Prof.

Farhat Hussain
Dept. of Obs & Gynae
Pabna Medical College

Cervical Cancer
Burden

Cont.

Incidence & Mortality of

Cervical Cancer in Asia

6561

Cervical cancer incidence rate

in South Asia

Age-specific incidence rates of

cervical cancer in Bangladesh as
compared to estimates for Southern
Asia and the World

Cervical cancer incidence in

Bangladesh- compared to other
cancers in women of all ages

Age Specific mortality rate of cervical

cancer in Bangladesh as compare to
estimates for South Asia and the World

Comparison of Incidence and

Mortality in the World

Predicted Number of Cervical Cancer

Cases In 2020 By World Area and Age
2002

2020
(% change)

2020
% burden

World

493,000

702,500 (42%)

100%

Women aged <65

396,500

549,000 (38%)

78%

Women aged 65

96,500

153,500 (59%)

22%

Less developed areas

409,000

639,500 (56%)

83%

Women aged <65

336,000

507,500 (51%)

79%

Women aged 65

73,000

132,000 (80%)

21%

More developed areas

83,000

92,500 (11%)

17%

Women aged <65

60,000

62,500 (30%)

67%

Women aged 65

23,000

30,000 (31%)

33%

Projections assume rates estimated for 2002 hold into the future.

What Causes Cervical Cancer?

sistent infection with oncogenic HPV (Human Papilloma Vir

is a necessary cause for Cervical Cancer

Age Specific Incidence Rate of

HPV & Cervical Cancer

Percentage of Cervical Cancer cases

attributed to the most frequent HPV
types in world

Causal Link Between HPV &

Cervical Cancer

Early Age of Marriage

Multiple Sexual
Partners

High Parity

Smoker

Oral Contraceptive Pill

Less Aware About

Reproductive
Health (Low SES)

Age at which Cervical Cancer Occurs

Any age of women can develop cervical cancer but women at or above
40 years of age have more risk of developing cancer

Less

High Risk

Why the incidence of Cervical

Cancer is high in Bangladesh
Illiteracy and lack of empowerment of women
Lack of awareness of women & family regarding the

disease.
Less use of cancer preventive tools
Less availability & accessibility for diagnosis &
treatment of cancer in early stage.

Symptomology of Cervical Cancer

Post Coital
Bleeding

Post Menopausal
Bleeding

Frequent Irregular PV
Bleeding

Symptomology of Cervical Cancer

Foul Smelling
vaginal Discharge

Severe Pain in Lower

Abdomen, Back &
Bone

Blood Mixed with Urine

Prevention
of
Cervical
Cancer

History of Cervical cancer

Prevention
The effort to eleminate cervical cancer
began 50 years ago with the introduction of
pap test which has reduced the incidence of
cervical cancer by 75% in countries that
have implemented quality control screening
programs.
The next significant milestone in cervical

cancer prevention came in 1980s with the

discovery of a link between cervical cancer
and HPV.

History of Cervical cancer

Prevention

In the following 20 years, the basis of

sensitive molecular methods for

detecting HPV i.e. HPV DNA test and
cancer prevention vaccine i.e. HPV
vaccine was established.
In 2006, HPV vaccine was

incorporated into cervical cancer

prevention efforts

Cervical
Cytological testing involvesCytology
collection of exfoliated cells from cervix
& microscopic examination of these cells after staining. The
specimen is obtained using Ayres spatula & Conical Cervical brush
& spread on labeled glass slide.

Ayres spatula & Conical

Cervical brush

Paps smear collection from

cervix

Cervical Cytology
Cytology-based screening have been implemented

for secondary prevention of Cervical cancer since

the mid 20th century,
Recent review of impact is highly variable with
efficacy ranging from 20 % to 90%,
In US, the incidence rates of cervical cancer have
fallen by 75% or more since 1960
In England, the incidencc rates of cervical cancer
was relatively constant, despite the presence of Pap
smear screening until 1988, following which there
was precipitous drops in rates in subsequent years.

What caused the variation

in cervical cancer rate
Organized

screening program with wide

coverage and quality assurance has led to a
concomitant reduction in cervical cancer
incidence and mortality due to detection and
treatment of precancerous lesions and earlier
stage treatable cancers respectively.

