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VIA Refresher 1

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VIA Refresher Part 1
Angelica Agapito, MD
Cervical
Cancer
Prevention
2
Global Burden of Cervical Cancer
Every 2 minutes,
a woman dies of cervical cancer.
FSM
Incidence: 493,000 new cases per year; 245,000 in Asia (50%)
< 13.6*
< 23.5*
< 37.9*
< 47.3*
< 126.6*
50% deaths/year (83% from Asia)
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Ferlay J et al. Globocan 2002. IARC 2004; Parkin DM et al. eds. Cancer Incidence in Five Continents,
Vol. VIII. IARC, 2002; http://www.who.int/healthinfo/statistics/bodprojections2030/en/index.html;
3
Greimal E et al. Gynecol Oncol 2002;85:140–7
*Rate per 100,000 population (all ages)
Situation in Yap
LEADING CANCER SITES IN
WOMEN
ORAL (1)
BREAST(3)
UTERUS (5)
CERVIX (2)
OVARY (4)
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4
Situation in yap
 Incidence high
 34/100,000
 72% die in 5 years
 2/3: late stage
 Actual situation may even be underestimated
5
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The 4 Most Common Cancercausing Virus Types
 HPV virus types
16 and 18
account for 71%
of all cervical
cancer cases
worldwide1
 HPV types 45 and
31 account for an
additional 9%
6
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1. Munoz N, Bosch FX. Et al IJC 2004
Natural History: From Infection
to Cervical Cancer
Years
Months
80%
Normal
HPV infection CIN I
epithelium
CIN 2
CIN 3
Invasive cervical c
Pre-cancerous
lesions
From incident to persistent HPV infection
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CIN = Cervical intraepithelial neoplasia
7
Monsonego J (ed): From Science to Practice. 2006, pp I-XII
Risk Factors
 Sexual activity before age 20
 Multiple sexual partners
 Exposure to STI
 Mother and sister with cervical cancer
 Previous abnormal Pap smear
 Smoking
 Immunosuppression
 HIV/AIDS
 Chronic corticosteroid use
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Who Gets Cervical Cancer?
 Every woman is
at risk.
 Usually in their
mid to late
reproductive
years
 80% of women
who get cervical
cancer live in
developing
countries
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Prevention:
Have a Healthy Lifestyle
 Regular exercise
 No smoking
 Eat a balanced diet
 Get enough rest
 Avoid stress
 Have a mutually
monogamous
relationship
 Regular medical checkup
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Vaccination
 Against HPV
 Reduce infection
that may cause
cancer
 Protective against
only some types
of HPV
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Who Would Benefit from Screening for
Precancerous Changes?
 ALL Women would benefit from screening for
precancerous changes.
 Only about 5% of women in developing
countries have been screened for cervical
cancer in the past 5 years
 Women who are not screened and treated for
precancerous changes get cervical cancer
 Approximately 70% of women in the US and
European countries have been screened for
cervical cancer in the past 5 years
 Screening and treatment has helped reduce
invasive cervical cancer incidence by as much
as 90%
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When Should a Woman Be
Screened for Cervical Cancer?
 Every woman should be screened for cervical cancer at
least once sometime during her life
 Women should be screened up to age 45 with VIA
 Screening should begin at least a decade before the
peak incidence of cervical cancer in a country
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Limitations of Pap Smear
 Complex laboratory
test
 Requires trained
cytotechnician for
reading and pathologist
for review
 Reports often take 1-6
weeks to obtain
 Follow-up of women is
difficult
 Usually available only
in large cities in many
countries
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Potential Alternatives to
Pap Smear
VIA/VIAM1
Yes
Yes
Yes
Yes
Yes
Automated Pap Smear
Yes
Yes
No
No
No
HPV/DNA Test
Yes
Yes
No
No
No
Cervicography
Yes
Yes
No
No
No
1
Visual inspection of the cervix using acetic acid (VIA) and with magnification (VIAM).
