eANeNsIUPY 0661 Jou pue uonUeneig 199Ue9 [e21A109 UO SouOIseIIN swosaid 11 dn 0661 wou, 349) Jo uonewawaydu pue yuawdoyaKap ayy ul sauOrsajw fay ayy sazueMUNs BuMoloy at -9467-0LOZ ON 28PI0 [aUOsiag Hod yBnowyp paras ospe sem 1a9ue) Jia) Jo jr]UO) pue UoNUanald Bl 4} (DAL) dnouy Guppy jeuy>2) =U ‘LOZ Ul “LLOZ ‘SL une jun Uojsnond Buuaensj>yse> 204 o UosUapre ayy sJeuASOY HOM $9.0 faseaDu Jay, Sem SIAN ’ZL02 UI L102 U SJeNESOY HOO Bs ©: popuedxa ue fey yo yuout {sara 6902 u sJeueS04 Hod ZL PaDAYaS Ul s1y We BulwBas yeiva> aay Jo Uosvaid aty panos awues ay 129UED jeouaD 4 Aun ay} ut 2toup Jo poyrau Buuaans ay se yseM poe made paxdope yy weary BuUaadrs J2DUe) eA eyo quaLUYsqESy ay UL saujaping 24 Uo 9900-5002 "ON OW HOG Jo uENss ay) YBnoxKy paypuneyAjeDyjo Sem eBoy BuUaa.ns 12Ue) OINE) ay 509 Uy weABOAd ayo uonezjeuonesado ay api cx panss sem 06'S AeW palep 0661'3-S6L ON (0Q)9pI0 waUILEdag Apuanbasqns “nvUAS jxqUO)aseasig ajgezjunuiio)-uoy ayo uawabeuew ayy apun gy Jain ysyqeIse pu UEIsap 0661 Udy ‘Sy -68 (OV) 2PI0 AANeNSIUWUPY panssi HoGauY ‘D661 UL “sanuoud sofew sy jo auo ‘58 Jouyuo> Ja>ue> e>iAza> aya WJ S661 Kuie@ Ul ypeq fem payseRS gy 4 ayy Jara} AjuMWWOD pue jendsoy ayp YIOG Ie saNNAN>e Jayjau led JaDUED ue uojenqeya se jam se Aquno> ay u suo stoven wy saquaD jepypaw paypads u uoquanasd(uenze ‘ora KjunuiuoD ayy ye uoguanasd ‘Avepuonas pu Arewd yo payssuo> sty ‘woneyndod jereuabaxp uy Ayeyow pue prow aonpas 4 Jaye AUeDyUOIS UeD yup st>Ue> Jo juUo> ay spemoy peaidde payabayu pue ansuayaduos yewasts © yu paubisaps(f3Dq) wesbox4 aque) pue vonuanay Due) auddy4 a4) Jonuoy pue uopuaneug s2>Ue9 Je>}ase) yo 3uawuo}anag")2010 2011 2012 2013 Department Personnel Order No. 2010-2976 dated July 13, 2010. Creation of ‘Technical Working Group (TWG) for the Prevention and Control of Cervical Cancer Department Memorandum No.2011-0128 - April 20, 2011. Guidelines on Free Cervical Cancer Screening in DOH Hospitals and Selected Health Centers. Department Memorandum No. 2011-0137 dated May 23, 2011. Extension on providing Free Cervical Cancer Screening in Fifty Eight (58) DOH Hospitals and Selected Health Centers. Department Memorandum No. 2012-0116. Guidelines on Free Cervical Cancer ‘Screening in DOH Hospitals and Selected Health Centers and Clinics Approval of Memorandum on the Turn-Over Ceremony of Cryotherapy Machines and Kick-Off Ceremony for the Conduct of Free Cervical Cancer ‘Screening during the Cervical Cancer Awareness Month on May dated April 16, 2012. Department Order No. 2012-0071. Guidelines for the Disbursement and Utilization of Funds Sub-allotted to Centers for Health Development & ARMM. for Strengthening the Implementation of Cervical Cancer Prevention and Control in DOH Hospitals and Selected Local Government Units. PhilHealth Circular No. 010, s, 2012 of the Implementing Guidelines for Universal Health Care Primary Care Benefit (PCB1) Package for Transition Period CY 2012-2013 wherein VIA was included as one of the services covered PhilHlealth Circular No. 002., s 2013 of the Z Benefit Package, Rates for Coronary Artery Bypass Graft Surgery, Surgery for Tetralogy of Fallot, Surgery for Venticular Septal Defect and Cervical Cancer D. Goal, Objectives and Target Groups The thrust towards CCPC is guided by its goal, objectives and targets as outlined inthe 2005-2010 National Objectives for Health (NOH). Target Groups: Toreduce morbidity and mortality due to cervical cancer. 1. To reduce the exposure of population to risk related factors primarily HPV infection, multiple sexual partners, aly initiation of sexual intercourse, and lack of screening. 2.Toincrease the coverage of women given appropriate screening to atleast 80%. 3.Toimprove early diagnosis and proper treatment of those identified with abnormal screening results. 4. To establish systems in support to delivery of quality cervical cancer prevention and control services. There are three levels of health prevention and control for cervical cancer consisting of components and package of ervicesin each, (see Table 4) Reference Manual 9yenueyyapuaiayay 7 ‘apos aig yo 10}285 pazijeubiew arp 04 ajqepsoye YoU s|ys0> ay) VanaMoy ayLeW auiddiyg alp UI algeyene Apeadfe axe saUDDeA Add ‘asodind siyy 404 “waists aun $Apoq aip suaxpBuans 1 yy pue ‘Sunse| Buo} aq 0} parade st auDsen jgH aip Woy UoR><}014 “sem [enue ay swayqord yay sayio quarasd ose ue> a ‘AgH a4) 0 pasodka ave uatwoM a1yeq Lan y JaDUe>feoyMa> Jo sase sou squanad uoneZIUMLIL Aa aRTY WOT A VO WO 2 KBSNENS “stop ys sofew paynuapt ai ssayppe aioyaroiy smu ays hyyeay Jo ‘vorowoud ayy wea6od ayo sapjoyayersyo sdnou6 sa\yo pue sjepyjo fe} pue jeuoneU jo quaus)wiue> pue woddns ayn aveiaua6 oy payunow aq Iu Zoesonpy “unsodxa ysu yenuatod wuanaud 0 jana Ayunuiwo> a4 ye uoruanard s9Ue) jeoiaa> BuneiBaqu pue saessaujrydjay BuneBedoxd u ‘Ayneay saa sysop Aygyeay yo uonowoug"waunean ayeudordde y29s 0 yGnoua Kea santas yene 0 oMMeyaq Buneas yeay annsod dojenap 07 padoy axe ways yo saquunu afxe) y “pareujwassip Ajapim axe saunseau annquanasd s22ue> je>|A489 4! 10] @ yyaUad jm UaUON “GulUaaNDS 1aDUe> eoqa> ou (UA) pue (xajdus sadzoy ‘eiphweyp) (Ss) SuoMDajU! parmwsueN AjenKas Ym UORDyUL JWENWIODUOD (IA) pe ‘UORDE}UL AgH YM ‘vawom w sd atndaperiue> jo asn pabuojod (n) Aayed-nus (a) ‘siaued ynxasajdynuy (‘abe Aiea ue y xs (1) ‘uonDayu Ag (!)“BuMAO}O} ayy auesapue> feos Jo qauudojatap ayy 40 1UNo>De yey 0122 Ys. Jofew a4 12DUeD fea oy YSU tp zoMpaH UeD aAAsay Ayyeay e BunOWOAg IRSA A OSH JO VONOWOAG "| ABBE, -slGarens Buymojo 4 yBnonp passaippest nun) pue uoyuanag 12DUe) FMA) saybayens "3 S 7 ‘auaibay eee cll 490Ue> /e]09> Jeuosiad Bulpnppuy sa>j,ues ‘a1e> yoddns Ly {pM uaWioN je ~ ‘aie2 auninos ‘sGrup jayjas pue uonenied ted todas er6ojoupkeg « _ 36e Auewy LZ 03 Lv 6815 fiabing « Arepsey 405950 papaps - vwouneat, pue Feds vo 30> rwousbouew 22005 | Scone) eee uoneIperouayD © Teo ani vw) Sao we peztuoo10 4371 L sues weubeu Fedo 3199 “aid wouneon, aeehew | uo pUE IND - ory arabe sansod vin ~ ro wonuonasg eon 8018 yum 0 ‘a anepue a6e hue y | ‘voneunyuo> saying Asdorg « | eee pasu yey annsod Ado2sodjo> « unos ustsom - ows aed a Buiuaanns sunpe ajewey - usem (VIA) PY pus po sie in Creed aad i nary Busn uoyradsul jensi, foc lesoteat) ‘wuasope arewayr-01 azioud (oewsy pue = caoa'sion) | —2jeu) sue>setopy OREUBDEA AH © | sioeyysueramsod | oy ae yo sieah y1-O1 Prone pue uonuanaud | ‘Aaeutag: a9 299 SAO9P | Yawuom pue UaW! 21534 le} . puepjosieak at Pueuaw iy | Vasey AupjesH jo uonowold sso wound an z | woud 1D BY yebue, eGeyped | x a gopeney Uanadd $0 [9A] Aq ‘S@d|Mag 42Ue) |e1A1) Jo abeyeg pue juauoduioy Aq syabuey “y aqeyThe government endeavours to promote the coverage of HPV immunization tos at least 80 percent after S yeas, and wil design a mechanism how tomate the cst of immunization become more affordable to the lower socio-economic group. ‘Strategy 3. Enhance Screening and Diagnosis Services Experiences in many developed countries showed reductions in cervical cancer incidence and prevalence by as much as 90 percent through well- organized screening programs, detection and subsequently treatment of cervical cancer precursors in early lesions (WHO Technical Paper). Studies have shown that early detection and appropriate medical management can lead toa five-year survival rate of 100 percent of women detected with precursor lesions, and 68-90 percent of women detected with early lesions In short, cervical cancer canbe prevented and treated ifthisis diagnosed early stage disease. Its a strategic approach therefore to make cervical cancer screening services and diagnostic interventions more accessible and affordable to women regardless of their economic status, place of residence (urban, rural) and sexual orientations and beliefs, For this purpose, fontine health care providers must be trained on cervical cancer screening technologies (eg. aceticacid wash, pap smear) and their health acites equipped with the needed equipment and supplies. Along this ine, the referral system for appropriate screening and diagnosis services must be developed and strengthened to ensure continuum of care and services, especially if immediate treatment is required after diagnosis. It may aso be necessary to strengthen the partnership between the publicand private health care fates for the needed services. Strategy 4. Improve the Delivery of Quality Treatment Appropriate treatment protocols have already been established for women found postive with cervical cancer. It is highly important that those found postive will have ready acces to these treatment services at the appropriate level of health care. Similarly as in the provision of screening and diagnosis services, the capabilities of providers of treatment services and care in appropriate health facilities must be enhanced. Their need for equipment and continuous stock of necessary drugs and medicines must be addressed. The DOH in partnership with the Local Government Units (UGUs) and Philippine Health Insurance Corporation (PhilHealth) must explore the possibility of subsidizing the cost of treatment especially among the poor through PhilHealth reimbursement or through other forms of assistance. Since management of cancer i very expensive, a scheme wil be designed to enable health facilities provide quality care and services to cients through partnerships with all the concerned groups of stakeholders toraise the needed resources. Financing is needed not only for developing the capability of health personnel but also forthe needed equipment in screening diagnosisand treatment