Screening for Female

Genital Tract Malignancy

Screening Generally
Is to seek about certain
problem in certain
high risk gp.
Validity of Screening Test
Validity of test determined by ability to
correctly categorise subjects to test-
positive or test-negative
Disease status


Test result Positive Negative Total
Positive a b a+b
Negative c d c+d
Total a+c b+d

Validity of Screening Test cont...
Sensitivity = ability of test to give a positive
result when disease is present
= a / a+c

Specificity= ability of test to give a negative
result when disease is absent
= d / b+d
Predictive value is determined by sensitivity &
specificity and also by the prevalence of
preclinical disease
Positive predictive value
= probability that a person with a positive test
actually has the disease = a / a+b

Negative predictive value
= probability that a person with a negative test is
truly disease-free = d / c+d
Validity of Screening Test cont...
When to Suspect
Gynecologic Cancer
Woman with:
Ovarian mass/cyst
Growth or ulcer of cervix, vagina or vulva
Abdominal mass, increased abdominal girth
Postcoital bleeding
New onset of hematuria or renal failure
New onset of bowel obstruction
When to Suspect
Gynecologic Cancer cont.
Premenopausal woman with:
Irregular menses
Women older than 35 or with
long history of irregular
menses
Postmenopausal woman with:
Vaginal bleeding
Abnormal vaginal discharge
Concept
Prevention is better than cure.
Cancer cx. Screening programs
are in adulthood
But ov. cancer programs are
still in relative infancy, why?
Phases of Tumourgenesis
Dysplasia Invasive
asymptomatic
Invasive
symptomatic
Cancer cx.
End. C.
As cancer ovary
Normal cells
Most Cancers Develop
In The Unscreened
And The
Underscreened.
CRITERIA FOR SCREENING
Disease:
Must be serious enough
Must be widespread enough
Must be fairly reliably diagnosable
Must be treatable
Must be affordable
Hopefully legally defensible
Criteria for Screening Test
1. Simple & quick
2. Capable of being performed by paramedics
3. Inexpensive
4. Acceptable to population
5. Accurate
6. Repeatable
7. Sensitive
8. Specific
Incidence of Gynecologic
Cancers in Egyptian Women with
cancer
0
5
10
15
20
25
Breast
Cancer
Cervical
Cancer
Ovarian
Cancer
Uterine
Cancer
Percent
Source: GLOBOCAN 2000.
Epidemiology of Cervical
Cancer

500,000 new cases identified each
year
80% of the new cases occur in
developing countries
At least 200,000 women die of cervical
cancer each year
Cervical cancer is the third most
common cancer worldwide
Magnitude of the Problem: -
Epidemiology of Cervical
Cancer cont.
Most common female cancer in
developing countries:
leading cause of cancer death in
women.
80-85% cases seen at late incurable
stages.
High risk patients:
1)Exo cx:
High parity?!!
Multiple partner
Genital infections
HPV & HSV II
Smoking
Sexual behaviour of
womens partner
Epidemiology of Cervical
Cancer cont.
2. Endo cx
Like endometrial C.
Age
Obesity
D.M.
Hypertension
Nulligravida &
Virgin
Low parity
Tamoxifen
Epidemiology of Cervical
Cancer cont.
Pathogenesis of CIN
Columner epith.
St.sq. epith.

CIN
Dysplasia
Dysplasia by
oncogen
Chlamydia H.S.V.
- H.P.V


Micro-organism.
Morphological Changes of
Cervical Cancer
Prevention of Cervical Cancer
Cervical cancer is a preventable disease
Primary prevention:
Education to reduce high risk sexual
behaviour
Measures to reduce/avoid exposure to HPV
and other STIs
Secondary prevention:
Treatment of precancerous lesions before they
progress to cervical cancer (implies practical
screening test)
Now : HPV vaccines.
Secondary Prevention of
Ca.Cx.
Key Point is to detect precancerous
lesions BY
- A good screening method

- PAP smear test is considered to be the
gold standard Has limitations ?
Alternatives to Pap Smear What are they?
Why screening for cervical cancer?
1. Is relatively common in
unscreened women.
2. Has a relatively good prognosis if
found early stage in its natural
course of disease.
3.Has a characteristic natural course
that is a slow progression through
a premalignant stage.
Why screening for cervical cancer? Cont
4. A premalignant stage can be
detected by noninvasive means (the
Pap smear , cervicography&VIA).
5. There are effective treatment
modalities to eradicate
premalignant lesions and early
invasive cervical cancer.

Screening by Pap. Cx. Smear
unscreened female have ten fold
risk > screened female


- Every sexually active female (18-35 y)
- Specially, high risk group.