Source: PATH 1997.
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COMPARING VIA AND PAP SMEAR
Zimbabwe CCS Study
Phase 2 Results
TEST
SENSITIVITY
(%) *
SPECIFICITY
(%) *
POSITIVE
PREDICTIVE
VALUE (%) *
NEGATIVE
PREDICTIVE
VALUE (%) *
VIA
(n=2,130)
77
(70-82)
64
(62-66)
19
96
Pap
Smear
(n=2.092)
44
(35-51)
91
(37-51)
33
94
*95% Confidence Interval
Source: University of Zimbabwe/JHPIEGO Cervical Cancer Project 1999
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Recent studies have
demonstrated the potential of
Visual Inspection of the cervix
with Acetic Acid (VIA) as an
alternative test to Pap smears
in the identification of cervical
lesions.
•Abwao, et al 1998
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Cancer Project, 1999
• Sankaranarayanan et al 1999
• Denny et al, 2000
• University of Zimbabwe/JHPIEGO
Cervical
• Ngelangel et al , 200
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1
VIA
Visual Inspection with Acetic
Acid
 best alternative to
Pap smear (DOH,
UP-PGH National
Study, 2000)
 DOH
Administrative
Order 2005:0006
 VIA as Primary
Screening Tool
for the
Philippines
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VIA
• Looking at the cervix
to detect
abnormalities after
applying dilute (35%) acetic acid
(vinegar)
• Acetic acid
enhances and marks
a precancerous
lesion or cancer by
turning it to a whitish
hue (acetowhite
change).
20
Normal
VIA positive lesion
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Why Use VIA in Low-Resource
Settings?
 Pap smears are usually not widely available in lowresource settings
 Testing for the presence of HPV is available only on a
very limited basis
 VIA appears to be at least as effective as Pap
smears in identifying women with precancer or
cancer
 VIA-based cervical cancer screening involves fewer
logistic and technical requirements than Pap smear
based screening
 Clinical decisions can be made immediately
 Less patients are lost to follow up because it utilizes a
Single Visit Approach
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How Does VIA Work?
 Counseling about the procedure
 Examination by a trained professional
 A speculum is inserted into the vagina
 3-5% acetic acid (vinegar) is applied to
the cervix causing little or no discomfort
 The cervix is inspected using the naked
eye for acetowhite changes that may
indicate a treatable precancerous lesion
 Any acetowhite changes are noticeable
within a few minutes after applying the
acetic acid
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Screening/testing itself has no
intrinsic preventive value.
TESTING
TREATMENT
For a program to be effective…
Testing must be linked to
treatment.
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COUNSELING
+
SCREENING
= SINGLE VISIT
+
APPROACH
TREATMENT
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Cryotherapy Unit
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Treating Women with
Unconfirmed Disease

Because of low morbidity associated with cryotherapy,
treatment of all women with VIA-positive result may be
cost-effective by preventing disease from progressing to
cervical cancer




26
In many settings, additional testing is not available or
easily accessed
The inconvenience to women of returning for additional
visits often results in loss to follow-up
Cryotherapy has the potential to significantly reduce the
probability of developing cancer or precancerous lesions
Low morbidity and complications associated with
cryotherapy
Cryotherapy is being used to treat cervicitis and other 6/28/2019
non cancer-causing lesions.
Normal Anatomy of the
Vulva, Vagina, and Cervix
Examination of the female
patient
 Includes:
• Observation of the external genitalia.
• Observation of the cervix and vagina through a
speculum.
• Palpation of the cervix, uterus, and ovarian areas.
• Sometimes rectal examination.
Examination of the female patient
 Demonstrate
 Privacy
 Explain procedure
 Answer questions
 consent
THE CERVIX
SIZE AND SHAPE OF THE CERVIX
 The cervix is the opening of the uterus.
 It is cylindrical in shape and is normally 3–4 cm
long and 2.5–3.5 cm in diameter.