of cervical cancer, the absence of such will hamper the provision of quality car. Efforts to investin equipment and human resource capability building are most essential in ensuring the delivery of quality health service Strategy 5. Strengthen Rehabilitation and Palliative Care Services Majority of cervical cancer cases in the country ae diagnosed inthe advanced stages where the chance of cue is very small. Considering the limited ‘numberof health care facilities nationwide capable of providing the necessary treatment such as chemotherapy and/or radiotherapy, and the high cost of sai treatments which are most likly unaffordable to the poor women, there i the more reason to equip and develop the capability of frontline health care providers on how to handle and manage terminally ill women suffering from cervical cancer. The DOH must propagate the establishment of community-based palliative care program so that family members, loved ones and other community members may learn the appropriate technique and approach in proving palliative care to their patients at home. Health institutions and health care falties must aso be supported to develop and implement their respective palliative care program. Strengthening te rehabilitation and palliative care services will help improve the condition ofthe ailing cancer patients. ‘Strategy 6. Strengthen Health Information System on Cervical Cancer For many decades now, our country lacks the necessary cervical cancer registry sytem that will record and report cervical cancer cases and deaths nationwide. Ths necessitates a review of the existing information systems avalable inthe country both inthe hospitals and also in public health facies in order ta determine the best means cervical cancer cases and deaths ae captured and reported, In order to havea harmonized cancer data, DDO in coordination with the Information Management Service (IMS) and the National Epidemiology enter (NEC) developed an Integrated NCD Registry to record and report ll types of cancer. A Cancer Registry Form was developed as a means to standardize the recording and reporting of cancer cases including cervical cancer. Te hospitals in both the public and private sectors including te RHUs are expected to adopt and use this registry, Non-government organizations (NGOs) and societies involved in cancer registry wl be requested to als upload thelr cancer data in order to reflect the true picture of cancer status inthe country. Hospital Tumor Boards willbe mobilized to oversee te establishment of cervical cancer registries inthe hospitals. n 2017, the DOH began to pilot the implementation of the registry in thirteen (13) selected DOH hospitals, with the traning of hospital staffin-charge ofthe medica records. The same traning is expected tbe cascaded down to the fed health offices for nationwide 6 Sotto LSJ, 1987;UICC, 1994. Reference Manual 21Jenuey anuaiayay wio4 vodey wounysydivonoy uunjnoads patepyosuo « | jeubenpasnxeos or yr | euleworyuqonseyg « away 26,2, © sodeig « sue [299 30} vonnjes poe Adesoqiokiy« tog jeujy « | one>e20} yHoq EWS « seawsded + ues uesue> «| sauleueai0 Ae» auypew yeuondo wos gens uono: Aees2yi0819 « arepanenied « (uosy>)3u0ues, Siequono) « {UBUIEDILI04 291095 pue ssoube1a aueougny + dnmojos +] peydsou Syuaans | uornjesauoyp aso au 6 reway + | jedyuni swoussassy senoi | agen Suer3 « wa ©] Ayjunuwo quay «| parayusip ana yBin « ‘301n08 Or « sopoa | voneupaen « PUD Buuaans 182Ue) (665) pe ano>y « sdaed «| psGojouper eee | Guyjsuney «| aualB i wee Suuzans vinioy | wnyroeds eben + ypsinn, | owssassy pes, soyasr aise + DUD>eAAAH | “6uIUEa>s vino mpi paved, awa «| _ mmawsua ‘sso seudans wowdinba wes sane : pareyossmies | yneoH ‘Ruewesboy so10001 sapyyped 212) yayeaH 30 [2X3] hq Japue) jeaata) Jo quawiabeuey pue uoquaraig ayy 20) syuawiauinbay “5 3)qe) 21 224 J0 S| snouen ye se0ue) jeajua> Jo uaUeaN pu uawaBeuew ‘uoQUaand ay 20} palayo aq Ue>\piya san/ues yo abeyPed BuImojo} ayy sMoUSS 2/92, sre) [e>yA19) Jo fox}Uo) pue Uo UaAaLg 349 10} SBPIAIAS Jo aBIPLY Guyew-uosnap 40 uonerquoud ainoss‘suoyerapsuo> fod soy paua>uo> je 0 payeuwassp Ajapum pu Ayadosd aq saypas asa Jo syns ey AuessraU ye apunppon saauauadxa pu sapmys jo synsa30a}00 0} puesajew ay UO ApMyssNonuu> ay epuabe yeas sy yo Ved Se yeu IM ‘unos ay yey queyodu st amy ayyu Dens sheMye jm ajuo> pue uoUannd sa>ue> ji Ut saupeoudde Daye mau puesayepdn eupar yxy payedonue st sepuapia pys uo padojrap aq sfene yn yuo pue uoquaraid12>Ue> en/Ua> uy sorooud pue sap Ao04 ‘PUDRAY [OU PUD TOOTOMCRPCY NUD) "g ABBYENS ‘uno> ayy. 2bue> jeDv.2> Jo osuo> pue uojuaraud ayy uy pausaDuoD sajyquaayenud sayy pue spp qjununo> souop ayy woy os} 4nq HO aX Woy Avo you se>:nose BuIEQoU 409 5]seq 10 oo) ayY aworeG Ue sty aysgese aq ose smu a>Ue>fe>/.2>J oquo> pu uojuakad ay 0, JuaWysanu yo SO>2y ue} >IBa}NS iy WO paseg-uoRreyo ued GayeNs wi J26uo} 1022-5 e Suye|nuuo oj seq ay) aODeg pyno4s WYN ‘smeNs uoneWWaWa/duy wesBoud aig jo uaUSsesse jeiaKO Ue ayenapuN jw .00 aig qd apew aq Auo ue sty jgeyene ae suonuanayu anjoaye Kmuaredde yyy soy pue‘seunsodxa wea yum payeDosse st 261 [eNUeYSgNS UPI so} aso AaeNOW pu fpr qiousyea16 ayy asneD erp asouy 0} Lan aq pynoysAyuoud jxquo> pue UoRUaRad 3DUeD U| TDBUSaHOTPUOOOTOUOT TORI“. ABSNENNS 1aueofesan oy anp syeap Jo vonerGayuajqssod ay 10} pamaiat aq pn apunuoneu Sanne yueay Aq pangns Gunsoday aseasig ageunon Alc}epueU ayn ‘uoruppe Uy “waysfs Burvodasjeudsoy say pue (sisHs) warsKs worewuoyy D/.95 \aeaH PIAL Bunsia ay Opava axe Kay se ssoUB.p a>Ue> Jo ssa pue Buuaans jeryue> jo aBerno> ayy Burana ul ajqsuodse/ 9 jp 3K YBNON Hod a ‘PUeY 240 ay UO “Ans!BSy qQN=IB Jo VONeUOWAyEUGiy/ istic” | Althe above Plus | Sameasabove Pus | + Giyotherapy | MAScreening-same as | Sameas above Provincial’ | + PapSmear machine above Plus: Plus: Hospital | « Cryotherapy | « 8/Gyne + Cervical For Papsmear: + Biopsy Pathologist BiopsyForep | * ViAsupplies Plus: | Cancer Registry Form + Curette + Wooden spatula and ervic brush Optionak + Colposcope + Fvative + Colposcopy + Hematoxylin and Eosin Hand) Stain + Microscope + WiAsupplies Plus * Gascylinder with nitrous oxide or Carbon dioxide Foc iopsy * Wasupplis Plus: «Specimen container + Formalin * Hand stain + Microscope | Tertary Cover GResional | Alltheabove Pus: | Alltheabove Plus: | Same asabove Plus: Same as above Hospital! + Gynecologic + Colposcope Blade Medical | ¢ Colposcopy Oncologist + Radiation oncology * foley catheter Centers) | # Radiotherapy | « Radiation facity * urine bag Chemotherapy | Oncologist + LEEP machine * pentose drain + Surgery + Anesthesiologist « Blade handle for + sutures, {LEER coniation, conization * cautery tip extrafascial + Infusion pump ForColposcopy. hysterectomy, * Surgicalequipment: | + Same as above plus: radical (riser clamp, Ochsner | + Lugolsiodine hysterectomy) clamp Alisclamp, Kelly | For Anesthesia clamp, blade handle, cautery machine, Mayo Scissors, Metzenbaum scissors) + Anesthesia Equipment: Anesthesia machine, ‘Oxygen tank, laryngoscope «epidural catheter, + spinal needle, ‘Anesthetic drugs, ‘endotracheal tube, += syringes and needles, ‘= I fluid, colloids, = Weatheter, ‘+ macroset, = cotton swab, + alcohol For Chemotherapy. ‘+ Chemotherapy drugs including premedications Catheter Macroset Alcoho! Cotton swab = Surgical tape FooLEEP: ‘sloop ‘* monsel’s solution + epinephrine Reference Manual = 23Fpnuewauaapy —$ suewonte ung sane uasayypu w6aq ssapue> 16ojopauA9 a>ue> aqny ued st 12>ue> yo ad ate Lan ay siueD>150)0>9U45 seo pataan ave nou aso enna pue “euler ‘uyogn‘ueyno ‘enya :Aouueu sue6ioaxn>npaiday SueWON 8 aye yy JaDUeD yo sad MEW any axe aad staauey 26oj0n2uh5"g sue -2u0q you 1epueD 1sea1q menses] aseasip a ']a9429UeD ISeaNg AyentDe ate sauog ayy Uy sja> J8DUED ay ‘auOg ayy 0} speatds 1DUED Ise ‘ajduvera 104 sown Avewuid atp se sue yo add aus ayy sown (one%selaw) Alepuodas ayy ‘\serseIaUNpaje> sssanoud si Ho} feu WM ((aepuonas) ayjoue'#poq ayy usa2eyd say 0 poojq 0 yds ayy YEnon nen puesow [eu!buo) Atewwd ayy wo4 em year ya018DUeD u>yyA “Apo 24 S204 ,24R0 0} pooyg aut YOu ones pue souEde> puesuBA ayy apenu5—> _2)UeD-poo}g uy nowy (1) ueApog au seDed21yO015assan yd ay fq yBnowy janen pue wasAs yduut ayy aperLS>Ds8DUeD-warsKs duu 49 yGnowg (‘mss jeuwou Guupunouns ayy apenu sj a0ue>- asst YB (2x Apoq aap speaudss>ue> ey SKem aan a4 “abe yn saseeput20ue> budojaap yo pooyyay ay os pue away Suosiad e ano aejnunone ue> (sy pu) store say 2>ue> Jo ase uoWwO> ese ap pue rego} Moyaq fIuo Yue sayseed pue euayreq asta se ypns‘suaBe snon>a}U, “Ue 0} pea ue yey 2uaB ut suoneynu asne> ue suom =U pue Ip 4004 SUDO} ayo pu sosaqse ‘yous anareBip se upnssuaGoupes ‘uns ayy wo shed (Aq) o)-eny Hed soleus eAejd oye ue>ayAsayy pue uaLIUOHIND 24) “Ue seeNqJ0 954240} 24NqUIUOD os pry uOUUO axoU axe yey SAUaB Jo raqumU ease aay BAAN 12DUED Se 10 SOIEIPUED SU YBIY way 2yeu ue> ype '2u96 Zy¥ 40 L YADA IUEINW e AD UAWON Jo jUaDadg acueND 44 12>UeD Buldoarapjoysu IA SuAIYBIDY SL TENE, 0 ,a\jou sy) woy payuayun sen py ‘yy 194 ut @Ua6 payee Ave Apeaye a4 ye SUeaL yeu) 22UeD 0} uoRsodipaid eaney ued aydoo4 “wes oy 2>ue> 196640} au sno sunfr ypgafdgynu Sayer uayO s2DUeD easMED OL ‘anf s0 uy, 20 vey zou sxe Ajensn tang syns snonsesip aney Ue Uo] jad JossaDoNd aN onuo> eA saU96 aA Ul YORAM y‘oNeyMUL 2661 upg ya 8921p sidnuo> yap Buyawos Aq paseo auo> yo yno Buynos a> eUOWY Ue ye>-14Redopose DaYD U's EON “sweysi>ue> van 1p 0 ej pue Aygeyon oun Supp subg ‘Saja fq aneyaq you ‘s20p p> vay 1anaMOH @>uaD>0feuUOU est pu ssoidode pays appins p> parenGax sy. -paBeweps|(YNG) PDE