VIA and Cervical Cancer Flashcards
How common is cervical cancer?
- 4th most common cancer among women globally
- 2nd most common in Africa
Where is cervical cancer located?
85-90% located at Squamocolumnar junction
Incidence of cervial cancer in Malawi?
Incidence: 72/100,000
Mortality: 54/100,000
5-year survival rate 2.9%
(Uganda 17.7%, Zimbabwe 26.5%)
Cervical cancer accounts for almost 20% of cancers in woman in LIC, in Malawi over 40%!
Incidence of cervical cancer in the world?
Worldwide 660,000 cases/year of which 53% dies
Why is cervical cancer worse in LMIC?
- HIV-prevalence (Malawi 12% women HIV+)
- Lack of access to national HPV-vaccination, cervical screening and treatment services (Malawi 2020 only 10% screened)
- Socio-economic determinants
Describe the anatomy of the cervix?
- The endocervix is composed of a thin secretory glandular epithelium.
- The ectocervix consists of a stronger stratified squamous epithelium.
- Ectropion mainly in early adulthood
Pathophysiology of cervical cancer?
Transformation zone has high mitotic activity, so vulnerable to HPV-driven neoplastic change if persistent infection
- glandular epithelium pushed out in to ectocervix (u.i.o. estrogen) and undergoes physiological squamous metaplasia (u.i.o. low pH)
- Occurs in 80% of premenopauzal women
- Becomes endocervical in PMP women)
How HPV causes cervical cancer?
HPV-viruses suppress p53 and rBp.
1. P53: This protein acts as a tumor suppressor, which means that it regulates cell division by keeping cells from growing and dividing (proliferating) too fast or in an uncontrolled way.
2. rBp (retinoblastoma protein): prevent excessive cell growth by inhibiting cell cycle progression until a cell is ready to divide.
The 4 major steps in cervical cancer development are?
- oncogenic HPV infection of the epithelial cells at the cervical transformation zone
- persistence of the HPV infection
- progression of a clone of epithelial cells from persistent viral infection to pre cancer cells
- development of carcinoma and invasion through the basement membrane
What is cervical intraepithelial neoplasia?
- CIN will always develop prior to the cervical cancer and only arises due to oncogenic HPV-infection!
- So no cervical cancer without hrHPV.
- Untreated high grade CIN (2 or 3) leads to cervical cancer in 20-30% of women over 10 years.
Main cause of cervical cancer?
- Hr-HPV detected in 99.7% of cervical cancer cases
> HPV-16 and HPV-18 found > 70% of the cases.
> Other hr-HPV: 6, 11, 31, 33, 45, 52, 58. - Increase the risk of cancer via DNA changes: Suppress p53 & Rb1 genes
- Usually cleared asymptomatically for most people.
Risk factors for contracting HPV?
- Early onset of sexual activity
- Multiple sexual partners
- Having a high risk sexual partner
Relationship between HPV and HIV?
HIV increases the risk of contracting HPV
1. Higher prevalence of HPV infection
2. Tend to have persistent infection with HPV
3. Tend to have infection with multiple types of HPV
Note: Cervical cancer is an AIDS defining illness in HIV infected women
Risk factors for cervical cancer?
- HPV
- HIV
- History of STI
- Immunosuppression (h/o transplant)
- Early age of 1st birth (<20 years)
- Parity greater than 3
- History of vulvar/vaginal cancers (HPV related)
- Low socioeconomic status
- Oral contraceptive use
- Cigarette smoking (reduces viral clearance)
Signs and symptoms of cervical cancer?
Usually asymptomatic in the early stages → need for screening!
1. Unusual/abnormal vaginal bleeding
- post coital, intermenstrual, post menopausal
2. Abnormal vaginal discharge (AVD)
- foul-smelling, ↑ quantity, change in texture +/- blood
3. Vaginal dyscomfort
4. O/E: roughened/hard cervix, los of fornices / fixed cervix
Diagnosis?
Part of routine screening for cervical cancer:
1. HPV-DNA Testing
2. Visual Inspection with Acetic Acid
3. Papanicolaou Smear (PAP Smear) = cytology
4. Colposcopy
Late signs and symptoms?