 The external os of the cervix opens into the vagina.
 The internal os is the point at which the cervix and
uterus meet, above the vagina.
Parts of the cervix
 Ectocervix—exterior to
the external os and
readily visible during
speculum exam.
 Endocervix—the portion
above the external os
and not easily seen.

Endocervical canal—
traverses the
Endocervix, connects
the uterine cavity with
the vagina; extends from
the internal to the external
os.
External cervical os
 The cervix and the external os vary in size and
shape depending on the woman’s age, parity,
pregnancy, and hormonal status:
 Small, round pinhole in the prepubescent girl or
nulliparous woman.
 Can be a large, irregularly shaped, gaping slit in
parous women.
External cervical os
 Nulliparous
 Parous
Speculum examination &
visualization of the cervix
Composition of the cervix
 The cervix is composed of dense, fibromuscular
connective tissue.
 It is covered by two types of epithelium:
 • Stratified squamous epithelium (usually covering
large areas of the ectocervix).
 • Columnar epithelium (covers the endocervix and
may also be visible on the ectocervix).
 The two kinds of epithelium meet at the
squamocolumnar junction (SCJ).
Squamocolumnar junction (SCJ)
 The SCJ is the place where the squamous and columnar
epithelia meet.
 It often appears as a sharp line of demarcation with a
slight difference in height between the two kinds of
epithelium.
Squamous metaplasia
 Metaplasia refers to the change or replacement of one
type of cell by another.
 Squamous metaplasia is a physiologic process that
occurs on the cervix—the columnar cells on the side of
the SCJ closest to the os are gradually replaced with
squamous cells.
 This process results from the exposure of the columnar
cells to the acid environment of the vagina.
Area of T-zone
Most susceptible
to carcinogens
NORMAL
CERVIX
The cervix
Effect of estrogen
 Cervical anatomy is influenced by estrogen—the location
of the SCJ changes throughout a woman’s life in
response to changes in estrogen levels.
 As a result of increased estrogen levels (menarche, oral
contraceptive use, pregnancy):
 Cervix swells and enlarges.
 Eversion of the endocervical epithelium out onto the
ectocervix occurs, pushing the SCJ away from the os,
making it easier to see.
 As a woman ages, the SCJ retreats inward toward the
internal os, making it more difficult to see.
Age Related Changes in the Cervix:
Puberty – Reproductive Years
 Increasing levels of estrogen and progesterone
 Columnar cells at the SCJ gradually transform into
squamous cells (SQUAMOUS METAPLASIA)
 Transformation Zone-different stages of squamous metaplasia
Transformation Zone(T-zone)
os
NEW SQUAMOCOLUMNAR
JUNCTION
ORIGINAL SQUAMOCOLUMNAR
JUNCTION
Columnar cells
Squamous cells
Chapter 3: Pathophysiology of Cervical
Cancer
Transformation zone
 The transformation zone is the area on the cervix
between the original SCJ and the new SCJ.
 The TZ is covered by metaplastic squamous
epithelium—squamous epithelium that has replaced
the columnar epithelium that existed in that area.
Cervix at Puberty
Cervix during the
Reproductive Years
Postmenopausal cervix
 The maturation or development of the squamous
epithelium depends on the hormone estrogen.
 In postmenopausal women, the multiple layers do
not accumulate, and the squamous epithelium
thins, becomes atrophic, looks pale, and is
susceptible to trauma.
Mature squamous cells now cover nearly whole face of cervix
Cervix at
Menopause
Puberty
Reproductive
Area of T-zone
Most susceptible
to carcinogens
Menopause
VIA Questions
 Question 1: Is the cervix suspicious for cancer?
 Question 2: Is the Squamocolumnar junction visible?
 Question 3: Is the cervix VIA-positive or VIA-negative?
 Question 4: Point to the acetowhite lesions in the
cervix.
 Question 5: Is the patient a good candidate for
cryotherapy?
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To be continued…
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