IePRUDgUKKODG ADH 120d s awn 84, vay - 1p 0 > ub Apoq ayy sap Ajenquana ‘pue sayedas Apoqano uD Aina {ueaN Sua ayo aSeaSP eS! DNYD ‘pou yseaug e pajje> st wat YseaNq a4p Ul SIS 3! PUR 12DUED feD|AsaD aye sy nuva> ay uses .20ue> ayy 22 sHed KpoqJayRO oy speards ay ana ‘Ses u21a4e Apogatp fo ued tp 4] paweU stents! ANY) “yaxquo> 0 yno mob Apoq ‘2us@> yoy u aseasip es s2Ue ‘prom .2u0 | 2uo jeulBuo ayy cy sey stows MoU LNs pul sassan Yeu pu poo ay eI Says UEP 0) pauue> ave soo sdnosb ews uaym mo SaSyAS¥ZWN“ua6%%0 pue suaUynu 10} Bupeduo> pue sans jeunou Buonsep 'Kpoq ay yo sued {ejsip pue uipunouns apenuy few yum 'SyOWNL suo} yUMOAG ypns sans pue j= Jo yuNos6 paynuoDun ueUbyeus a Jo} WAY eS! YaDNYD [esauan uysapuey “y 4a2Ue) J221A48) Jo ABojorwapidy ayy Zaaydey)pelvis, whichis the area below the stomach andin the hip bones. Although te breasts not directly connected tothe female reproductive system, breast cancer is sometimes included in the list. All women are at rskf getting gynecologic cancers and as age increases. Each gynecologic cancer has diferent signs and symptoms and ik factors asmentioned may increase the chance of getting a disease, When gynecologic cancers ae found early treatment i most effective C Cervical Cancer 1. The Female Reproductive System Theorgansinthefemalereproductivesystem include the uterus, ovaries, fallopian tubes, cervix, and vagina. The female reproductive tractsclasscally divided nto the extemal and te intemal genitalia. The external genital organ are preset inte perineal area and include the mons pubis, clitoris, urinary meatus, labia major, labia minora, vestibule, Bartholins lands, and perurthral glands. The internal genital organs are located inthe true pelvisand indude the vagina uterus, cervix, oviduct, ovaries, and surrounding supporting structures. The partf the reproductive organ thats finterests the ceri. The cervix (igure 3) ithe narrow portion atthe lower one third of the uterus. The cervix connects the vagina (birth canal) othe upper pat ofthe uterus The word cervix originates from the Latin word for neck. The Greek word for neckistrachelos. The cervix may vay in shape from cylindrical to conical. Uterus Fellopian Tube It consists of predominantly fibrous tissue in contrast tothe primarily muscular corpus of the uterus. The anatomical Position of the cervix include attachment of the vagina obliquely around its mide part which divides the cervix into an upper, supravaginal portion and a lower segment in the ‘vagina called the portio vaginalis. The supravaginal segment is covered by peritoneum posteriorly and is surounded by loose, fatty connective tissue - the parametrum - anteriorly and laterally. Figure 3. The Female Reproductive Organ The cervical canals fusiform, with the widest diameter in the middle ts length and width varies, usually between 2.5 to 3.0 cmin length and 7.0 080 mmatits widest point. The width of the canal varies withthe party ofthe woman as well asthe changing hormonal levels. The cervical canal ‘opensint the vagina atthe external os ofthe cerviat the lower portion and int the uterine cavity superiorly. Inthe majrity of women the exteral sis incontact with the posterior vaginal wall The exteralosis small and round in nulliparous women. The oss wider and gaping fllowing vaginal dlvery. Often lateral or stellate scars are residual marks of previous cervical lacerations. A single layer of columnar epithelium lines the endocervical canal and the underlying glandular structures. This specialized epithelium secretes ‘mucus, which fciitates sperm transport. An abrupt transformation usually is sen at the junction of the columnar epithelium ofthe endocervi and the nonkeratinized stratified squamous epithelium ofthe portio vaginalis. The stratified squamous epithelium of the exocervx i identical to the lining of the vagina, The transformation zone (Figure 4) of the cervixisan important anatomic landmark for cncan. Tiss the region ofthe cervix where the columnar epithelium has been replaced and/or is being replaced bythe new metaplastic squamous epithelium, This coresponds to the area of cervix bound by the original squamacolumnar junction atthe distal end and proximally by the furthest exten that squamous metaplasia has occurred as defined by the new squamocolumnar junction The squamous epithelium, whichis seen asa translucent smooth epithelium witha pinkish tng, should be examined in great detain order to define the landmarks of the transformation zone, The original squamous epithelium is darker pink in colour compared with the ight pink or whitish: pink colour of the metaplastic squamous epithelium. f one looks closely itis appaentin some women that a few aypt openings, which look like tiny cular oles, are scattered over the surface ofthe squamous epithelium. In ome women, alternatively, ane may look forthe nabothian flies, Dysplasia ofthe cervix develops within ths transformation zone. The position ofa womans transformation zone in elation to the long axis ofthe cervix, depends on her age and hormonal status, Reference Manual 25yenueyyanuaiajay 97 -abeys esejdskp pu 2jgepayapsayeo ue ynoyumn ino Kew eseydsfpasanas 10 aerapout ‘sase aus u‘sueakY-7 UM eseydsip alaas 0 aerapous 0} sassaiGoudyuanad OL ynoqe Aug sek ge aBeJapun vawom BuoWe Kuen ued Ajsnoauequods sanosas tseydsfp puso sase> yo aous0 uaniad gp nogy sen uonDayul jgH Wo doakap 0 J2>UeD20}sayeI HaUUR a yosaREWNS| (¢ayqe, 235) seate Buypunouns 0, ue xasa> tp ow fjdoap a1ow peards pue mou6 oy ues yao J2DUe> say anssh JeqA9 a4) ul seadde oy wlBoq jewou ou ave JUN I> \>IYM UL ‘esejdsip se umouy sabuewp YBnowyp 06 xuasa> at Jo sao ay x18) a4 Ul sieadde s2>ue> auojaq “aw 1840 Anos soanap Aes JeDUe> eDINB) LOOT “ef “ZZ-T1 *Z adUe_D sMaTAsy amNyEN “Te 19 UeUIPooM, Wosy paydepe ‘s]J9D J29UeD Jo juaudopeaaq *s aNB1I ‘papayuyare fp mou arou9|doad sou swoyduus ou sesne> fensn uon>aju aH @DUS WuaWEEN mol paeap si stun dtp pue snewordUhse axe nave) a Jo suomayu SOW “wnjayydD fe} a UI SHEEN ews YBnowA wn Yd axp yo sof seq aA saxpeas yy BuyoUy uostd ayy mown (assnoaqujeue 0 [eueA sayy) Ayat>e enxes Buunp ups eyuab aly Jo peIUOD asop YBnouta peards Ase step sMAA UOUOD es “sj (esoanu 0 us) eyaupid ayy aj yy SAS YG ave gH 72DUED eDMLRD Jo asMeD uyapun few uns AgH SH YOY YUM ORDA >yuoNyp pue waysiag “Pays}g1se- AM S1JeDUeD [IAD (MIM UBtOM BuOWe UORDEyU! AH Jo fo eEAGo}oND ay, "TUNA OLOTANG VOUT ST epue) Je>4At9) 30 ABojon3 ayy “7 (srenstapaw) 1a43) aul “p 2anBLy em uber, (nuayn oy Buruodo) 190 E2029 anssoopua muveoowa twonount seuuunjooowends XIAs99 [EULIONLess than 50 percent of cases of severe dysplasia progress to invasive carcinoma, with much lower rates seen in younger women. Several studies have indicated that the mean interval for progression of pre-cancer to invasive cancer is about 10-20 years. Tis make cervical cancer a relatively easily preventable disease and provides the rationale for screening. More than 90 percent of infections are cleared eee ‘eat are mg 08 ann eri, {Comprehensive Cervical Concer Control: Guid to Essential a Practice, WH02006) Figure 6, Progress in HPV Infection (Adapted from Cervical Cancer Screening, Lyon, IARC Press, 2005, (IARC Handbooks of Cancer Prevention ‘Vol. 10) 3. Risk Factors to Cervical Cancer Anything that increases the risk of getting a disease s called a risk factor. Having a risk factor doesnot mean that a woman wil get cancer or not having risk factors doesnot mean that a woman will not get cancer Risk actors for HPV infection are elated to sexual behavior, and include early onset of sexual intercourse especial i near time of frst menses, multiple sexual partnersand having partners with multiple partners. Notall women with HPV infection wil develop cervical cancer. Women who do nat regularly havea Papaniculau (Pap) smear or Visual Inspection with Acetic Acid (VIA) to detect HPV or abnormal cellsin the cervix are at increased risk of geting cervical cance. ‘Most genital HPV infections regardless oftype, are shor lived, Te body's defense mechanisms eradicate them, without any associated abnormalities and without any risk for cancer. HPV infections that persstarelnked to pre-cancer. The conditions or o-factrs that lead HPV infection to persistand progress to cancer ae not wel understood but the following probably play aoe: 1 Host elated cofactors, + Immuno-suppresion/ Weakened immune system ‘Sexual Behavior: having fst serual intercourse at a young age and having many sexual partners High Parity / giving birth to many children HPV related cofactors = Typeof HPV see Table 6) = Simuitaneous infection with several high risk types = High viusload Exogenous co-factors = Tobacco smoking = (infection with other STI (herpes simplex, chlamydia, gonorrhea) Long term (>5 years) use of oral contraceptives Reference Manual 27fenueyyeovarajey 2 “voneupren sae uaddey e4M >Ipaid 0 sauD eR Jeu JOUYO YMA 2>uaUad> Woy ayejodeLXe O} MUS! 1 ey UeaUL S=DUaLaYIP ase\ OReUPDEA OWe UaRs asouy VEU ao ale asuodsal aun J jaa] 24 puesaipoque wnsas dojarap UatoM pa)daul aya jo ley ynogy “aseyd weanispoo|q ou sey pue woRDa}UL [esoonuy fund 13245 AgH Yum 2ua.ayip Ue odus uy PaulE}sNs pue snosoBn st sasmuh asa iim UoNDeU finyeu 0 asuodseuApoquue ‘4 wear)spoojq ayy Ui sazebuD stu aly UayM aseyd e aney eM SUoNDajUsuIRBe Dajod (e}2qru ue saseaU‘g sedaH) saUDDeA [eA ue "(uawiom pay>ajul AlH) sJenpiaipur passaiddns-aunuw ut 1260 sjsisiad uon}>ajul ynq ‘payep!on| [jam tou s} uoNDapUI Jo aDUELeEP Ut ‘yununwy sn2> 90124) 90 0} yno4p axe adoUab awe ayn YHA suOR>2,U-ay um JOU ave UOIDeU