- Annually up to the age of 35y
- No need to extend screening > 35y if smear is N.
- At each pregnancy
- If new risk factors appear after 35y.
d- If + ve smear colposcopy
When: c.
b. To whom :
Importance: a.
Alternatives to Cytology
Visual Inspection of the cervix:
Unaided: Downstaging.
Aided with acetic acid: VIA:
Naked eye
Aided with acetic a and magnification( VIAM)
Cervicography
Colposcopy
Speculoscopy
Automated pap smear
HPV DNA test
Infrared Spectroscopy & Laser Fluorescence
Limitations of Pap Smear
Complex laboratory test
Requires trained cytotechnician for reading
and pathologist for review
Continuous monitoring needed to maintain
high-quality results
Reports often take minimum 1-2 weeks to
obtain
Follow-up of women is difficult
Usually available only in large cities in many
countries
COMPARISON BETWEEN
SCREENING METHODS
Source-Program for Appropriate Technology in Health [PATH] 1997.
Effective Safe Practical Affordable Available
Visual
Inspection:
AA
Yes Yes Yes Yes Yes
Visual
Screening:
Unaided
No Yes Yes Yes Yes
Automated
Pap Screening
Yes? Yes ? No No
HPV
Screening
Yes Yes ? ? Yes
Cervicography Yes? Yes ? ? Yes
HPV Vaccine ? ? Yes ? No

VIA ..represents a proven,
simple means of identifying
cervical intraepithelial
neoplasia in developing
countries.
Commentary: P. Blumenthal. Detection of cervical
intraepithelial neoplasia in developing countries.
The Lancet March 13, 1999
Comparison between :
VIA and Cytology
Sensitivity(%) Specificity (%)
Cytology 47--62 60-95

VIA 76-84 79-83

VIA& PAP SMEAR
Recent studies have demonstrated that
"VIA is a safe, simple and effective
adjunct to the Papanicolaou smear
for cervical cancer screening and
can be helpful in reducing referrals
for colposcopy without
compromising quality of care.
MEANING OF Acetowhite
All acetowhite patches are not cancer:
Any of these epithelial changes can
become acetowhite:
Healing or regenerating epithelium
Congenital transformation zone
Inflammation
Immature squamous metaplasia
MEANING OF
Acetowhite cont.
HPV infection
CIN / CGIN
Adenocarcinoma
Invasive squamous cell
carcinoma

Endometrial Cancer
Screening
Screening of unproven benefit
Transvaginal ultrasound
examinations
Helpful in evaluating vaginal bleeding
Endometrial sampling
Risks include discomfort, bleeding,
infection, uterine perforation (rare)
PRE-INVASIVE LESIONS OF END.
Malig.
Potential
Pathology
Little or none
Replacement of
usual gland cell by
cells having cilia,
sq. cells
Metaplasia
1-3% over 15y
Irregular glands,
minor budding or
out pouching
Simle
hyperplasia
3-4% over 13y
Back to back
glands, budding,
papillary process,
minor stratification
Complex
hyperplasia
23% over 10y
Atypisim + back to
back + budding
Atypical
hyperplasia
Early Cancer Detection of
ENDO.
Fractional curettage
Isaac Aspiration curette
Aspiration cannula (cytology)
Manual Vacum aspirator(MVA).
Ovarian Cancer
Screening
Benefit to screening is unproven
Annual bimanual gynecologic
examination
Transvaginal ultrasound
CA 125 serum levels
Screening may result in more
unnecessary surgeries than new
ovarian cancers
Screening For Early Diagnosis
Ovarian Malignancy
Modalities:
1- Clinical.
2- Cul-de-sac aspiration.
3- Imaging techniques.
4- Tumour markers.
5- Radio immuno scientography.
6- Multimodels.
PRE-INVASIVE LESIONS OF
VULVA
Risk factor:
Postmenopausal +
Vulva dystrophy VIN



Vulval infectious disease.
Chronic granulomatous.
VIN: I, II & III
Paget`s: may be associated with paget`s of breast.
Dermatoses
Leukoplekia
Krausons vulva
Lichen simplex
Early Cancer Detection
of Vulva
Colposcopy Taulidine blue VIN
Biopsy Acetic Acid
Breast
Population - women, age 20 +

Breast self-examination Monthly,
starting at age 20

Clinical breast examination Every three
years, age 20-39

Mammography Annually, starting at age 40 *

Beginning at age 40, annual clinical breast examination should
be performed prior to mammography. Most other affluent
countries recommend mammography every other year between
ages 50 and 70.