Cervical Cancer Prevention in CEE and the NIS: The Way Forward. John Sellors, MD PATH (Program for Appropriate Technology in Health) Seattle, USA. Overview of Presentation. Global burden of disease Regional statistics and challenges Overview of screening technologies and programmatic issues
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John Sellors, MD
PATH (Program for Appropriate Technology in Health)
Age standardized rates per 100,000 (based on world population)
(Sellors et al., CMAJ 2000)
2 yearsNatural History of Cervical Cancer
Screening strategies are intended to identify these abnormalities.
**Koutsky et al., NEJM, ‘02
Barnabas and Garnett, ’02, unpublished
Fahey et al.
U. Harare/ JHPIEGO
11.7Accuracy of conventional cytology to detect HSIL
Conventional Pap test is still the only screening test ‘proven’ to reduce incidence and mortality rates of ICC.
CIN is slow growing.
Many low-grade CINs regress.
Abnormalities missed by one screening will probably be detected in next interval.
ICC usually due to lack of screening rather than cytologic errors.Pap Test Is Problematic But…
ThinPrep ‘proven’ to reduce incidence and mortality rates of ICC. (Cytyc)
automated LBC sample prep system
~60,000 selected cells distributed in a thin layer
smaller area than conventional Pap
specimens read optically or digitally
*FDA approved for screening
As of Sept. 2001
AutoPap 300 (Tripath) and Trac Cell 2000 (Accumed International)
automated LBC sample prep
visual intelligence computer technology
sorts by probability of abnormality
*FDA approved only for mandatory rescreeningLiquid-Based Cytology (LBC) and Computerized Reading
Pros ‘proven’ to reduce incidence and mortality rates of ICC.
randomly selected cells in thin layer
better quality fixation and less ‘debris’
quicker reading - 3.2 min (double for Pap)
amenable to HPV testing and immunohistochem. for different antigens
more costly than Pap - worse compliance?
retraining needed for smear-takers and pathology lab
morphology changesLiquid-based Cytology: Other Considerations
HC IITM (Digene, Inc) is the only FDA approved, commercially available test.
Sensitivity and specificity of HC II for the detection of CIN 2/3 infour specimen types
n=200, colposcopy clinic
Sellors et al, 2000
a CIN 2/3 in
VIA 77% 85%
VILI 92% 85%
*for high grade disease
Sankaranarayanan et al, Int J Cancer 2004
Proportion of HC II positive specimens with viral levels above a cutoff (RLU > 15.0)
n=200, colposcopy clinic
CIN System above a cutoff (RLU
CIN 3 includes CIS
‘Condyloma/HPV effect’ separated from CIN 1 (together had been ‘Mild Dysplasia’)
HSIL contains CIN 2 & 3
LSIL includes HPV
ASCUS distinct from atypia due to repair, reaction, infectionImportant Changes in Terminology