euMJeU aye yUMUALJO UoNeINP ue uopaoid jo aaiSap ayy “uorDayu jemeu s9ye jal 01 Sepoquue wns dojnap uawon yo yariad 99-5 fIuo “uonewiUeyU! f30|a>NpUl 3oU op pue andy ou ae fay asnedag asuodsay unui) snosoB i ajowoud you op suonDayu agH eNUaD "UONDEIU Ag OT BSUOORDY aU IsELZe'L9'YS za'a9'6s'as'95'75'15 prev zv0r'LL'9 ‘'svee'seee'le's1'91 (Glib [e31U96 jewarxe Ypim payeDosse s[uaBooUo-UoN) | _GsdUe> pur ese|dsAp je>1A199 apa pare|>0sse 10 31U9B09U0) ‘AdH ¥s1Y MOT ‘Ade 51a YBIH, (£002 paw £1643 n 420u0) pomae) yum paropossy sad AdH $0 wopsvoy}ss0) 2160jojwapidy) ‘uomrajuy Add Jo uoLD>y)ISS0I) “9 21904 (9 ajge) 29s) ‘sysem jeyuab asne> ynq ‘apue> jeoyua> yum payeDosse you are [1 pue 9 sodA AgH YSU Moy sadhiouab jgH 9Su-y6y hq pasnen asoyy woy a\geysinBunsypu ae ew |ja> Jeena u saBueyp apedS-mos0 ubiuagasne> rey sadfioua6 jg ate Sty Moy AjuowwoD ssa] puno, ar (as pue shee“) sed 31ua60>U0 s01N9 sase> (hie) esejdoaujeyaunds ey jeuben pve (LNA) exseydoau erayude ex ena (np) esetdoau eyauyda enuy jaya e yo wari os-se asne> gL pue gL AH 122Ue> fel [ed snowenbs ut ey) ewoupserovape ul uoulwe>aou sgt AgH 99 Pue S'as'96'75'TS ‘Sy’ ERSé'€e'Le'1'91sadfvoua6 apn asay saDUeD EAD o} pea UD ey. sou ae sadiaoua6 jae yy YBIH SU Yb se pasapsuo> sad uazop efjqewupoudde yu YSU MO] PUES YBIY se paysseP Apeoig ae AgH «LL pue g sad Agi Aq pasned Ajureur yyoq ‘sum jeyua6 pue (gy) stso.ewoded Kioyadsax ajuann{ quauinoa4 se ypns suo)D>aju eNUa6 UBlUaGJayR0 Jo} ajqsuodsas os st .dH @plpLOM ‘sepue> etna> Jo aniad 07 euoppe ue 14 uno>%e asey "Bs PU Zs ‘SpE ‘EE ‘LE AAU ‘SUO}Oa PHOM je Ul ames ayy are sad ngH YOWOD {SoU Is. a4 'BL/9L-AdH J9YY “SUoIs} [emi apeaB-o Jo quadiad z¢-91 pue Suo|sa jeayva> apes6-yBiy jo wansad /9 ~ Lp uBaMyaq saseDJ2DUeD reps jo quensad 0 1240 0} ynquyuo> sad aygewuanaud-aupren om ay ~L PUP OL-ndl'3PIMP HOM 2160]opo4.au Kpms Jo sone ayy 0 anp Ajay Sou) 2>ue> jenn ul >uayeraid jgH Jo uoneWnsasapun ue ianaMO} "Usa at Jo AAMAS YIM saseaDUl Ag Jo auajenaid ay) (si payeyop 40 pappaquia uyyesed ‘anssi ysay) spa jeo1sa> ul UONDeIap YNG AdH JO SueaWU Aq paunseaws| uoR>ayUL ‘aH 12 [evap ansenu pu (SDE-ND'7-ND ‘L-ND) SuOs|snoseouevnd jo saBeys warBYIp 0 (UawON [ewOU Kje>/6oj0¥0) AewoU Woy, SuyGuessuoisa erGojoydous jute ut ynsey uonajujouaD jh “Uayn a4La> ai ul UoR>ajU AgH UO sesn>o, Moja passrosp se oNstES ay) cuoqeindod ayy u uojayul agH Jo uapsng ayy ssasse 0} anuepin e se Aquo pasn pue Ajsnorine> pajaidsaqul aq pinoys eyep asaya ‘pasn suBisap Apmys pue spoyyaus ‘uon>aiap ¥NG AdH Jo Suonedium atp 0) ang -axnyexay Gunsixa yo sasfjeue-eyaur pue smarnas aewaysKs woy panvap ale says Ded} JewuaBoUe ayy 4o pea re vaping nah ay UO eyeg saDUe> [eo quaDiadg pu sta>ueD jeabuLreydoo yo wuanred 1 “(luad pue eulBer‘n)na) eeyua6 jewayxa 4o si3ue9 Jo uated op a>Ue) jeu Jo yuaniad 0 DU jea}80 Jo sase> Jo yuaniad gg] asneD oy payewisd s|AgH “UORDaJUfeUab asneD 0 amour se sed Og wey asow wiyn jo ‘Sadfioua6 jg yo Sad paspuny auo ue atow ave arayy suots)j>qup ynowyM pe YAWN UOWOM pue uaw jo Den feyuaGoue atp u puny Auowwo> st uonDayU AgH “SEU fenUaBloue Layyo wajs jesus s igh yo ADUapuAa BuywoAb e osfe | zaUy ‘AdH Jo a2uayeneid'gGenital Wars. HPV can cause a numberof cancers It also causes genital warts (condylomata acuminatum) which grow inthe cervix, vagina, vulva, or anus in women and the penis, scrotum or anus in men. Genital warts very rarely progress to cancer. HPV can also cause RRP, an uncommon, but, serious condition ofthe larynx. Between 90 ~ 100 percent of genital warts are caused by HPV genotypes 6 and 11. Genital warts are very common and are highly infectious. Although they do not usually result in death, genital warts cause significant morbidity, Incidence rates for genital warts rise sharply in women aged 15-24 years and in men aged 20-29 years with the peak rates seen in 20-29 year old in both sexes. Incidence may fll sharply among females but remains high in males up to age 40, Almost 50 percent of women infected with HPV 6 or 11 will develop genital warts within 12.months and 64 percent within 36 months. HIV infection is associated with an increased prevalence of genital warts. Recurrent respiratory papillomatosis is caused by transmission of HPV genotypes 6 or 11 from mother to child during birth. Although itis uncommon, a maternal history of genital wartsis associated with a231-fold increased risk of RRP ina newborn child. Recurrent respiratory papilomatoss isa potentially devastating disease characterized by the growth of wart like benign neoplasms throughout the respiratory and digestive tracts and often requires repeated surgical intervention. (Human Pappiloma Virus and HPV Vaccines: Technical Information for policy-makers and health professionals, WHO 2007) Reference Manual 29lenueyy aouerajay Og ‘Se0}A19g [OUD PUP BANUARALY JeDUED [eDIAIED JO MO} “L aINBIY oddng uonenjene seyny eposoyorsg 404 19424 40 e1qi6436 jateg ennenied 4 Adesaujokso t ia Buueeios seaws ded oBiepun ‘120k ¢ 10 (iA) s100k ‘23 uewoMm quouneesy, Adexoyjokio 1942 dojo, ‘Beinooue - pue weweBeuey || ofiepun oj espe |! obiopun oy asiipe seoueg yoadsng || jeuuougyyeanisog || jeuuon/eaneBon r r uuogeupoen - { K . Bo} NEO JO VIA~ — ta! soy JueuIssessy JUEIIO - ut Auueey ‘sisouBeig pue Buusaiog ee uoqueneig KiepieL uopuanaig A1epuoseg uoquensig Arewlid (2in6yj22s) ywouyean pue wawaGeuew sadoud vanp so paves Aeyeypawu ag smu enue) adsns yao ewougeyannisod nay synsay Bu1uaans aout vawoy say ByuBans ai yo nsx ay] uo paseq pase fiadaid pue pauaans hpyeudoudde‘pssasse Arajdwo> ‘34 pynoys Buuaans ofiapun « pabeanoova ave oym asoy ‘Aue od ao} (Gulu2ans o6apun 0 payasuno» pue uoneuPrer ‘uorowoud asap ‘gye2u) seoyu2s uoquarand Awd yaya papyosd aq Ayumuo> atp u asx 10 Ay>e) wpeay aA 0} Buso8 uEWON e exp aunsua oy paLaXD 29 snus soy ‘wawom payer oy sanrLas januoD pue axnuanaydJ2DUeD Je}NA2D Jo uosinoud aly Wy SsDoud|esnO ayy a}OU 0 ELOY | uoRpnponul y 4a0ue) [22113 GursouBeg pue Guluaans ‘uonuanaig gsaydeypB. Prevention of Cervical Cancer Providing accessible and affordable services and actively promoting them to the target women can significantly increase the use of services and thereby reduce cervical incidence. Cancer prevention is an action taken to lower the chance of getting cancer. There are diferent ways to prevent women fram developing cervical cance. These include (i) undergoing routine screening (VIA or Pap test); i) adoption of healthy lifestyle practices; (ii) undergo cryotherapy to treat a pre-malignant condition or to keep cancer fom starting and (v) HPV vaccination, While adopting a healthy lifestyle practices would help, vaccination against the HPV is recommended bythe DOH, especially now that vacine supplies are already avilable in the local market. It must be noted though that HPY vaccination is not a substitute for the routine cervical cancer screening using the Pap — Smear or ViAin the low-resource healt settings. The procedures to undertake the VIA or Pap test have already been discussed in Chapter 3, 1. Promotion of Healthy Lifestyle to Prevent Rsk Factor Exposure Promoting healthy ifestylesvery crucial in preventing cervical cancer through avoidancein the exposure frisk factor contibutingtothe development of the disease in particular. Anything thatincreases the chance of developing cancers called a cancers factor, anything that decreases the chance af developing cance is called a cancer protective factor. Some risk factors for cancer can be avoided, but many cannot (e.g, both smoking and inheriting certain genes are risk factors for some types of cancer, but only smoking can be avoided). Avoiding risk factors and increasing protective factors may lower the risk but it does not mean that one will not get cancer. 1.1 Risk Factors to Cervical Cancer 1.1.1 Infection from Human Papiloma Virus. The mast important risk factor for cervical cancer is infection by HPV 16 and 18, As discussed in Chapter 2, HPV isa group of more than 100 related viruses, some of which cause type of growth called a papilloma, which are commonly ‘known as warts. HPV can infect cells onthe surface ofthe skin, genitals, anus, mouth and throat through vaginal, oral oranal intercourse. itis spread ffom one person to another through skin to skin contact with an area ofthe body infected with HPY. Infection with HPV is common and in mast people the body is able to clear the infection on ts own, Sometimes the infection doesnot go away and becomes chronic Chronic infection is caused by certain high-risk HPV types that can eventually cause cervical cancer. 1.1.2. Multiple Secual Partners and Co-Infection with HPV and Other STs The isk of cervical cancer increases withlifetime numberof sexual partners (with 6 or more). Women who are co-infected with HPV and other sexually transmitted agent, such as Chlamyélia trachomatis or herpes simplex virus 2 are mare likly to develop cancer than women who ae nat co-infected. Women with previous abnormal Pap smear results ate also of higher risk to cervical cancer. Women with male partners who are not circumcised are also at higher isk to cervical cancer 1.1.3 Smoking. Smoking exposes the body to many cancer-causing chemicals that affect organs other than the lungs. Tobacco smoke contains ‘mare than 7,000 chemicals of which 7 are known carcinogens. These harmful substances are absorbed through the lungs and caried in the bloodstream throughout the body. Tobacco by-products have been found in the cervical mucus of women who smoke. Based con studies, these substances damaged the DNA ofthe cll ofthe cervix and may contbuteto the development of cervical cancer. Smoking also makes the immune system les effective in fighting HPV infections. The risk of cervical cancer increases in women who are current smokers with the numberof cigarettes smoked per day and also for adolescent girls who started smoking at early age. Women who smoke are about twice as likely to get cervical cancer compared to non-smokers. 