- Loss of appetite, weight loss, and fatigue
- Persistent pain in the pelvis, back and legs
- Leg swelling (lymphatic edema)
- Genitourinary symptoms:
- difficulties/painful urination or passing bloody urine
- difficulties/painful bowel movements or bloody stools
What is part of the routine screening for diagnosing cervical cancer?
- HPV-DNA Testing
- Visual Inspection with Acetic Acid
- Papanicolaou Smear (PAP Smear) = cytology
- Colposcopy
Efficacy of HPV screening?
Sensitivity 96%
Specificity 91%
Note: Not possible in MDH
What is VIA screening?
Visual Inspection of the Cervix with Acetic Acid
Procedure for VIA?
- Ensure privacy
- Lithotomy position
- Insert specula at 45◦ angle
- Visualize cervix & clean
- Apply 3-5% vinegar with cotton swab
- Wait for 1-3 minutes
- Inspect the cervix for white lesions
VIA positive management?
- cryotherapy
- Loop Electrosurgical Excision Procedure (LEEP)
- Send sample for histology
When to do cryotherapy when VIA is positive?
- Entire squamocolumnar junction is visible
- Entire lesion is visible and does not extend into the endocervix
- Lesion covers less than 75% of ectocervix
Follow up of cryotherapy?
- Follow up 1 year after cryotherapy
- Treat infection with antibiotics
If patient not eligible for cryotherapy what do you do?
- Loop Electrosurgical Excision Procedure (LEEP)
- Send sample for histology
Follow up for LEEP?
Follow up 6 weeks after LEEP for review of pathology results:
1. If results show CIN1 or less, rescreen within 3 years (1 yr if HIV+)
2. If results show CIN2 or CIN3, rescreen after 1 year.
Diagnosis for patients with visible lesion in the cervix/vagina?
- Direct biopsy and send sample for histology
- Perform a vaginal and rectal examination
What investigations to order for patients with visible lesion in the cervix/vagina?
- Bloods: FBC, U&C&E, LFTs, PITC for HIV.
- Imaging: Abdominal & pelvic US, CXR (MRI scan)
Management if abnormal PAP smear?
- Colposcopy with directed biopsies
- If no lesion seen perform endocervical curettage
Management if abnormal biopsy results?
- CIN1: Rescreen after 1 year
- CIN2: Offer cryotherapy or LEEP
- CIN3: Offer cryotherapy or LEEP
- If HIV positive, offer Hysterectomy
Management of invasive cancer?
- Invasive cancer: Complete FIGO staging
- Management depends on the stage
What to take note for VIA+ pregnant women?
- PAP Smear can be done (without endocervical sampling)
- Do NOT do LEEP, cryotherapy or cervical biopsy
What is FIGO staging?
the International federation of gynecology and obstetrics staging for cervical cancer (FIGO) is based on the cancers size, location and spread
- higher stages indicate more advanced disease and a a less optimistic outlook
Primary prevention?
- HPV vaccine for girls aged 9-14yrs
- Health education on healthy sexuality (both girls and boys)
- Promotion of condom use
- No smoking
- Promote cervical cancer screening
HPV vaccine doses?
Two doses ofHPV vaccine, given 6 to 12 months apart.
Examples of HPV vaccines?
- Gardasil (Quadrivalent)
- Targets HPV types 6, 11, 16 and 18 - Gardasil 9
- Targets HPV types in Quadrivalent as well as 31,33,45,52 and 58 - Cervarix (Bivalent)
- Targets HPV 16 and 18
Secondary prevention?
Screen and treat where necessary
1. Papanicolaou Smear (PAP Smear)
2. HPV-DNA Testing
3. Colposcopy
4. Visual Inspection with Acetic Acid
Tertiary prevention?
Treat where possible:
1. Surgery
2. Chemotherapy
3. Radiotherapy
4. Palliative care
Misconception of cervical cancer?
Misconception that HIV non-reactive patients are not at risk for cervical cancer
Barriers to getting screened?
- Rumours about VIA-screening being painful & dangerous
- Lack of husband support (supposed infertility and 4 weeks abstinance)
- Waiting time, transport issues, unkind treatment
