PREVENTION OF

CERVICAL CANCER AND

TREATMENT OF
PREMALIGNANT
CONDITIONS

FACILITATOR- Dr. Benjamin

O. Elly
MBChB, MMed(Obs/Gyne),
Gyn.Oncologist.
PREVENTION?
 It’s the action of stopping something from happening
or arising.
 Preventive healthcare consists of measures taken for
disease prevention. Includes measures to avoid
diseases or injuries rather than curing them or treating
their symptoms
 Disease and disability are affected by environmental
factors, genetic predisposition, disease agents, and
lifestyle choices and are dynamic processes which
begin before individuals realize they are affected.
WHY PREVENTION?
Treatment
 Expensive
 Complicated
 Associated with loss of reproductive function
 Castration.
 Emotional and sexual effect

Mortality and Morbidity

 5 year survival rate for cancer ovary< 40%
TYPES…
I.  Primary prevention---aims to prevent disease or injury before it
occurs i.e. to prevent initial infection e.g. administration of
prophylactic vaccines.

II. Secondary prevention-- to detect and treat early disease. E.g. screening
asymptomatic individuals.

III. Tertiary prevention-- treatment or mitigation of damage or also

prevention of cancer recurrence by post treatment follow up.
CERVICAL CANCER
 Globally, cervical cancer is the 2nd most common cancer overall,
contributing to over 500,000 new cases and over 300,000 deaths
annually.
 Most of these cases (80 %) occur in Africa and other (LMICs).
 In Kenya, it is the 2nd leading cause of cancer deaths contributing
to 10% of all cancer deaths.
 It accounts for 5,250 (12.9%) of the new cancer cases and 3,286
(11.84%) of all cancer deaths annually.
 Among women, it ranks as the second cancer in incidence after
breast cancer, but ranks top in cancer deaths (GLOBOCAN,
2018).
INTRO…
 CIN usually found in women in their 20s, CIS in 25-35 year olds
and ca cervix in women >40yrs.
 10% women with CIN have a concomitant VIN, VAIN.
RISK FACTORS

A. HPV (16,18,31,33,35,45, 51,52,56,58,59,68,73,82)

 Multiple sexual partners

 Early onset of sexual activity <16 yrs
 Unprotected intercourse (no barrier or chemical contraceptives )

 Age, mean 51 years.

 Most develop only subclinical infection
 Majority spontaneously clear infection ~12 months
B. Co-factors are important in disease development
 Smoking
 Immunocompromised (HIV, drugs, transplant)
 Oral contraceptives
 HSV & other STIs e.g. chlamydia infection
 High parity
 Low socioeconomic background
 low beta-carotene intake
 Diethylstilbestrol (DES) exposure
1O PREVENTION
 - Prevention of dysplasia
-Avoidance of HPV exposure
 Abstinence

 Barrier contraceptive use

-Avoidance of co-factors
 Smoking

 HIV

o Education of young women and men about risk factors and

need for frequent screening

o Use of printed media and TVs to pass information to general

public
1O PREVENTION…
 Vaccines

 A bivalent vaccine targeting HPV16 &18; (Cervarix). It's

approved for females aged 10-25 . Given at 0, 1 and 6 months.
 Quadrivalent vaccine targeting HPV 6,11,16 & 18 (Gardasil),
given at 0, 2 and 6 months. Is approved by the FDA for use by
females aged 9-26
 Nanovalent vaccine targeting HPV types 6, 11, 16, 18 31, 33, 45,
52, and 58 .
 Girls and boys aged 9–14 years, a two-dose schedule (0.5 mL at 0 and 5–13
months)
 15 years & above, and for immunocompromised patients irrespective of age, the
recommendation is for three doses
1O PREVENTION…
 Delay sexual exposure until cervical epithelium attains
physiological maturity.
 Limit on sexual partners
 Maintain local hygiene and treat STIs
 Diet rich in Vit. C
 β-Carotene
2O PREVENTION
 Prevention of invasive disease
 Early Detection & Treatment of pre-invasive
precursors.
 Involves screening.
 Cervical cytological screening (“Pap smear”)

 Colposcopy

 VIA
 VILI
PAP SMEAR
 The best screening tool for premalignant lesions is
cytology..
 The most common site if dysplasia is the T-zone
HOW IS IT PERFORMED?
 Two specimens are obtained with the pap smear…
I. An ectocervical sample performed by scrapping
the T-zone with a spatula
II. An endocervical sample obtained with a
cytobrash in a non pregnant woman or a cotton
tipped applicator in a pregnant woman.
WHAT CYTOLOGICAL SCREENING
METHODS CAN BE USED?
1. Conventional method: specimens are smeared
on a glass slide, which is placed in a fixative and
examined microscopically.
2. Thin layer - liquid based cytology : the
specimens are rinsed into a preserving solution
and are then deposited on a slide as a thin layer
of processed cells.