1.14 Multiple Ful-Term Preanancies. Women who have had 7 or more full-term pregnancies have an increased rskof developing cervical cance. This can be due to: having had more exposure to HPV infection due to unprotected intercourse to get pregnant; i there are hormonal changes during pregnancy making women more susceptible to HPV infection or cancer growth; or (i) the immune system of pregnant women might be weaker allowing for HPV infection and cancer growth. 1.1.5 Young Age a the Fist Sexual Intercourse and Full-Term of Preanancy. Women who have had fist intercourse at early age have higher rskto developing cervical cancer. Likewise, women who were younger than 17 yeas when they had their fist full-term pregnancy are almost 2 times more likely to get cervical cancer later in life than women who waited to get pregnant until they were 25 yeas or older. Reference Manual 31[enuew aruaapy —E passauppe aq pjnoys verpren6quaved a s0/pue “wap Aq saruo>/sanss| ~ wy pue hayes ‘sasuodsas yeiGojounwiay - ‘synsaayen = “(BL naH pue | Aad) sIsaUaBOUDIeD xB UL AgHJO.ajOX ~ Sumo ‘24 120 pynous ueprendquased Jay 10/pue quaidoas atp yum uossmasip‘apueadaore aupoen sapueyua Buyjasuno> pue uowenpy © >pnaderay ous IDeA Ad ® 42)Ul) [291129 paleal-AdH IaDsad 0/ 404 swUNOIDe gL AdH PUE YL AH) 2uPIeA 2INDe\AYdod es] QuDIeA AH © Uorquanaidsanue> jeousa> Jo asodind ay soy ayqeyene Aje30] mou are saUDIeR AgH papuawuora jeo0 se sweboud Gunsire Bulsnaouejanins panuquo> Jo} /paau aly saziseyduua pue 12>ue> je>yAsa> Jo uoNuanaid Jo} 2uDdeA AgH Alp Jo asn ay} UO LOR!eWOJU! saxeYS a>soyyse] (Ml) UaWOM 40} UOHEZIUNWILH| ayy yBnoup (6904) MaD0s fenGojoraury pue jeouiaisqg auddiayg aun Jo O¥HYM) aaWWO Aoe>oxpy yea} aANonpoxday suaWoM ay) woneupsen Add atp wo uoneULOyUY 215eg LZ oneupre, ewoyydeg ueuny 244 °Z ‘uorDayuy (0) 2uesisat suawon aip Gusseaur smi ‘Guons pue Ayyeay sjj> Kpoq daay uonusnu pue yap 1adoxd Bumney ONT PUD Ig TadTg b'1 “Buen jo no jor Supreme sjendsoy Hog aus ut ajgeene Ajuo axe wasard ye saniias uonessay Bupjows- uy “Bunyows Uo saya jt plore 0} uonessaD unyows seyowoud yog ayy 120Ue> pue sauer-aidjeoyaa> Jo st aly zonpad 0 Kem ueLodusayLoue st Burs oN "TORDRSAY OUFOU €°7'L ‘AdH plone day ue> (pj sak gz aye Agesajaid)Japjo sauwonag avo jun x95 ut BuiBebuy STIG TTL ‘uonayu ysuebe wayshs aunuwuut ayy astwosdwo> 24 LN pjnow yeu) sgty AIH 0} uo sasodxa osje siaused-ajdnynuu yim yuawaBebug ‘paprone Ajayajduuod aq 0} s| uosiad saxgoueyo asouy "um (sfenua6 pue ‘snuenow aia aq) Aad um para auwodaq ue> eur Apog ay Jo Seal tp Jo peqU0 STOUOARES FANT PIO LCL Aadue) [e>1A19) Juanadg 03 SarqDeLg aAISATT AYDIEAH ZL (L107 aouarquoy Guuueyg yey OHM woneioqeyo> apumppom yBnoxy padojarap aoueping paseg-2avapig-sapiAaiy 14 Yoogpue} eqo}9¥) "ews ABA aq 0} {yBno4 st yBnowp ast 90) YAMA payeDossesi2nuED jeoyaD Jo aq aly YaDUeD eLa> oy ONDA gH aISsiad yo yuawdojnap ay dn paads 0 sade ao 10 steaf 40} (93) saundanenuo> eso pauiquio exo Jo asn au SLE FONE) IR] SPMNCRSOUO TO L°1'L -quejdsuen uebvo ue pey aney oun asoig pue aseasip untuuujoyne ue 40j payean UeWHOm e ayy ‘asuiodsau aunusuHstayp ssazddns 0 snap Butalavas vatuons axe 4a9Ue> [eD1AL2> 40 4S ye UALLON, 4o-dnos6 sayiouy “nom jeuuou wey ase .2>UeD anseAL Ue ot doarap YB .2DUeD-tdfe>.ABD eA YA UAWOM UY peasds pe yo 34 Sunmos puesya> 20 GuiKonsap uyueyodus st waysfs aunt ay suon>ayuljgH Gumta6 0 ysusayBi4 ye uawoM saneyd pue warsts aunwuu {poq ayy saBewep‘Satysasne> yey) avo ai “AYH) Sma AOUapyepouNuuM UewINy TORCTCOM-OOMATT 9".‘© Women wih have received the HPV vaccine should continue cervical cancer screening, as recommended. ‘© Sexually active women, including those with prior abnormal cervical cytology canbe vaccinated (benefit limited tothe HPV genotypes to hich they have not been exposed to) ‘© Breastfeeding women can receive the vaccine (does not contain lve viral DNA). ‘© HPV vaccines work best when given before a woman has her first sexual contact. ‘© HPV vaccine is contraindicated to those with history of hypersensitivity to any ofthe vaccine component a prior dose ‘© Vaccination during pregnancy is not recommended (although teratogenic effects have not been reported). Those who become pregnant before completion of the dose may receive the remaining dose/s after completion of gestation ‘© HPV testing prior to vaccination is currently not recommended 2.2 Importance of HPV Vaccination HPV isa common virus that is easly spread by skn-to-skin contact during sexual activity with another person. It is posible to have HPV without knowing it so tis posible to unknowingly spread HPV to another person. Safe, effective vaccines are available to protec females and mals against ‘some of the most common types of HPV and the health problems that the virus can cause. HPV vaccine isimportant because it can prevent most cases af cervical cancerin females fits given befor a person i exposed tothe virus. 2.2.1 KPV vaccines prevent serious health problems, such as cervical cancer and ater, less common cancers, which ae caused by HPV human papillomavirus) including genital wats 2.22 As with all vaccines the benefits outweigh potential risks. Vaccines strengthen the body's immune system - they donot overoad it No reputable science shows that getting recommended vaccines hursthe immune systems of healthy kids 2.23 Protection from HPV vaccine i expected tobe long-lasting, 2.3 Type, Safety and Efficacy of Vaccine There are twotypesofvacineo prevent HP: (bivalent andi) quadrivalent vaccines The isttypeis given tofemales only and protects against HPV ‘16and 18. The other type is given to both males and females and prevents HPV 6, 11, 16 and 18. Itcan also prevent some vaginal and vulvar cancers, and genital warts. Foods and Drug Administration (FDA) has licensed the vaccines as safe and elective, Both vaccines were tested in thousands of people around the word. As with all vacines, WHO and FDA continue to monitor the safety ofthese vaccines vey carefully. 2.4 Who should get this HPV vaccine and when? HPV vaccine is recommended for adolescents both males and females, most especially to those 10-14 year of age. Due to limited resources, the curent priority targets though of DOH are females, 10-14 years ol, tisimportant for adolescent to get HPV vaccine before their fist sexual contact — because they would not have been exposed to HPV, Once a girl or woman has been infected with the virus, the vaccine might not work as well or ‘might not work tall. Table 7 summarizes the recommended schedule of HPV immunization for various target groups: Reference Manual 33Jenuey) apuaiajay pe ‘ranUe> [e|a> ie 3Su}e6e Dayo Jou op sauD2en ayy asnenaq Buluaa.ns 1>Ue} jesAra> JejnBay paausaBunok 2am fay Vay pareuDden 21am uur uaA] sase> ueUa> us3) deg © YIM pas ag ose Aew ALD SUEWOM UO AdH PUY UED Y>IYA sa YN ‘dH UY Sins }s2) yo pue ‘io3sy[>}pau sed ‘abe suewon ayy uo pue Ayuaras sey) Uo Buupuadep‘payeax aq jjensn ued sep asauy seDUeD qu] wim saunatuos Ue nq ‘aw JaKO feUOU awwoD2q UaYO sja> euuoUgy “sdoyanap JaDUe> aojaq panoW.aL aq UeD Kay ey} Os KUED ayy UO S92 Jewrouge puy ue sa yp 40 deg au yiA40 ssa) deg 1)n621 35 yas pynoys vowoy Suuaais sa>ueD [ena so} MNSGNS Us| uONeUDDeA, Suquaeins aurnoy 105 aymsqns e20N s] uoneUDDeA gz “parades st /oveuBaxd J tun auDyen AH J242J0S2S0p fue 26 ou pjnoys wewow eUBaid e“uMoUy | OW Laka [Un api jes tp uo aq 01 ing Youeubaud e Gurpua sapisuo> 0) uoseai& yous queUBaid vay auDdeR gH ay) Sunvay yueuBaxdaxoM fou apy aUD2eA AgH ax 306 OU aon 0] wo Sargeqs9 swajqoud pasne> aup>eA a4IaU MoySSalpmyssauD>en jg Jo} suojepuawiuo>e1 2a jgH ulpnpur ‘auDden Kue Bunye6 aye uy few adoad aos “suoseauAuew oy Ure, ajdaageasneu pur ‘axpepeay aA ‘UalG sem Yous ayy a104m Ued papnpuIspayE aps pu ‘uouNLIOy'spayo als snoUas ou paMOUsSlpmsasay), SBUPDRA 0} SuoNeDI WOULD BwIOS 97 “uogeuprenatoaq panos yim womDaju gH Ue Aa pasne> (sHeM 40 sa>Ue9 ay) siuaygoud ypyeay aun> 203891, 30U Op saUNIeN AgH ‘s|y SUONDaIU AdH Busia yo pl 196 10 Yan YOU IM SAUDI AgH SZ “au auo suaddey uo Dequo> jens van gH 396 0 aqssod 511 5@ uosiod sagoue YM DeIUOD yenxasaney ou aun yxy 4 4p gH WM para aq Ue> auQan/Da1 Kay) aUDDen ay Ul papnpul sad AgH ay AIM UONeUDIEA ‘oq parpayur you ian Kay 14209q 1 14G1 BUDDeA gH UeJO5asOp¢ Ie BuNyab ax0jaqpeIUOD enxaspeyfpeayeakeyoYMa|dOa47'S'Z ‘AdH 0 pasodsa Bulag asojaq(s10ys) sasop ¢ e126 0 UeYodUH AB St 9S9q 40M 0} BUDIeR AgH AyD 14 SUIBAQ ‘pejUOD fenxas aoyaq Sasop aay ye at2jdwoD 0} 5] UoneUD.eA AgH WON yyBUEq sow ay Sia6 UosiAd eye\pauns aq Oy Kem 99 a4) L'S*Z aupren ayy 326 04 aun 950q 94151 UOYM §°Z ae eden TO] Tae eo een wie saddn 1a3nE aeinosnwenuy ws quajeaupend- ss ee wonsefuy0 0p eeesog oA Tag WopeRSUTORY poreteToG oop ten] opaten] _oma10] sone eu) = smyesquous | sayequou | a6evesuntuy peas rrol " aopriaa| sopxswon| —onnao| sojewsy puesojew —— yeyesyuow9 | seyesyuowz | abe ye awinéuy PE plo-sieak $1-01 quajeaupend; 2500 nf 2500 pt esog ul @ aby paunbay sasoq = dnoup aby ye6ue, seupren ‘inpayps uoezjunwuwy suANOY AH “Z a1eL.Glient Assessment 1. Importance and Scope of Client Assessment Cervical cancer testing usually is performed as part ofa mass reproductive health screening program or some other primary healthcare services, such a prenatal of postpartum vist, initiation or continuation of family planning, post abortion car, voluntary sterilization or assessment for STIs. Clientassessmentismastimportant prior to screening and reatment.Itbriefy describes the cent’ significant vital data, including the sexual histor, the bref medical history focusing on the gynecologic history. The following are important information taken from the cent during the interview: Obstetrics - Gynecologic (0B-GYNE) History Sexual history Family and social history Medical history lent assessment is important both to the health provider and the client. It gives the health providers the client's background specific on the reproductive health information before the client i screened and treated, indicated. For the client, the assessment creates an awareness ofthe importance ofthe cervical cancer screening and treatment inthe precancerous stages. 