Prevention of carcinoma cervix- primary secondary and tertiary prevention ●Cervical cancer ➢Risk factors ➢HPV vaccination and guidelines ➢HPV testing ➢Cytology ➢VIA/ VILI ➢Screening guidelines ➢Colposcopy ➢Ablative and excisional procdures ➢Management of invasive cancer ➢Global strategy to accelerate the elimination of cervical cancer as a public health problem

1. PREVENTIVE
STRATEGIES IN
GYNAECOLOGICAL
MALIGNANCIES
DR. SHUBHI DUBEY
BATCH OF JANUARY 2021
MODERATORS-
Dr.Veena
Dr. Nivedita

2. CONTENTS
Cervical cancer
Risk factors
HPV vaccination and guidelines
HPV testing
Cytology
VIA/VILI
Screening guidelines
Colposcopy
Ablative and excisional procdures
Management of invasive cancer
Global strategy to accelerate the elimination of cervical
cancer as a public health problem
Vaginal and vulval cancer

3. CARCINOMA
CERVIX
Deaths (2020)-
342 000
HPV 16 and 18 causative for >50%
of the high grade precancers
Incidence
(2020)- 604 000

5. RISK
FACTORS
DEMOGRAPHIC
RISK FACTORS
BEHAVIOURAL
RISK FACTORS
MEDICAL
RISK FACTORS
Race
Low
socioeconomic
status
Increasing age
Young age at first
intercourse
Multiple sexual
partners
Cigarette
smoking
Dietary deficiency
Inadequate screening
High parity
Chronic immune
suppression
HPV infection (Herpes
and Chlamydia act as
cofactors)

6. HPVAND
CERVICAL
CANCER
Causative for >95% of the cervical cancers
Low risk types- 6, 11
High risk types- 16, 18, 31, 33, 45, 52, 58
HPV 16 is the most oncogenic- causative for 45% CIN
and 55% of carcinoma cervix
HPV INFECTON
PRECANCEROUS
CHRONIC INVASIVE
SELF RESOLVE

8. COMPREHENSIVE CERVICAL CANCER
CONTROL
Primary prevention (vaccination against HPV)
Secondary prevention (screening and treatment
of precancerous lesions)
Tertiary prevention (diagnosis and treatment of
invasive cancer)
Palliative care

9. CERVICAL
CANCER
CONTROL-
A
COMPREHENSIVE
APPROACH

10. HPV
VACCINATION
 4WHO prequalified vaccines- against HPV 16 & 18
 Safe and effective in preventing HPV infection, high
grade precancerous lesions and invasive cancer as
per clinical trials and post- marketing surveillance
 Most effective if administered prior to HPV exposure
 TARGET POPULATION- GIRLS AGED 9-14YRS
PRIMARY
PREVENTION

11. ACTIONOF
HPV
VACCINES
COMPONENTS:
Ag- sp component- generates immunity against
HPV
Non- sp component- adjuvant/ delivery system
rDNA technology expresses the L1 protein coat in
HPV in yeasts without genetic material VLPs
(virus-like proteins)

12. HPV
VACCINES
BIVALENTVACCINE (CERVIRIX)(2009)
- HPV 16,18
QUADRIVALENTVACCINE (GARDASIL)(2006)
- HPV 6,11,16,18
- 97-100% effective if administered prior to HPV
infection
- 44% effective if administered after HPV infection
GARDASIL-9 (2014)
- HPV 6,11, 16,18, 31, 33, 45, 52, 58
- 97% effective in the HPV naïve population

13. INDIANACADEMYOF PAEDIATRICS

14. FOGSI
RECOMMENDS
SCREENING AND MANAGEMENT OF PREINVASIVE LESIONS OFTHE CERVIXAND HPVVACCINATION- FOGSI GYNAECOLOGYONCOLOGYCOMMITTEE-
JANUARY 2018

15. FOGSI
RECOMMENDS
SCREENING AND MANAGEMENT OF PREINVASIVE LESIONS OFTHE CERVIXAND HPVVACCINATION- FOGSI GYNAECOLOGYONCOLOGYCOMMITTEE-
JANUARY 2018

16. SINGLE DOSE
VACCINE
Based on the IARC India HPVVaccineTrial & Costa
RicaVaccineTrial
Simpler delivery system
Lower program costs
Might accelerate introduction of HPV vaccines into
National Immunisation Schedules

17. WHEN ISTHE
VACCINE
CONTRA-
INDICATED?
Hypersensitivity reactions to the previous
doses
Bleeding disorder/ anti-coagulant therapy
Pregnancy
CAN BE GIVEN IN BREASTFEEDING WOMEN
< 26YEARS OF AGE IF NOT PREVIOUSLY
VACCINATED

18. SCREENINGOF
PRECANCEROUS
LESIONS
Amongst asymptomatic women
WHO recommends using HPV tests
- HPV DNA: detects high-risk strains of HPV
- HPV mRNA: detects HPV infections leading
to cellular transformation
BENEFITS:
-Objective and simpler
- Cost effective
SECONDARY PREVENTION

