Visual Screening

Screening for Cancer Cervix by Visual Technique
Professor .Surendra Nath Panda,M.S. of Obstetrics and Gynecology M.K.C.G.Medical College Berhampur, 760004, Orissa, India
Cervical Cancer
Magnitude of the Problem: 500,000 new cases identified each year 80% of the new cases occur in developing countries At least 200,000 women die of cervical cancer each year
Cervical cancer is the third most common cancer worldwide

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Cervical Cancer: Aetiology

Cause: HPV -a sexually transmitted infection
Women are generally infected with HPV in their teens, 20s, 30s Cervical cancer can develop up to 20 years after HPV infection
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Screenig For Cancer Cervix by Visual Technique
Natural History of Cervical Cancer:

Current Understanding
Normal Cervix About 60% regress within 2-3 yrs HPV Infection HPV-related Changes
Low-Grade SIL (Atypia, CIN I) About 15% progress within 3-4 yrs High-Grade SIL (CIN II, III/CIS) 30% - 70% progress within 10 yrs Invasive Cancer
05 November 2012 Screenig For Cancer Cervix by Visual Technique
Source: PATH 1997.
Cofactors High-Risk HPV (Types 16, 18, etc.)
Prevention of Cervical Cancer

Cervical cancer is a preventable disease Primary prevention:
Education to reduce high risk sexual behaviour Measures to reduce/avoid exposure to HPV and other STIs
Secondary prevention:
Treatment of precancerous lesions before they progress to cervical cancer (implies practical screening test)
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Secondary Prevention of Ca.Cx.

Key Point is to detect precancerous lesions Down staging Answer: - A good screening method
PAP smear test is considered to be the gold standard Has limitations ? Alternatives to Pap Smear What are they?
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Qualities of a Good Screening Test?
Effective Safe Practical Affordable Available
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Limitations of Pap Smears for National Screening Programs

Pap smear-based programs require complex logistics, advanced training, and well managed program implementation for adequate testing to occur. These elements are not available outside large cities in many low-resource settings.
Even in large cities, quality pap smears are possible but ongoing supervision, refresher training and continued supplies are necessary.
Cytology is not viable as a nationally accessible screening method in many developing countries in Low Resource Settings.
Alternatives to Pap Smear Screening

Why?
Cervical cancer is a significant public health problem in many countries. Cervical cancer is a sexually transmitted disease. Cervical cancer is preventable (i.e., Methods of screening and treatment for precancerous lesions exist). Pap Smear as a screening methods may not be appropriate or adequate for many low-resource settings.
Cervical Cancer Screening

Other Options: Visual inspection with acetic acid (VIA) Visual inspection with acetic acid and magnification (VIAM): Gynescope or Aviscope
Colposcopy
Cervicography
Automated pap smears

Molecular (HPV/DNA) tests
Approaches to Cervical Cancer Prevention in Low-resource Settings

Effective Safe Practical Affordable Available Visual Inspection: AA Visual Screening: Unaided Automated Pap Screening HPV Screening Cervicography HPV Vaccine Yes Yes Yes Yes Yes
No
Yes
Yes
Yes
Yes
Yes? Yes Yes? ?
Yes Yes Yes ?
? ? ? Yes
No ? ? ?
No Yes Yes No
Source-Program for Appropriate Technology in Health [PATH] 1997. 05 November 2012 Screenig For Cancer Cervix by Visual Technique 11
What Is VIA / Cervicoscopy ?

Visual Inspection after Acetic Acid
Also known as Aided Visual Inspection of Cervix, or Acid Acetic Test Looking at the cervix to detect abnormalities after applying acetic acid
Acetic acid is used to enhance and mark the acetowhite change of a precancerous lesion or actual cancer Sensitivity and specificity of VIA - 70-92% Positive Predictive Value - 15-20%
History of Research on Visual Inspection

Historically, before the advent of Pap smears and programmatic screening, healthcare providers relied on looking at the cervix to detect abnormalities.
Schiller test has been used for many years(to aid in differentiating "mature" normal from "immature" abnormal epithelium).
After the 1950s, when the Pap smear became the standard for cervical cancer screening-.
Increasing numbers of women undergoing this test led to increased utilization of the colposcope (initially developed in the 1930s) to confirm screening findings.
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Years later, given the expense and inconvenience of colposcopy services, clinicians began to explore whether unmagnified visualization of the cervix (with acetic acid) could be used as an adjunct to cytology so that patients in need of colposcopy could be identified more effectively and efficiently. However few studies were conducted, that examined the value of unmagnified inspection of the cervix after the application of acetic acid (VIA) for purposes of identifying a normal "transformation zone" or detecting precancerous lesions of the cervix (i.e., primary screening).