2, Steps in Client Assessment Its best to have a one-on-one interview with the client in the clinic usually in a private room to ensure privacy and confidentiality, which are Important considerations in talking to women about cervical cancer. The client will be confident to express and discus her concems and conditions in such environment. 2.1 Prepare the Client 2.1.1 Greet the woman and validate her biographic data (name, address, etc) as recorded inthe Client Assessment, Screening, Diagnosis and Treatment (CASDT) Form. 2.1.2 Counsel the client about cervical cancer. Explain the nature of cervical cance, isk factors, how VIA testis done, possible findings and {treatment options inorder for he to understand the disease andthe procedure to be undertaken Refer to Chapter 6 for more details regarding counselling of clients on cervical cance. 2.1, Establish rapport with the woman by giving her an opportunity to ask clarifications related to the disease an the procedure to be done. Reference Manual 35Fenuey aouavajay 9 “yos pue yoows aaj pynoys uawsopqe yy" (uojwo>sip/ured yeuwopqe sueyduo> uewom ayy) ssaurapuay ssasse 0 aunssnd yb Bus uawopqe jo seave ie ayedjeg Al ‘Suyjams puesaios uado‘Sapou ydw uajoms Ssausapuay 105 ulo1B ayy auIeR3 “H) pny 106 jo apuasoidajo,pul Kew ew Uosuaysp[eulwopqe 0 suebio paveua own) eayeypul Aew ey sassew Jo} uaWopqe ay) 2UNLEXS ‘sqlew \prans pue sien o apuasaid‘oypunesayse ‘uns 2 Jo ssaupas ay Uosayuo.e10}>5p Uys Aue 10} P94) 7 (s1o;op Aq pausioyad ago) paxay soouy yun auldns Buf waned ap UM UaWOPge aA PAY) 3 “yseaiq amp autwerg a (s10}9p fq pauuoyiad 29 0}) s6un aig pue ay aipayeynosne pu wsayp ayn uNweXG'p “pau pue yon sou ‘aha a ‘peay ‘Uns tp UIE, > (ua) x9pur ssew Kpoq pue yBiay YyBIeM aye “subi eun aq aye -wioj J9Sv) 24) synsa pions pue uoyeUER fe>sfyd wiopag UoNeUWER fe"sKyd 30} UeWOM ay aedady FEZ uewom ayy jo Asoqsy enipaw pue ‘Jepos pue Aye ‘enxas“3NA9-B0 a YSIS EEZ -uaspyup so -ou puesnyes nd ‘a6essauppe‘aureu wap 24 ynoge woNeUOU! eq SY TET -wiog 19sy) 2 isn waIp a MAUI LEZ aD a SSESSY EZ wuoy jUasUOD PEUUOJU| « (weisks voReUUOJU| JUaWABRUEW UO g Je;deYD 0} JeJay) WHOS LaSWO < ‘SunOS vad < sedeup Ug aisem auy onseid moje LUOReUILUE|UODEP 104 UONNIOS eUUOIYD %5'0 winjnoods ‘9uy S}EOUgN] PUB UEM O} UORN|OS sues |eULIOU 40 J9}eM WEN sono|6 uoneuluiexa ‘spuey Bulysem 40} sa}em pue deos < seqcang Jeyowowybioy < aj29s BuyBiom < uinjnoods jeui6en enjenig « ‘2ounos 146!) < Jeded ueejo ipa parenos a1qe) Bulujulexe « qweueMDy, RAMA AA ‘apes uaeay sno oy Buyue> suayp Bussasse ui suo} pue sadn uawdnbe Buoy ax aney nok ew ansuy zz‘v. When a mass is palpated, Use deeper palpation to determine the size, shape, consistency, tenderness, mobility and movement with respiration of any masses. Ask the women to take a breath to help relax the abdominal wal As the woman breaths out, push the abdomen down more deeply and identify any tender areas 4. Examine the extremities fr gross deformity h. Perform pelvic examination i. Ensure to obtain consent from client before performing pelvic examination, Refer to Chapter 8 on Information Management System forthe sample ofthe Informed Consent Form (Form 3) or use your own form, ifavailable. i, Advise diet to urinate orto void ifnecessary. ili Ask the woman to undress from waist down and drape herself before going to the examination room, iv. Wash hands thoroughly with soap and water. Use clean or highly disinfected gloves. Ve Inspect the vulva fr any lesions, rashes, ulcerations, masses and presence of pubic lice. vi Separate the labia majora using the thumb and midle finger of one hand and inspect the labia minor, clitoris, urethral and ‘vaginal opening, vi Check for urethral discharge, abnormal vaginal discharge and lesions such as ulcerations, warts, fissures, masses and refer to physician for further assessment and management. vif urethral discharge fs noted, take a smear for Gram stain and test for gonorthoea and chlamydia if laboratory faces are available, otherwise refer. i Perform bimanual and speculum exam. (Tobe performed by doctors) 23.5 Recotd al findings onthe CASDT Form, D. Screening for Cervical Cancer 1. Definition and Importance of Screening Screenings the application of test to detect a particular disease among apparently healthy population who may beat risk. tis looking for cancer before a person has any symptoms. Screening test refers to any clinical procedure that involves visual inspection or sampling of cells to detect the presence of disease precursors or pre-cancerous changes. This helps find cancer at an ealy stage, which wien properly treated can prevent it fram developing into an advanced stage. A study in 2002-2006 showed that females aged 15 to 19 years have a cervical cancer incidence of one to two per milion screened, Detection of precancerous lesions and ealy stage cancer decreases the mortality of cervical cancer. tis possible to eradicate most deaths from cervical cancer by use of the diagnostic and therapeutic techniques now avalable, (COG Bulletin ~ Clinical Management Guidelines for Obstetrician-Gynecologist, Number 109, December 2009) 2. General Principles of Screening 2.1 The ideal disease to screen has the following characteristics: 2.1.1 Common (prevalent) 2.1.2 Significant cause of illness and death Reference Manual 37enuewyaouaiajey BE 66} HOMION uoNUenesg 490UeD JeorLeD ‘Anas BuDHON aWeBEUEW ANeND OT ‘vejnoqued ul 120Ue> 1 ‘tapsospfo160}0D2uA6 onuo> pue quaraid 0 ps0 usays0M \peay eo saniqsuodsa ty Jo au st Ayjewuouge joa Supnpu ‘seplosip.160j0.2u45 fue oj uawon yo Buuaans ‘dn-oyoy puesasay Sua. seb yun wana 0 12>UeD ajewa sags alps 12Ue>[21N2) uaurabeueyy Aaypeg yrreaH 30 2104 °E ‘uonerado pauieysns so/pue Aynuguo> pasnsu3 0|'¢°7 uoyeyuauajduy pue Guruueyd i, 2jqsuodsa wee) yuawaGeuew yyea4 jo wuausytuwo> wHer-BU0] 6'¢7 ‘sapunosai ayenbape WM 8'EZ 340) oj wars uonewwoyur yea y LEZ waists anueansse Ayenb y 967 ‘sqynsa3say Bujuaans seas deg euusouge fannsod yA yum aso4y 14 ayqefene wautean pu dn- oj, eudonddy ¢'¢7 uatudinba Jo 19s jeuonsuny e pue Buluaanrs oy Adds Kpeas pue ‘2enbape jauuosiad yjeay pauen so Ayigeyene ayn yBnoxy dn-mo}oj pue wausean sisouBeYp ‘SuIwaeDs 4, samnparoud yo Kyjenb YBIH¥'EZ pavenpur se wausyean apyraud pue anisod pauaans asoyydn-moyoy pue uaans 0 pede> yum wars aed yyeay Y EE aBesano yoy anaype 0 202d ur uawom jo wauymnas annraye uy EZ Syuaans oajnpayps ay uo pauuoj- pm pue ysu we woneyndod aya yo (9508 15] 1) aBesano> yBiy yum uoneIndod yabuer pauyap-jaMy Le oSonsuapexeyp Bumoo ayy sey wosGoud Buyuaansjap1 ay. ¢ (fapypads pue Ayanysuas) Aoeanare alqeuoseay ¢°7°7 uoyeindod yabiey ayy 0 ajqeadanne pue ajqerreny 7-7 ansuadhau ¢77 ssejued pu ausenu-uon 777 ea 01 Ase set aunparosd ajduns 177 -sonsuapereyp Burmoyos ayy sey foo) Guruaa.rs ap! ay 77 \veap pueaseasip ayo uossoiGoxd yuanau jm aseydjetuyp-aid ye wauTeDN YZ (swoyduss ou ys ae ano areyn aseasi jo wed ea) aseud yntuyp-audajgeaag ¢17There ae 2 types of crening program that may exist in each locality o fact 3.1 Organized Scening Program - with well-defined target population, coverage goals, good quality screening tes, provisions for inviting women for screening, a system for diagnosis, follow-up care, treatment, and indicators for monitoring and evaluation, In ths regard, there isa need for the health fcity to identify and mastrist the women who are eligible fr screening within ther catchment population, 3.2 Opportunistic Screening Program -screning done outside ofan organized program, and done on women seeking health services for some other reasons (x. pre-natal care, family planning child immunization) In any type ofthe screening program, the health faiity management must ensure that screening tess are available and accessible to all women within their catchment population. inthis regard, health management has to design and implement a cervical cancer prevention service package to ensure that ‘© Safe effective, appropriate and acceptable screening and pre cance treatment services are available and accessible to eligible women ina timely manner. ‘© Services ate well coordinated and ecient inks are maintained withthe various service components for example, community, clinical, laboratory, and other health services and health sectors ‘© Services meet the needs of women using a holistic approach and ensuring client’ rights to continuity of care, privacy, dignity, and confidentiality. ‘© Functioning equipment and supplies, as well strained staf are available at the service sites to ensure uninterrupted services. 