19. APPROACHESTOCERVCIALCANCERSCREENING

20. HPVTESTING
NON-AMPLIFICATIONTECHNIQUES- nucleic acid
probe tests
AMPLIFICATIONTECHNIQUES-
 Target amplification(PCR based)-Cobas 4800
 Signal amplification- Hybrid Capture, HCT II,
Cervista HPV HR, Cervista HPV 16/18
 Probe amplification- ligase chain reaction
Target and signal amplification techniques are the
most commonly used tests

21. HPV
TESTING

22. CERVICAL
CYTOLOGY
Identification of atypical cells in the cervix
OPTIMISINGTHE PAPTEST:
- Avoid menstruation
- Abstain from vaginal intercourse/ douching/ vaginal
tampons for 24-48hours
- Optimum cervical visualization using speculums
- Avoid touching the cervix prior to the test to avoid
removing the dysplastic epithelium, if any
- Sampling of the transformation zone at the
squamocolumnar junction

23. CERVICAL
CYTOLOGY

24. CERVICAL
CYTOLOGY

25. LIQUID
BASED
CYTOLOGY
Liquid-based cytology- sample is
collected by a brush deposited into a
small bottle of preservative liquid
- At the laboratory the liquid is treated &
a layer of cells is placed on a slide.
FDA APPROVED :
1. Sure Path : centrifugation and
sedimentation through a pressure
gradient
2.Thin Prep : filtration and collection of
Vaccum packed cells on membrane and
transferring to slide
3. Mono Prep

26. LIQUID
BASED
CYTOLOGY

27. AUTOMATED
CYTOLOGY
Computerized analysis of Pap smear slides.
1.Autocyte (semi automated):
 Scans the slides & records images of 128 of the most
abnormal fields found on the slide (most significant
abnormality found in the center).
 When the findings of both the reviewer and the computer
match then, a diagnosis of “within normal limits” is given.
 Sensitivity: 97.2%
2. AutoPap.:The material on the slide is reviewed and scored
based on an algorithm, as to the likelihood of an abnormality
is given.
 97% sensitivity

28. CERVICAL
CYTOLOGY
BETHESDA
SYSTEM
CYTOLOGY
REPORT
SPECIMENTYPE-Conventional/Liquid based
SPECIMEN ADEQUACY-Satisfactory/Unsatisfactory
Results
NEGATIVE FOR
INTRAEPITHELIAL
LESIONS OR
MALIGNANCY
EPITHELIAL CELL
ABNORMALITY
NON-
NEOPLASTIC
FINDINGS
ORGANISMS
SQUAMOUS
CELL
GLANDULAR
CELL
- ASC-US
- ASC-H
- LSIL
- HSIL
- SCC
-ATYPIA
-FAVOURING
NEOPLASIA
-AIS
-ADENO
CARCINOMA
-ATROPHY
-KERATOSIS
-
METAPLASIA
-INFLAMED
-TRICHOMONAS
-FUNGUS
- BACTERIAL
VAGINOSIS
- HERPES
- CMV

30. CO-TESTING
Co testing : HPV testing used along with Pap smear.
The combination of both tests together provides
nearly 100% sensitivity, while maintaining the
specificity of cytology.
For women aged 30-65 years, co-testing has been the
preferred method.
The negative predictive value is high when both test
results are negative and there is a very high level of
reassurance.

31. VIA
VISUAL
INSPECTION
UNDERACETIC
ACID
Low cost and effective method of screening in low
resource settings
Offers immediate diagnosis & possibility of
simultaneous treatment
Application of 3-5% acetic acid:-
3-5ml glacial acetic acid added to 95-97 ml distilled
water
Reversible if application of diluted acetic acid(3-5%)
Coagulation of the cellular proteins,
Swelling of the epithelial tissue, columnar cells and
dehydration of the cells
Examined after 1 minute

32. VIA
VISUAL
INSPECTION
UNDER
ACETICACID

33. VILI
VISUAL
INSPECTION
WITH LUGOL’S
IODINE
 Squamous epithelium contains glycogen, whereas precancerous
lesions and invasive cancer contain little or no glycogen.
 Precancerous lesions and invasive cancer do not take up iodine
and appear as well-defined, thick, mustard or saffron yellow areas.
 Lugol iodine: Potassium iodide: 10 g added in Distilled water: 100
ml, Iodine crystals: 5 g added while shaking .
VILI Category Clinical Findings
Test-negative:
Squamous epithelium turns mahogany brown
Test-positive:
Well-defined, bright yellow iodine non-uptake areas
Suspicious for cancer:
Clinically visible ulcerative, cauliflower- like growth or ulcer

34. VIA-HSIL VILI-HSIL

35. STRENGTHSAND LIMITATIONSOFTHEVARIOUS
SCREENING MODALITIES
SCREENINGTEST STRENGTHS LIMITATIONS
CYTOLOGY -High specificity -Moderately sensitive
VIA/VILI
-Cheaper
-Simpler
-Immediate results
-Variably sensitive and
specific
HPVTESTS
-Highly Sensitive
-High NPV
- Lower specificity
- Expensive