 Both methods are equivalent for cancer screening

but the liquid based method has the advantage of
doing reflex HPV DNA typing.
SCREENING PAP SMEAR
 Age < 21 yrs. - no screening regardless of sexual
activity. Due to Transient nature of most HPV infection & cervical
cancer is extremely rare in the first 2 decades of life.
 Age 21- start pap test with cytology alone without HPV
testing
 The frequency of recommended pap smears
 i. Age 21-29: repeat pap every 3 years with cytology alone
 ii. Age 30 to 65 – repeat pap every 3 yrs with cytology but
no HPV testing or repeat PAP every 5 years if both cytology
and HPV testing.
 For HIV +, screening done yearly until 65 to 70 years.
 Pap smears should be discontinued;
a. After age 65 yrs, if negative cytology and or HPV
tests for the past 10 yrs and no history of CIN 2,3 or
cervical carcinoma.
b. Any age if total hysterectomy and no history of
cervical dysplasia.
PAP SMEAR CLASSIFICATION
BETHESDA SYSTEM
Abnormal endocervical cells ( 1% of abnormal pap
smears)
DIAGNOSTIC APPROACHES TO
ABNORMAL PAP SMEAR
 Accelerated repeated pap… an option when finding ASC-US,…
repeat pap at 4-6 moths intervals until there are 2 negative pap
smears. If a repeat pap again is ASC-US or worse, do colposcopy.

 HPV DNA testing… also an option for finding ASC-US. Perform

a repeat conventional pap smear or can use the original liquid
based cytology specimen. Colposcopy performed if high risk
DNA found.
CLASSIFICATION OF
CERVICAL DYSPLASIAS

HISTOLOGIC APPEARANCE OF CERVICAL
DYSPLASIA WITH PROGRESSIVE SEVERITY
ADVANTAGES OF PAP SMEAR

 Simple to perform
 Minimal morbidity
 Readily accepted among women
 79% of women in US > 18 years of age had PAP in preceding
3 years
 25.2 % of educated women in Kenya
 Significant lead-time (pre-malignant phase). Treatment is clearly
effective in reducing incidence of invasive disease!
DISADVANTAGES OF PAP SMEAR

 False negative rate range btw 10 to 50%

 Invasive cancer might show negative cytology in 50%
 Opportunistic screening
 Relies on health care provider and/or patient to undertake screening at
regular intervals
 Marginalized groups of individuals remain at risk
In 50% newly diagnosed cancer there is no PAP smear ever or last
PAP more than 5 years previous
COLPOSCOPY

 Colposcopy is a medical diagnostic procedure to examine an

illuminated, magnified view of the cervix as well as the vagina
and vulva.
 Colposcopy- magnifies the cervix 10- 15 times.

 Aided by acetic acid which makes the vascular patterns more

visible.
 either:
i. Satisfactory/ adequate- entire TZONE visualized
ii. Unsatisfactory/inadequate- entire TZONE cannot be
visualized
 Indicated for women at risk for cervical cancer based on:
 Abnormal cervical cytology
 DES exposure
 Suspicious symptoms/physical signs
 High-risk HPV DNA
 Goal: To confirm or refute presence of significant lower genital
tract neoplasia
 Facilitates biopsy of suspicious lesions as visualized using
acetic acid and magnification
VIA & VILI
 VIA: examination of the uterine cervix after application of 3-5%
acetic acid.
 Tumor cells have high proteins content that is denatured by acetic
acid which then appear white.

 VILI: Generally performed after the VIA test and requires the
application of Lugol's iodine, a compound that reacts with
glycogen resulting in a brown or black coloration.
 Normal cells have glycogen and take iodine to be brown or black
in colour, abnormal tumor cells do not take iodine and appear
yellow in colour
SATISFACTORY COLPOSCOPY
UNSATISFACTORY COLPOSCOPY
VIA NEGATIVE
…
VIA POSITIVE
…
VILI NEGATIVE
VILI POSITIVE
 Endocervical curettage (ECC). All nonpregnant
women undergoing colposcopy which shows
metaplastic endothelium entering the endocervical
canal will undergo ECC to rule out endocervical
lesions.

 Ectocervical biopsy- lesions identified on ectocervix

by colposcopy are biopsied and sent for histology.
 Compare pap smears and biopsy - to ensure the level of severity
is comparable.
 Cone biopsy- if a pap smear is worse than histology,( suggesting
the site of abnormal pap smear cells are not biopsied), then a cone
biopsy is performed.
 Other indications for conization are
 Abnormal ECC histology

 Lesion seen entering ECC

 Biopsy showing microinvasive carcinoma of cervix

NB… risks of cervical stenosis and cervical incompetence

MANAGEMENT OF DYSPLASIA
ACCORDING TO HISTOLOGY
TERTIARY PREVENTION

 Effective treatment of precancerous lesions can help to

reduce the incidence of invasive cervical cancer
 Early Simple hysterectomy for stage 1A1, LEEP,
ablation or cone biopsies
 Radical hysterectomy in stage 1A2 to 2A
 END…..
 THANK YOU
 QUESTIONS?