4, Target Coverage and Frequency of Screening Target age group isa key factor in detecting precancerous lesions and cervical cancer in particular. A well-defined target contributes tothe success of the program, as oneis able to determine the appropriate age to initiate and discontinue screening, For Cervical Cancer Screening in general, the following are recommended target population and frequency of screening based on the Philippine Saciety of Cervical Pathology and Colposcopy (PSCPC) 2012 Cervical Cancer Screening Clinical Practice Guidelines (CPG) recommendations by age group. 4.1 Women 21 years old and above are recommended as the key target for screening, 4. However, women who began sexual activity at age 17 and younger should be screened 3 years ate initial sexual activity. 43 Tohhave an impact on the incidence of cervical cancer, itis important to screen as many women as possible. The program ideally aims to screen 80 percent ofthe population at risk 4.4Women who were tified a having precancerous lesions need to have thos lesions treated before they progress to cancer Asshown in Table, the more frequent the screenings done, the higher the reduction of the incidence rat of cervical cancer. The estimated incidence of cervical cancer could be reduced to 84 percentf women are screened every 5 yeas. In fact, screening every year can reduce the incidence by 93.5%. Reference Manual 39yenuew anuaiajey Bujuooieg Je0U99 [BOIAIAD UO Hdd Z102 (Od OS) AdoasodjO9 pue AB9jO\Ied feO!NED 10} AO}DOS OUCH ———ET (e102 '12 yoxeyi vo 1n0 29 Ww snsuesu0d Z102 :@I0N) ABOIOKKD eoinieg jewrougy Jo wewebeuey 10} seujaping snsuesu0g (gOOS¥) UoMUaAaid J90UeD IeoMNIED 10) AIDS UEDUBUY ZI. 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This screening testis used as altemative screening to see abnormalities inthe cervc using 3-5 percent acetic acid (vinegar). is commonly used in low resource setting where see and teat approach is possible. Ths procedure can be done by all levels of health cate, which doesnot requite any Sophisticated equipment and maintenance other than the supply of acetic acid speculum and a ight source 5.3 The Visual Inspection Using Lugolslodine (ViLI)s a visual examination ofthe exocervix and squamo-columnar junction (SC) using the naked «eye and Lugols iodine. The procedure is done using Lugols iodine which is more expensive than acetic acid, It canbe performed at any level of health care with proper training and where see and treat approach is pssible, 5.4 The HPV Test looks for HPV infection that can cause cel changes. The cls are cllected using a brush or swab to obtain cells fom the eri. It may be used for screening women aged 30 years an older, ora any age fr women who have unclear Pap test results. HPV testing had better specificity in women 30 yeas and older and sensitivity in detecting cervical intraepithelial neoplasia (CIN 2) or (IN 3) i higher. Continued screening isneededto identify the other 30 percent of oncogenic HP types for which the vaccine provides no protection. See and ret approach isnot possible. Table 9 summarizes the key features ofthe above-mentioned screening tests: Table 9. Comparative Features of the Different Diagnostic Tests of Cervical Cancer, “VIAis also referred to as direct visual inspection (DVI). ] HPV Feature Cervical Cytology VIA vu ome Sensitivity and specificity | Sensiivity= Sensitivity = | Sensitivity = Sensitivity= forhigh grade lesions and | 47 to 62% 67 t0 79% | 7810 98% 66 10100% Specificity Specificity = Specificity = 60t0 95% 49 to 86% 73t091% Number of visits required | «Requires 2ormore | » Canbe used Can be used + Requires 2 or more for screening and visits ina single vist ina single vist visits treatment approach in setting | approach in setting where outpatient | where outpatient treatment is treatmentis available available Type of Provider + Competently tained | » Competently * Competently ** Competently nurse, midwife, trained nurse, trained nurse, trained nurse, physicians to obtain | midwife, physicians | midwife, physicians | midwife, physician and fix the specimen | _toperform and to perform and to collect sample interpret the test interpret the test + Competently trained lab technician to process the specimen Feature Cervical Cytology via vit en (ONATest) Reference Manual 41fenuewarvaajay Zp e002 s204e9 vo aise 10) ‘oveby euoewew| UOk} “jsejdooN feiNeg 10} 84U99.95 [NIA vo eMUEH eORPeLd Y “Se Isp pUE Hs “UEUEREICUCIOWWES, FT “sh wana 49, paau tp Burpjone aygeiene Apye;pausun ynsa1 ay "paypne} uaym Ayse9 spa9|q ey UOISa Jo ssew es avayR 1 22Ue 3Dadsns pue ‘raplog pastes NOYIIM 20 YM ‘seade aIYMOI22" asUap pauyap- yam "DuNsip‘dieys axe ayy! aarysod yA ‘Steadde eave auyprorane weDy!UbIs OU y! anNeBoU yA “SNso4 jo sauoBaqeD aap axe axoUy »1'2woxxpuo pue enfeydoynay eseyderaw snowenbs aimyeunwuonewweyul yim pareDosse wnyayiida Bunesouabas pue Buleay ay suonpuos ayo ul paniasgo aq few ‘akamoy "pay Bulwanyorare sul umyatpids (eww oy paseduio Apwojsaxow steaddesp pue pty ‘asuap ious ‘pide sieadde 12 abueyp anymoware anewseyp sow 3yL IND [JM 190UeD je>HNeD pue suOIsa| weuByjewaud ay) UaIUOD YANG pue ‘yng seapnu paseanujoseauy“suiaoid ejna> jo uoyeydoand 10 uone;nBeo ajqissanas sasne> pue sao atpsareiptyap poe naDy Pde rare} ‘uonenyddesaye saynunu may esoy ay suuny wiyjauyida feuuougy pal | wmiaypide seuunjo> puexeuusnjo> uyurd st wnyjayyida snowenbs jeMLON ‘feads 0 gens uoyo> eBuisn poe 2298 aynyp %¢-€ Jo uoneaydde aye ajnunu auo “we sno uaBojey & 40 146 yo) 3YBUq e Buss ‘ava ax Jo uoRDadsut afo payeu saajonu Guryasannosi mo] ul sa0ue> [12> Joy poyety Buuaans aanewiayea|geydanre pur ssauid ‘ansuadiaul‘ajduis es sty (VIA) PPy an =>y yam uonredsuyyensiq ay) “9 (seunsod soy .2n2y 29m 2111p Suoows fioypads yb a0asip Buoy oN $015 249 payuepy Aa snpuypu so uoq ododays Apypads (somyobau ay sma g ym 2x04) 21) passa aq Sus My Joy SUDA KaMSUaS yb 25005 Buoy so s01 aya Aq paynvapyAypeue sjonpipu Jo uorvodaxd aps) Auaysuas “Bunuor4.0} 0 1 uouokooUDyLDS ->:s) “SE abe J0n0 UBLION ul Apypads yBIH « ‘suo}sa| payeja1 40 uon>ayur ‘AdH ou st x04) yey saaquerend ‘Ajjenta ynsax 10) annebau y « aimny aun Uujaseasip [e>tna> Burdojanap 104 4511 saqeai6 eye ale u1ysinBunsip gnoypi) sad ‘AdH 31u2609u0 EL s1D9ap Asa & ppe sna2e Aq vey, Bujurers ‘auipo} éq paonpo.d ‘2 eIpAUILL! IM © Jewjuju Buypaau ainparaid ayduuis « | | | aeipauw yum © ewjuju Buypaau aunparoid ads « pis yo wuoy aun urasar a4 Jo piodas yuauewiag « ‘Ayoypads yBIH © 30) Buluaa.os 006 e 40} eayi> ay jo sow sjaau coum uawom pue seBuey> 10109 ‘sapinosau ayenbape suoysa] sosun3aud parap 01301503 « ‘yun sums Uy « ‘yen uawoN papaau | papaou sauddns pue swiesBord Ayenb yiog saynuapl « sayddns pue | quawdinbaajduise | —_y61y us panaiyse 359} anndalGo « | quowdinba ajduis « queunesn aq ued Ayeious quasaid quauyean ayeipauiu pue a2uapiouy are sadAy yoy | ayeypauuut soy ynsaz 404 synsas saDUe> feD|ara> uruonnpas yeu, aauapine yan sieaK (95 saK0 103 pasn pur paydanse Aiapim ©6.1 Prepare the following equipment, supplies and forms to be used: Equipment > examining table, preferably with stir-ups for dorsal ithotomy position » uterine forceps: long thumb forceps, sponge forceps, or uterine forceps > vaginal speculum, bivalve (reusable or disposable) light source: floor lamp or flashlight imer roplios ‘Acetic acid (3-5%) High level disinfected gloves 0.5% chlorine solution Lubricant Cotton balls Cotton swab Tray or container ‘Small bow for acetic acid solution Drapes Plastic bin/container to soak used vaginal speculum Forms > Client Assessment, Screening, Diagnosis and Treatment (CASDT) Form > Consent Form » Referral Form pv vvvvvvvvvyY 6.2 Perform VIA. (Note: The steps below follow the procedures in pelvic examination under Section C.2.3) {6.2.1 Counsel the woman about the test. 6.2.2 Soak a clean cotton swab in 3-5% acetic acd and apply (do nt rb) it tothe cervix for 1 minute. el the woman that she might feel a Slight burning sensation, Remove the cotton swab and dispose in leak-proof container. Observe the eric for acetowhite changes for ‘1 minute. 6.23 Inspect the transformation zone, especialy near the squama-clurmnar junction (SC) careful. Check whether cervix bleeds easly and look for any raised and thickened vite plaques oracetowhite epithelium. if acetowhite lesion are identified, note the size, location, extension, intensity of whiteness, borders and demarcatons. 6.24 When visual inspection hasbeen completed, use caton swab to remove remaining acetic acid wash nthe cervix and vagina. Dispose the swab in aleak:proof container. 6.2.5 Remove the speculum and place speculum in 0.5% chlorine solution for 10 minutes for decontamination. 6.2.6 Perform bimanual examination and recto-vaginal examination (f indicated) 6.27 Askthe woman tosit up and get down rom examination table and ask to dress herself. Tell the patient to wait outside for some reminders before going home. 6.2.8 Remove used contaminated cover in the rubber sheet. 