Early Detection of Breast
&
Genital Tract Malignancies
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
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.
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
To screen or To screen not ?
• Recommended
Screening
– Cervical Carcinoma
• Not yet , for…
– Ovarian Cancer
– Bronchogenic
Carcinoma
– Skin cancer
– Breast Carcinoma
– Colorectal Carcinoma
– Oral Cancer
– Endometrial Cancer
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.
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%.
Incidence And Mortality For Cervical
Cancer Vs Breast Cancer, [United States,
2000]
192,000
200,000
150,000
100,000
40,200
50,000
12,900
4,400
0
Breast
Cervical
New Cases Per Year
Source: American Cancer Society, 2000
Breast
Cervical
Deaths Per Year
Natural History Of Cervical Cancer
HPV
Infection
years
57%
11%
LSIL
HSIL
Invasive
Cancer
35%
1%
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
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
What Makes the Cervix
Vulnerable?
HPV and Genital Cancer
Normal
Cx
Mild
Dysplasi
a(CIN I)
Moderate
Dysplasia
(CIN II)
Severe
Dysplasia
(CIN III /
CIS)
Invasive
Disease
Elements of Screening of Cervical Cancer
History
&
Raising Awareness
Visual Inspection
of the cervix / VIA
Colposcopy and Biopsy
Pap smear
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
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
Abnormalities Seen After Acetic
Acid
•
•
•
•
•
Aceto-white
Margins and surface
White gland openings
Mosaic & punctation
Abnormal vessels
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
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
Visual inspection with Lugol’s iodine
(VILI)
Original source: Alliance for Cervical Cancer Prevention (ACCP)
www.alliance-cxca.org
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.
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, illdefined 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.
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
Categories for VILI test results:
VILI Category
Clinical Findings
Test-negative
Squamous epithelium turns brown and
columnar epithelium does not change
color; or irregular, partial or non-iodine
uptake areas appear.
Test-positive
Well-defined, bright yellow iodine nonuptake areas touching the squamocolumnar junction (SCJ) or close to
the os if SCJ is not seen.
Suspicious for
cancer
Clinically visible ulcerative,
cauliflower- like growth or ulcer;
oozing and/or bleeding on touch.
VILI: test-negative
• The squamous epithelium
turns brown and columnar
epithelium does not
change color.
• There are scattered and
irregular, partial or noniodine uptake areas
associated with immature
squamous metaplasia or
inflammation.
Photo source: IARC
VILI: test-positive
• Well-defined, bright
yellow iodine nonuptake areas touching
the squamocolumnar
junction (SCJ).
• Well-defined, bright
yellow iodine nonuptake areas close to
the os if SCJ is not
seen, or covering the
entire cervix.
Photo source: IARC
VILI: Suspicious for cancer
• Clinically visible
ulcerative, cauliflowerlike growth or ulcer;
oozing and/or bleeding
on touch.
Photo source: IARC
Management options if the VILI result is
positive:
• Offer to treat immediately, (without colposcopy
or biopsy, known as the “test-and-treat” or
“single-visit” approach).
• Refer for colposcopy and biopsy and then offer
treatment if a precancerous lesion is confirmed.
Management options if the VILI
result is suspicious for cancer:
• Refer for colposcopy and biopsy and further
management. Further management options
include:
– Surgery
– Radiotherapy
– Chemotherapy
– Palliative care
Strengths of VILI:
• Simple, easy-to-learn approach that is minimally
reliant upon infrastructure.
• Low start-up and sustaining costs.
• Many types of health care providers can perform
the procedure.
• High sensitivity results in a low proportion of
false negatives.
• Test results are available immediately.
• Decreased loss to follow-up.
Limitations of VILI:
• Moderate specificity may result in over-referral
and over-treatment in a single-visit approach.
• Less accurate when used in post-menopausal
women.
• There is a need for developing standard training
methods and quality assurance measures.
• Rater dependent.
The Alternative…Downstaging !!!
The detection of the disease at an
earlier stage when still curable…
Just
Insert a speculum and look at the
cervix
Warning signs of early cervical
cancer
1. Yellowish and friable epithelium
2. Abnormal contour
3. Ulceration
4. Atypical vessels
5. Very severe colposcopic atypia
6. Large, significant lesion
7. Canal lesion, going out of range
8. Perimenopausal and post radiation
Mimics of cervical cancer
1. Severe cervicitis e.g., herpes, syphilis
2. Benign ulceration e.g., trauma
3. Foreign body reaction
4. Granulomatous cervical conditions
5. Granuloma inguinale
6. Lymphogranuloma venereum
7. Schistosomiasis
8. Cervical condylomata
• Cololposcopy aids differentiation.
• Histology is the gold standard
ACCP/ACS Guidelines for Screening
• When to Start Screening
– Initiate cervical cancer screening about 3
years after the onset of vaginal intercourse.
– Screening should begin no later than 21 years
of age.
– The need for cervical cancer screening should
not be the basis for the onset of gynecologic
care.
(CA: A Cancer Journal for Clinicians 53(1):27-43, 2003)
ACCP/ACS Guidelines for Screening
• When to Stop Screening:
– Women aged >70 years with an intact cervix with
>3 documented, consecutive, technically
satisfactory/normal/negative cervical cytology tests
and no abnormal/positive cytology tests within the
10 years prior to age 70 may stop cervical cancer
screening.