Then, in 1982, Ottaviano and La Torre published an important study involving 2,400 women who were examined visually and colposcopically after a cervical wash with acetic acid.
"naked-eye" (unmagnified) inspection detected abnormalities in 98.4% of the cases (i.e., in 307 of 312 patients assessed colposcopically as having an abnormal transformation zone). These authors concluded that "colposcopic magnification is not essential in clinical practice for the identification of the cervix at risk."
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In 1990, Abrams published his experience with the "Gynoscope," a monocular telescope with a magnifying power of 2.5,
high correlation between the (visual) Gynoscope examination and cytology. should be considered as a practical adjunct that will encourage better sampling by the clinician.
World Health Organization (WHO) supported a study in India between 1988 and 1991 in which unmagnified visual inspection with acetic acid washing was evaluated as a "down staging" technique.
VIA was found to be effective in identifying women with cancer at an earlier, more treatable stage.

Several other comparative studies in Kenya, Zimbabwe and South Africa suggest that visual inspection with acetic acid performs comparably to the Pap smear and/or other screening tests. More recent studies have also demonstrated that "VIA is a safe, simple and effective adjunct to the Papanicolaou smear for cervical cancer screening and can be helpful in reducing referrals for colposcopy without compromising quality of care.
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Needed Equipment and Supplies for VIA

VIA can be performed in any clinical setting when the following are available:
Examination table, preferably with stirrups or leg supports Sterile speculum, preferably Cusco's Sterile gloves Source of light, a lamp or a torch Cotton swabs Forceps Syringe for acetic acid lavage Acetic acid in dilutions of 3-5% Stationary, to record examination findings
The Examination
The procedure and the reason for it should be carefully explained to the woman to be examined and she should be made as comfortable as possible. Take into consideration the privacy of the patient. Put patient in lithotomy position (if possible) or suppine with legs bent at knees. Good visualization is essential. Direct the light source to the genital area. Observe and record any abnormal findings in the external genitalia.
Lubricate the speculum with warm water and insert into the vagina with the speculum closed.
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The Examination
Open the speculum and adjust the light source so as to get a clear view of the cervix. If there is excess mucus or discharge, clean it with a cotton swab soaked in boiled water or normal saline solution. Observe any abnormal findings. Wash the cervix with the acetic acid (3-5%) with the help of the syringe. Alternatively can be applied with a cotton swab. Wait for approximately 1 minute. Inspect the cervix for acetowhite areas.
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The Examination
Important Do not perform the examination if the woman is having menstrual period or is using intravaginal medication. Advise her to come back when the mensus or the treatment is over. Do not apply acetic acid if there is a gross lesion suspicious of malignancy, refer patient directly to oncology / tertiary care facility.
Objectives Of Acetic Acid Examination

Locate the squamocolumnar junction Identify any lesion & its limits Decide whether the lesion is CIN Determine whether invasion is possible Select a site or sites for biopsy if appropriate
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What does Acetic Acid do?

Acetic acid
Dissolves mucus Induces intracellular dehydration Causes coagulation of protein
As a result cells with increased

Nuclear / Cytoplasmic ratio ratio Nuclear density Chromosomal aneuploidy
Become opaque acetowhite area test positive
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Abnormalities Seen After Acetic Acid

Aceto-white Margins and surface White gland openings Mosaic & punctation Abnormal vessels
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What May Be Acetowhite

All acetowhite patches are not cancer Any of these epithelial changes can become acetowhite
Healing or regenerating epithelium Congenital transformation zone Inflammation Immature squamous metaplasia HPV infection CIN / CGIN Adenocarcinoma Invasive squamous cell carcinoma
Reporting Visual Inspection Findings

BEFORE ACETIC ACID APPLICATION- Unaided visual inspection of Cx Clinical Down staging
NORMAL: Smooth, pink Clear mucoid secretion Central hole-'external os' Nulliparours-round Multiparous-slit or cruciate Cervix in postmenopausal women is atrophic
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Normal Cervix
26

Hypertrophy Redness or congestion Irregular surface Distortion Simple erosions (do not bleed on touch) Cervical polyps (with smooth surface) Abnormal discharge: foul smelling, dirty / greenish, cheesy white, blood stained Nabothian follicles Prolapsed uterus
ABNORMAL: -
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ABNORMAL: Clinical interpretation can be:

Infection Ectopy (Erythroplasia)
Benign tumour
SUSPICIOUS OF MALIGNANCY: Erosion that bleeds on touch or friable Growth, with an irregular surface or friable
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AFTER ACETIC ACID APPLICATION- Aided visual inspection of Cx Acid Acetic Test
Acetic Acid TestNegative Acetic Acid TestPositive
Aceto-white area(s) not present Aceto-white area(s) present
Important: All findings, normal or abnormal, should be carefully recorded in a printed form. The patient should be informed and explained the follow-up procedure accordingly.
Action Plan
Negative Follow-up after 3-5 years according to the decided policy. Advise to come back if develops symptoms.
VIA
Positive
Treat / Refer to an appropriate centerPHC/ Secondary / Tertiary / Oncology Centre
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Action Plan
Management of VIA Positive Cases: If infection is suspected /present take a swab and send for analysis.Treat the patient accordingly. Re-examine after six weeks. If no signs of infection: - perform Pap-smear and / or Colposcopy: I. Pap-smear / Colposcopy negative: re call for follow-up in 6-12 months. II. Pap-smear / Colposcopy positive: call the patient for appropriate treatment
VIA - The Status To-Day

A randomised trial of early detection of breast and cervical cancers using low cost technology approaches - Professor I. Mittra, Tata Memorial Hospital, Mumbai.
The study is now in its 3rd year and 110,000 women have so far been randomised. VIA appears to be more sensitive but less specific than the PAP smear.
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Why VIA as an Alternative in Low-resource Settings?

Non-invasive, easy to perform and inexpensive Can be performed by all levels of healthcare workers, in almost any setting Skills consistent with service delivery tasks performed by nurses/midwives in MCH/FP clinic settings Results are available immediately
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Why VIA as an Alternative in Low-resource Settings?

Initial treatment can be provided at the time of the examination All system requirements are available locally Potential for immediate link to treatment Approach suitable for lowest-resource settings
***
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VIA
At the service of women
A
THANK YOU

Visual Screening

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Screening for Cancer Cervix by Visual Technique

Cervical cancer is the third most common cancer worldwide

Cervical Cancer: Aetiology

Screenig For Cancer Cervix by Visual Technique

Natural History of Cervical Cancer:

Cofactors High-Risk HPV (Types 16, 18, etc.)

Prevention of Cervical Cancer

Screenig For Cancer Cervix by Visual Technique

Secondary Prevention of Ca.Cx.

Screenig For Cancer Cervix by Visual Technique

Qualities of a Good Screening Test?

Effective Safe Practical Affordable Available

Screenig For Cancer Cervix by Visual Technique

Limitations of Pap Smears for National Screening Programs

Alternatives to Pap Smear Screening

Cervical Cancer Screening

Automated pap smears

Approaches to Cervical Cancer Prevention in Low-resource Settings

Yes? Yes Yes? ?

Yes Yes Yes ?

What Is VIA / Cervicoscopy ?

History of Research on Visual Inspection

Screenig For Cancer Cervix by Visual Technique

History of Research on Visual Inspection

History of Research on Visual Inspection

Screenig For Cancer Cervix by Visual Technique

History of Research on Visual Inspection

History of Research on Visual Inspection

Screenig For Cancer Cervix by Visual Technique

Needed Equipment and Supplies for VIA

Screenig For Cancer Cervix by Visual Technique

Screenig For Cancer Cervix by Visual Technique

Objectives Of Acetic Acid Examination

Screenig For Cancer Cervix by Visual Technique

What does Acetic Acid do?

As a result cells with increased

Become opaque acetowhite area test positive

Screenig For Cancer Cervix by Visual Technique

Abnormalities Seen After Acetic Acid

Screenig For Cancer Cervix by Visual Technique

What May Be Acetowhite

Reporting Visual Inspection Findings

Screenig For Cancer Cervix by Visual Technique

Reporting Visual Inspection Findings

Screenig For Cancer Cervix by Visual Technique

Reporting Visual Inspection Findings

ABNORMAL: Clinical interpretation can be:

Screenig For Cancer Cervix by Visual Technique

Reporting Visual Inspection Findings

Acetic Acid TestNegative Acetic Acid TestPositive

Aceto-white area(s) not present Aceto-white area(s) present

Treat / Refer to an appropriate centerPHC/ Secondary / Tertiary / Oncology Centre

Screenig For Cancer Cervix by Visual Technique

VIA - The Status To-Day

Screenig For Cancer Cervix by Visual Technique

Why VIA as an Alternative in Low-resource Settings?

Screenig For Cancer Cervix by Visual Technique

Why VIA as an Alternative in Low-resource Settings?

Screenig For Cancer Cervix by Visual Technique

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