6.29 Immerse both gloved hands in 0.5% chlorine solution then remove gloves by turing inside out and dispose gloves in a leak-proof Container. reusing surgical loves, submerge in 0.5% chlorine solution for 10 minutes for decontamination, then wash with soap and water then dry with clean, dy doth or air ry. 6.2.10 Record the findings in the CASOT Form. Reference Manual 43,Jenuey)apuarayay py (OHM Woy peydopy) 1e9URD yoedsng YIM XIA2D Jo Sey “9g eINBLy ‘ane ny ak an a a yn NVI (WIA) PPV 21422 YsM Uo},2adsuT jons!A Jo} 44D aouadasey PIU 42ND oy jeuayed ayy yn yj WwaUN}eaN, ue uonenjeraJayliny Jo Ape oy © 0 uewom tp J924 TADUDDPRSTTOY £9 (OHM 04) payaopy) NSeY eANISOd VIA WIM ain ED | ice a (WIA) Plo 21422 UsiM UoH}2edsuT jons!A Yo} 4uDYD a2uauajay [D2IUIID ¥PIND oy ead ayy ano jy yuauaB_ueW saying Jo 22s (Uo}sa| a4 J8N0> you saop ‘aqoid AdexaypoK1 40 jem jeuyBer ayy 0} 40 eue> ery ayy OW sPUaIXe UOIsa| ‘XID ay) Jo 4667 UeUy axow sardnav0 uoIsa} ayy a1) ‘édesayiok 14211642 04 5] urs ay 2goud Adera\poD Un 67 e EM patao> ABeNbape aq Ue Lose aly ]em jeuGeA atp 0110 -opua.ay oj Supuayo ou 'ax20p904 UO 2/qSIAauNUes UOse ayy AdeayOKD 10128140 Wad ABBTATSOO MATEY 9 j99 J0 Sey “48 eINBI (OHM w104y perdopy) unsey eAyeBeN VIA UHM xiu99 Jo Sepy “ee en = = == € . BALLY93N VIA (WIA) PIpy 2422 ysm uo2edsuT jonsiA Jo} 4u0Y49 aouadajay [DDIM 42INdD “Buysor yiqweadas sy sea < aye wun 0224 | ABST SAPDBSU PIA TO} |'¢'9 29-29 saunbiy w umoys axe A yun Yeu) 2ouadayas fea.) pInb y waIp axa UM YOReUIWeXd aad pu say VIA ay Jo.ynsaL at ssmDs1q ‘Unsay VIA uo paseg quowabGeuey) €-9Table 10 describes results ofA and the corresponding intervention. Table 10. VIA Classification Relative to Clinical Findings VIACLASSIFICATION CLINICAL FINDINGS FOLLOW-UP VIA NEGATIVE '* Acetowhite area far away from T-Zone «+ Faint acetowhite areas without sharp outline «* Streak-like acetowhite appearing at the brim of endocervix + Dot lke pale areas in the columnar epithelium (metaplasia) faint line atthe squamocolumnar junction * More diffuse acetowhitening with columnar epithelium staining with acetic acid # Button: like acetowhite area with ill defined margin (Nabothian cyst) ‘= Return for repeat VIA after S years VIA POSITIVE « Sharp, distinct, well defined opaque/dull acetowhite areas, with or without raised borders near squamocolumnar junction © Cryotherapy ifeligible or ‘© Refer for further evaluation if not eligible for cryotherapy ‘SUSPECT CANCER, * Cauliflower lesion, mass that bleeds easily to touch ‘= Refer for further evaluation and treatment Reference Manual 45enue aouarajay OY sy8eM oz < weuBaid ‘ch agoud ou puotog euro uy ou J0 agord Adesewjokio jo Jjeurep puowag uu Z UU) 210u spUBpxo 10 JON [EUBER oO SPUBIX® EL < UOHEOT: ‘akoge pue pjos1e0K | e7e ey 80089) snoseaUR2-a1d Budojerep Jo ysy JseuBy ie UeLOM sepniou Gnas ae aai9 UL | UoqUaneld J20UeD [eD1A199 JO} WeABeIQ Moly edwes “6 anBLy weue=H91 1940 af 2N A sreh 219013 Arana uot ‘seek Adesohig eu viAeedons ¥ ¥ ‘wouean seaue ouonenjers &——————[_annsog ‘nneBon s2uny 104 23) F F ¥ 480K | Jaye VIA eedou t "ano J wooed so) sy90m 2 8 wrod $ rerov}ueno, 260K | J9Ue VIA yeodat oj osun69 Adesoyoho woHed ft + ysonbsi suewem uo asaynasie s0e% seupea sdecoy f f war esun69) f Adeseyjokia pusunuosey sieek ¢ ul VIA yeadeu £ jlo = on Adeyohig J20ue woadsns, a ennsod enyedon f _t Via wowed t 18089 [2910109 HROGE UBWIOM TESUNED |] jono7 Krepucoeg pue Ale Sujuoet0s J20u89 jeoini20 aney 0} 268 ajqiBjo Jo UOWOM Ie @BeINDDUy | —_janeT AYUNUIOD VIA pur uauissassy 19119 oHUeneld J90UED JeOMNIeD 10} weIBeIG Mol o}dWES “pave2iput jt uauiesn oF dn YIA Gujob.epun siuarp jo moy aun sarensnt 6 ain6i47.Papanicolaou (Pap) Smear 7.1 Screening Guidelines 7.1.1 Women aged 30 to 65 years should be screened with cytology alone every 3 yeas, or cytology and HPV testing (co-testing") every 5 years. Studies of screening intervals in women with history of negative cytology resuits show increased risk of cancer after 3 years. In the Philipines, ue to the disease burden (and lover sens of tology), ether annual ening using conventional ogy or biennial screening with liquid based cytology is recommended. 7.1.2 The high rate of cervical cancer in women greater than 65 years old in the acl setting, warants continuation of annual screening with conventional cytology, bienil screening with liquid based cytology, and every 5 yeasifo-tsting with HPV DNA testis use.” 7.13 Screening for vaginal cancer in women who had total hysterectomy for benign condition, except premalignant cervical lesions, isnot recommended.” 7.1.4Women who have been immunized against HPV 16 and HPV 18 should be screened by the same regimen as non-immunized women."* 7.2Specimen Collection 7.2.1 Advise patient to refrain from the fllowing at east 24 hous befor smear-taking > douching, which means rinsing the vagina with water or another fd > using a tampon > sex use of any vaginal ceam, ely, medications. 7.2.2 You may take the smear at anytime during the client’ menstrual cycle. The best time however of taking the smear is one week after ‘menstruation when there are less red blood cells and other cells that may obscure abnormal cls 7.23 nthe presence of copious discharge suggestive of infection teat the infection fst to minimize the chance ofa false (or (+) result 7.2.4 Collecting device for obtaining cervical cytology specimen: The combination of spatula and cytobrush, or the combination ofan extended tip spatula and cytobrush has shown tobe the most effective device to obtain satisfactory smears and collect endocervical els. The extended tip spatula showed the most favorable result in detecting cytologic abnormalities.” The use of any of the two combinations (spatula and ctobrush, or extended tp spatula and cytobrush) as cllecting device in obtaining cervical cytology specimen is recommended.” In low resource setting, Ayres spatula with saline dipped cotton swab may be used. Dipping ofthe cotton applicator in saline wil increase the Yield of endocervical ells 15 SGOP GPG for the OB-GYN 2nd edition Nov 2010. Reference Manual 47fenuew aruaay a ‘ainpeoold au JO 9120 ——— :sexom aueo yeayuernistyd Bueley ‘sBurpulg wounsog ‘(aW7) Poued lengsuey se] ‘OWEN S3Ueed uuo4 senbay sews deg “y Woy ‘wio, sanbay 1eaws deg ain dn jy pue Appavion aBeped aun aqey OL YL ‘ajo ypea 0 Bunpas 10 Burjang wy way) wanaid 1 sapus at Jo sua yyoq uo sped Bupeld Aq Ayadoud uawspads yped ‘gel ays 03 saps ayn Bulpuas 10,29 6 YZ "sau ayy Jo} peq atuo> 0} UBM UeWIOM ay) NPY SL -wnyoads eben ayy anouiay ‘ps wo 00} | ynoge! poy ‘pasN st ‘exds ey osovae p> ay s26ueyp azul oy saps U AajepoUU aps ayy uo UaUDEdS ay xy aaeNy YM UaLUDadS a1 Aexds gL apis ss6 cup saynoue oyu seats pue uawinadsyeyda20}9 WEIR SPL ‘apis ss6 ayy owu sees pue uawiDads jeryaiaopue UIELGO FPL ‘ABuypuone saya ‘asymsauyo ‘Bujvaans ip paaroid feuuou Assos xysa> | eUlBeA pue xMUaD ay aNIOSqO/AAIENSIA Ey L “uoneuwers 4o ap pue abe waned jo aweu ayy yy (uadjeqasn you op) ;pued pea eGusn (pua-pasoy Aygeajsd) apy tp age] pue sedaug pL 32) ay) Moge EWM ay} jaSUMOD pL (€7) worpas sapun uopeujurexs >yjad wy sasnparoad ayy mojfoy Mojag stays ayy :210N) seunparoid HZ wuea pest seU90 jexsoyeu Kuoyesoge} ABOIOND uo} Brep waned Aeids sey 40 oyoore 946 “@nnext (pue-persoy,Aiqesoyeud) Sepis 8219) snug aleo 40 ‘o}e011dde dy uojoo pedaip oules 40 “einteds s,<4Ky :e0Insp UOH}IaI10 UUohnOs JUEIDEJUISIP 40 4OZIUEIS aiqesodsip 10 e\gesnel : wnynoeds jeuiBep S@R01D, 1yBiysey 10 duse} 1001.4 Uuonisod Awoyoun| 1esi0p 40} sdn-ins wm AIgeseyeud ‘eiqe) BUNUN XS AAAAA AAAAAA aqeuysarddns Bumoyo tp Jo Ayiqepene ayy ansi syeuayew pue sayddns ¢°77.5 Transport specimen to laboratory 7.6 Follow — Up: Emphasize tothe patient the importance ffllow — up especialy wen the patient needs further management 7.7 Management of Patients with Abnormal Pap Smear/Cytology Results 71.1 Atypical Squamous Cell of Unknown Significance (ASCUS) 4 HPV DNA testing, repeat cytology and colposcopy are triage options in. women with (ASCUS).- b. Women with ASCUS who are HPV DNA negative may be flloweel up with repeat cytologic testing at 12 months. Women with ASCUS Who are HPV DNA positive should be refered for colposcopic evaluation. 1 Endocervical sampling should be done for those who have no lesions identified or those with unsatisfactory findings on colposcopy."® 4. Women with ASCUS who are found to have CIN on colposcopy should be managed as per 2006 consensus guidelines for the management of IN Women with ASCUS who are HPV positive but with no CIN identified on colposcopy may be followed up with repeat cytology at 6 and ‘12 months or repeat HPV DNA testing at 12 months. {Repeat cytologic testing for women with ASCUS should be performed at 6 and 12 months until 2 consecutive normal results are obtained. After which, women may return to routine cytologic screening.” 4. Colposcopy is recommended for women with ASCUS or with greater cytologic abnormality on a repeat test.” ‘h. When colposcopy is used to manage women with ASCUS, repeat cytologic testing at 12 months is recommended for women in ‘whom CIN is not identified. Women found to have CIN should be managed according to the 2006 consensus guidelines for the management of CIN.” 7.7.2. Low grade Squamous intraepithelial Lesion (LSIL) a. Colposcopy should be used a the inital triage option inthe management of LSIL except in special population.” . HPV DNA testing should not be used as inital triage option in women with LSI.” Endocervical sampling is preferred for non-pregnant women in whom no lesions are identified and those with an unsatisfactory Colposcopy, butis acceptable for those with satisfactory colposcopy and a lesan identified in the transformation zone. 4. For those in whom CN2,3 isnot identified on colposcopy fllow up wll be HPV DNA testing at 12 months or repeat cytology at 6 and 12 months.” ¢-Ifthe HPV DNA tess negative orif2 consecutive repeat cytologic tests are negative for intaepitheli lesion or malignancy return to routine cytologic screening is recommended,” {.Ifeither the HPV DNA testis positive or repeat cytology is reported as ASCUS or greater, colposcopy is recommended, Women found to hhave CIN should be managed according tothe 2006 Consensus Guidelines on the Management of CIN.” Reference Manual