Early Detection of Breast & Genital Tract Malignancies

1. Early Detection of Breast & Genital Tract Malignancies

2. Screening…? • Organized identification • High coverage of a target population • Continuous quality assessment. • Feasibility of treatment & follow up • Of a pre - clinical disease state • By a test that is repeated at a given interval

3. OR… • Screening can be defined as • The application of diagnostic tests or procedures • To asymptomatic people • For the purpose of dividing them into two groups: • those who have a condition that would benefit from early intervention • and those who do not.

4. An Ideal Screening Program… • Features of the disease • Significant impact on public health • Asymptomatic period during which detection is possible • Outcomes improved by treatment during asymptomatic period • Features of the test • Sufficiently sensitive to detect disease during asymptomatic period • Sufficiently specific to minimize false-positive test results • Acceptable to patients • Features of the screened population • Sufficiently high prevalence of the disease to justify screening • Relevant medical care is accessible • Patients willing to comply with further work-up and treatment

5. Recommended Screening Cervical Carcinoma Breast Carcinoma Colorectal Carcinoma Not yet , for… Ovarian Cancer Bronchogenic Carcinoma Skin cancer Oral Cancer Endometrial Cancer To screen or To screen not ?

6. Effective Screening Program • Should be tailored to suit the principles for national cancer control programs. We Should NOT copy other’s programs... Otherwise… Too much money & effort will be spent with minimal impact on the incidence & mortality from the disease.

7. Cervical Carcinoma • Second in frequency among women cancers. • It is still the most frequent cancer in the developing countries. • 400,000 new cases identified each year • 80% of new cases in developing countries • At least 200,000 women die each year • Screening programs reduced the mortality from cancer cervix in developed countries by 70%.

8. Why… Source: American Cancer Society, 2000 Incidence And Mortality For Cervical Cancer Vs Breast Cancer, [United States, 2000]

9. years 57% 11% LSIL HSIL >10% Invasive Cancer 35% 1% Natural History Of Cervical Cancer HPV Infection Source: PATH, 2001

10. HPV infection • Condyloma Accuminata • Exophytic • Frond like surface • Lesion may be single or multiple • Located within or outside the transformation zone

11. HPV infection • Subclinical HPV • Flat lesions undetectable naked eye • Best assessed after acetic acid application • Shinny, snow-white lesions • Irregular outline • Satellite lesions beyond the transformation zone • Strong or partial uptake of Lugol’s iodine

12. What Makes the Cervix Vulnerable?

13. Normal Cx Mild Dysplasia(CIN I) Moderate Dysplasia(CIN II) Severe Dysplasia (CIN III / CIS) Invasive Disease HPV and Genital Cancer

14. Elements of Screening of Cervical Cancer

15. History Taking • Ask the client if she has experienced any of the following symptoms: • Abnormal vaginal discharge • Contact bleeding • Irregular vaginal bleeding • Ask about risk factors. • Start of sexual intercourse at a young age • Multiple sexual partners (ask in special circumstances: need extra skills). • Male sexual partner having other partners (ask in special circumstances: need extra skills) • Clinical history of infection by human papilloma virus or the presence of condylomata acuminate • Note all findings in the medical record

18. Acetic Acid –enhanced Visual Inspection of the Cervix “VIA” 1. Acetic acid coagulates mucus, which becomes easier to remove. -allows a better view of the cervix 2. Acetic acid constricts the superficial vessels and blows up the columnar papillae so that they become pale. allows a better view of the squamocolumnar junction 3. Acetic acid causes dehydration of the cells and coagulation of cellular proteins, thereby reducing the transparency of the epithelium allows a better recognition of dysplastic epithelium

19. Abnormalities Seen After Acetic Acid • Aceto-white • Margins and surface • White gland openings • Mosaic & punctation • Abnormal vessels

20. What May Be Acetowhite • NOT All acetowhite lesions are cancer • Any of these epithelial changes can become acetowhite • Healing or regenerating epithelium • Congenital transformation zone • Inflammation • Immature squamous metaplasia • HPV infection • SIL • Adenocarcinoma • Invasive squamous cell carcinoma

44. VIA: Conclusions • Alternative to cytology or HPV testing • Effective in identifying precancerous disease • Identify cancers • Effective in ruling out disease • Specificity of VIA is likely to depend on: • training intervention • presence of STDs in population screened • importance placed on picking up diseased cases • Positive predictive value of VIA can be increased through sequential or risk-based triage screening

45. Visual inspection with Lugol’s iodine (VILI) Original source: Alliance for Cervical Cancer Prevention (ACCP) www.alliance-cxca.org

46. What does VILI involve? • Performing a vaginal speculum exam during which a health care provider applies Lugol’s iodine solution to the cervix. • Viewing the cervix with the naked eye to identify color changes on the cervix. • Determining whether the test result is positive or negative for possible precancerous lesions or cancer.

47. How VILI works: • Squamous epithelium contains glycogen, whereas precancerous lesions and invasive cancer contain little or no glycogen. • Iodine is glycophilic and is taken up by the squamous epithelium, staining it mahogany brown or black. • Columnar epithelium does not change color, as it has no glycogen. • Immature metaplasia and inflammatory lesions are at most only partially glycogenated and, when stained, appear as scattered, ill-defined uptake areas. • Precancerous lesions and invasive cancer do not take up iodine (as they lack glycogen) and appear as well-defined, thick, mustard or saffron yellow areas.

48. What infrastructure does VILI require? • Private exam room • Examination table • Trained health professionals • Adequate light source • Sterile vaginal speculum • New examination gloves, or HLD surgical gloves • Large cotton swabs • Lugol’s iodine solution and a small bowl • Containers with 0.5% chlorine solution • A plastic bucket with a plastic bag • Quality assurance system to maximize accuracy

49. Categories for VILI test results:

50. VILI: test-negative • The squamous epithelium turns brown and columnar epithelium does not change color. • There are scattered and irregular, partial or non-iodine uptake areas associated with immature squamous metaplasia or inflammation. Photo source: IARC