• Screening is recommended for 70+ year old women not
previously screened and for whom information about
previously screening is unavailable and for whom past
screening is unlikely.
CA: A Cancer Journal for Clinicians 53(1):27-43, 2003)
ACCP/ACS Guidelines for Screening
• Screening After Hysterectomy
– Vaginal cytology screening tests are not
indicated after total hysterectomy for benign
gynecologic disease.
– Hysterectomy for CIN2 or greater is not
considered benign.
CA: A Cancer Journal for Clinicians 53(1):27-43, 2003)
ACCP Guidelines for Screening
• Screening Interval:
– After initiation of cervical screening, perform
annually with conventional cervical cytology smears
or every 2 years using liquid-based cytology.
– Women >30 years of age with 3 consecutive,
technically satisfactory normal/negative cytology
results may be screened every 2 to 3 years unless
they have a history of in utero DES exposure, HIV+,
or are immunocompromised.
CA: A Cancer Journal for Clinicians 53(1): 27-43, 2003)
Abnormal PAP smear: Colposcopy
Multimodal Spectroscopy
Recent FIGO Recommendations For the Management of
Abnormal Smear
( Benedet,2000)
Persistent inflam., persistent ASCUS, LSIL, HSIL, AGCUS,Invasive
Colposcopy ± Biopsy
Normal or LSIL
LLETZ
6 mo smear x 2
TT
Normal
Annual screening
HSIL
Persistent
Invasive
Appropriate
LLETZ
Large Loop Excision of the Transformation
Zone
Against Breast Cancer
Elements of Screening of Breast Cancer
History
&
Raising Awareness
Clinical Breast
Examination
Mammography
Breast Self
Examination
Approach to the Client
• Explain to the client the importance of breast
examination as a tool for early detection of
abnormalities especially cancer that results in
better prognosis.
• Explain and train all clients to perform breast selfexamination and instruct them when, how to do it
and abnormalities to look for.
• Maintain good communication channels with the
clients whose screening shows suspicious results
to ensure that follow-up can be achieved: note the
client’s telephone, address and who to contact.
• Respond to all the client Needs and inquiries and
provide reassurance while encouraging her to
perform extra-necessary procedures
History Taking
• Ask about risk factors:
–
–
–
–
–
–
–
–
Family history of breast cancer
Menstruation after age of 55 or before age of 12
Menstrual cycles lasting more than 40 years
Hormone administration
Obesity
Smoking
Previous uterine cancer
First pregnancy after age 30 or no pregnancies
• Ask about symptoms:
–
–
–
–
Pain
Swelling in breast or armpit
Discharge from nipple
Discoloration of the skin
• Note all findings in the medical record
What changes should She be aware of?
• A change in size – it may be that one breast has become
noticeably larger or noticeably lower
• A nipple has become inverted (pulled in) or changed its position
or shape
• A rash on or around the nipple
• A discharge from one or both nipples
• A puckering or dimpling of the skin
• A swelling under the armpit or around the collarbone (where the
lymph nodes are)
• A lump or thickening in the breast that feels different from the
rest of the breast tissue
• Constant pain in one part of the breast or in the armpit.
Clinical Breast Examination
• Yearly Done
•
• Postmenstrually
• Should be part of any
•
gynecologic examination.
• Refer client to a MOHP
hospital if needed.
• Explain the procedures to
the client, and ask her to
undress to the waist and
stand relaxed.
•
•
•
• Inspection
Ask the client to put her hands on
her waist, and to push inwards to
contract the chest muscles.
Inspect both breasts for any
puckering, abnormalities of the
skin, change in the nipple such as
swelling or retraction, asymmetric
appearance or nipple discharge.
While the client lies on her back,
inspect breasts to detect any
abnormalities.
Inspect for any abnormal
discoloration of the skin
Note all findings in the medical
record.
Palpation
• Palpate the breast tissue for any breast masses as well
as the axilla and supraclavicular area for any enlarged
lymph nodes.
• Be sure that all parts are felt carefully.
• Milk the nipple after massage of the areola medially to
identify any fluid discharge.
• Describe as none, clear, milky, pinkish or dark-bloody
color.
• If any abnormality is detected by examination, refer to
specialist for mammography.
• Note all findings in the medical record.
Breast Self Examination
• Tell the client to conduct breast self-examination once
every month after the end of menstruation starting at
the age of 20 years for life.
• Palpation of the breasts during bathing is
recommended.
– Soap and water on the skin facilitates palpation of the breast
tissue.
• It is important to note the normal consistency of the
breasts at the first examination so that she will be
aware of any changes in subsequent examinations.
Diagnosis Vs Screening ??
Mammography…A debate
• Before the age of 40 and after 70 there is
NO recommendations for routine
mammographic screening
• Currently, the American Cancer Society
and the American College of Radiology
encourage mammograms every two years
for women ages 40 to 49.
• Yearly mammographic examination are
done from the age of 50-70 years.
Other tools..
• Breast
Ultrasonography
• MRI
• Thermography
• BRCA
Thank you !!!