Limitation of Paps smear

Cytology

has limited sensitivity (51%) for detection of

precancerous lesions and treatable cancer. Thus repeated
cytology over short intervals (Annual, biennial and triennial) has
been used to achieve program efficacy.
Cytology is a subjective test and poorly reproducible. Without
quality control it is impossible to achieve and maintain the clinical
performance.
Cytology is labour intensive and has been refractory to high
throughput automated screening.
Despite the low cost of consumables, high quality cytology is
expensive
Three visit approach (cytology, colposcopy and Rx) is needed for
an intervention cycle
The rate of loss to follow up associated with multiple visits is high.

What makes a screening program work

For successful implementation of cytology based screening program the
key considerations are
A multidisciplinary approach involving gynaecologists, family practitioners, nurses &

cytopathologists are essential

Training of involved manpower adhering to clinical practice guideline & their
accreditation system of call/ recall program where every woman in the screening age
range receive regular invitation.
Establishment of quality assurance in every stage of process smear collection,
laboratory reading, colposcopic management
Presence of administrative infrastructure support to track women in the process
Provision of political support which ensures adequate funding, including evidence
based advances

The requirements for

successful Screening in Low
resources settings

Screening, diagnosis & treatment provided in site

or in clinics accessible to majority of at risk women

Low cost, low technology screening test that
allows immediate treatment of abnormalities
Wide coverage of at risk women
Educational programs for health workers & women
to
ensure
high
participation
&
correct
implementation
Built in mechanism for evaluation of screening
program

Visual Inspection with Active Acid (VIA)

VIA involves naked eye inspection of the cervix one minute after application
of 3-5% dilute acetic acid. VIA has been widely investigated as screening
test & is now an acceptable test in low resource setting.

VIA Negative

VIA Positive

Advantages of VIA
The sensitivity of VIA in detecting high grade

precancerous lessons & invasive cervical cancer is

similar to that of cytology.
The test results are immediately available & thus is a
screen-andtreat or single visit approach. Therefore
treatment compliance among screen in positive
women is high.
The test involves minimum expenditure & is safe.
The test can be performed by nurses or paramedics
with short training and thus the test is feasible in low
resource settings.

HPV Test
HPV test involves looking for HPV DNA in the cervix. The kit contains
special conical brush and a vial with Specimen Transport Medium (STM).

HPV Test Tools

Specimen is collected for HPV Test

Colposcopy
Colposcopy allows magnified viewing of cervix & vagina with
colposcope. Morphological features of transformation zone of cervix
like aceto whiteness, margins, blood vessels & iodine uptake is noted
with colposcope.

Colposcopy

Colposcopy guided biopsy

Indications of Colposcopy
Positive screening test

results like
Paps smear positive,
VIA positive,
VILI positive.
Suspicious looking cervix
Post coital bleeding
Clinically apparent
leukoplakia

HPV vaccine
HPV infection leading to cervical cancer can be prevented
through vaccination. Vaccination offers primary prevention
against cervical cancer. There are both bivalent & quadrivalent
vaccine against cervical cancer.
The bivalent vaccine (Cervarix from Glaxo Smithkline) is
composed of HPV 16 &18 antigens in the form of VLPs
combined with a novel adjuvant system called ASO4

Cervarix

HPV vaccine (CONTD.)

In order to obtain maximum effectiveness, vaccination
need to be given before the onset of sexual activity, which
means vaccinating young girls between 9-13 years. Since
all sexually active women continue to remain at
risk of acquiring an HPV infection throughout their
lives, therefore women between 10 to 45 years can
be benefited from vaccination.
Cervarix is administered in three doses (0,1 & 6
months) via intra muscular injection into the
deltoid area.

HPV vaccine (CONTD.)

Cervarix provides protection against HPV

16 & 18 for 8.4 years till date.The antibody

level remains 10-11 fold higher than
natural infection.

Cervarix provides cross protection against

HPV 31 & 45.

Antibody Response to vaccination

Cont.

HPV vaccine (CONTD.)

Vaccination along with regular screening offers the best possible
protection against cervical cancer. Screening is done to ensure that an
infection caused by a non vaccine HPV type does not progress to invasive
cancer.

Vaccination + Screening = Protection against Cervical

cancer

Conclusi
on
Careful integration of primary and
secondary prevention programs would lead
to greater reduction in cervical cancer
making it a disease of the past.

Victim of cervical cancer who has been

treated and now is leading a normal life

Thank You