36. WHO
GUIDELINES FOR
FORSCREENING
ANDTREATMENT
OF
PRECANCEROUS
CERVICAL
LESIONS

37. WHO RECOMMENDATION
POPULATION
INITIATION OF
SCREENING
FREQUENCY OF
SCREENING
GENERAL POPULATION 30YR 5-10YEARS
PEOPLE LIVINGWITH
HIV
25YR 3-5YEARS
WHO GUIDELINES FOR FOR SCREENING ANDTREATMENT OF PRECANCEROUS CERVICAL LESIONS CERVICAL CANCER
PREVENTION- 2ND EDITION

38. RESOURCE
BASED
CERVICAL
CANCER
SCREENING
RECOMMEND
ATION
SCREENING AND MANAGEMENT OF PREINVASIVE LESIONS OFTHE CERVIXAND HPVVACCINATION- FOGSI GYNAECOLOGYONCOLOGYCOMMITTEE-
JANUARY 2018

39. RESOURCE
BASED
CERVICAL
CANCER
SCREENING
RECOMMEND
ATION
SCREENING AND MANAGEMENT OF PREINVASIVE LESIONS OFTHE CERVIXAND HPVVACCINATION- FOGSI GYNAECOLOGYONCOLOGYCOMMITTEE-
JANUARY 2018

42. ROUTINECERVICALCANCERSCREENING
(ACOG/ASCCP PRACTICEADVISORY)-APRIL 2021
POPULATION RECOMMENDATION
<21YEARS No screening
21-29YEARS Cytology every 3 years
30-65YEARS
- Cytology every 3 years
- HPV testing every 5 years
- Cotesting every 5 years
>65YEARS No screening
POST- HYSTERECTOMY No screening

43. RESOURCE
BASED
CERVICAL
CANCER
SCREENING
RECOMMEND
ATION
SCREENING AND MANAGEMENT OF PREINVASIVE LESIONS OFTHE CERVIXAND HPVVACCINATION- FOGSI GYNAECOLOGYONCOLOGYCOMMITTEE-
JANUARY 2018

44. WHO GUIDELINES FOR FOR SCREENING ANDTREATMENT OF PRECANCEROUSCERVICAL LESIONS FOR CERVICAL CANCER PREVENTION- 2ND EDITION

45. COLPOSCOPY

46. COLPOSCOPY
 Colposcopy is the examination of the lower genital tract under
magnification and is coupled with obtaining directed biopsies of
suspected lesions.
 Bright light source with variable magnification using a optical lens
system
 PRIMARY GOAL- to identify preinvasive/ invasive lesions for biopsy

47. COLPOSCOPY
SOLUTIONS USED:
• Normal saline: removes discharge and mucous and helps assess
vascular pattern
• 3-5% acetic acid: mucolytic and causes denaturation of cellular
proteins (acetowhitening) transient whitish hue in lesions
• Lugol’s iodine solution:
- Stains mature glycogen rich, mature squamous epithelium dark
purple brown
- Stains dysplastic epithelium yellow due to poor glycogen store

48. MODIFIED
REID
COLPOSCOPIC
INDEX

49. SWEDE
SCORE
Score
• 0 – normal
• 1-4 – benign lesion
• 5-7 – high grade lesion
• >8 – high grade lesion suitable for see and treat

50. NPPCDCS
 BENEFICIARY- 30-65YEARS
 SCREENING METHOD-VIA
 SCREENING FREQUENCY- EVERY 5YEARS

51. ABLATION
-CRYOSURGERY
-CO2ABLATION
-THERMALABLATION
Involves physical destruction of tissue and is
generally effective for non-invasive ectocervical
disease
PRE-REQUISITES:
- Exclude glandular neoplasia or invasive cancer
- Visualisation of the entire SCJ and upper limits of all
lesions of colposcopy
- Endocervical sampling should be negative for high
grade CIN
- Concordant cytology and HPE reports
Modalities- Cryosurgery and CO2
Decline in ablative procedures due to lesser
morbidity and ease of LEEP

52. CRYOTHERAPY
Ablates transformation zone and CIN
Cryoprobe Gas(NO2) Cold
temperature  Expanding layer of ice
(ICEBALL)-20 deg celsius- LETHAL
ZONE Necroses cervical epithelium
-20 deg celsius: Cell death
Used for:
- Ectocervical lesions
- Circumferential cervical length adequate
to avoid thermal damage to the vagina
- CIN limited to 2 quadrants

53. CRYOTHERAPY

54. CO2 LASER
ABLATION
Under colposcopic guidance
CO2 Infrared laser Heat Boils intracellular
tissueVaporises tissue
For large, irregular CIN lesions ifTZ is seen fully in
colposcopy
Can be used if CIN lesion extends to the vagina
Cervical tissue vaporised to a depth of 5-7mm

55. CO2 LASER
ABLATION

56. EXCISION
-LEEP/ LLETZ
-COLD KNIFE
CONISATION
-CO2 LASER
CONISATION
 Favoured when:
-Risk of invasive cancer is high
-In case of lesions or SCJ not completely visualised under
colposcopy
-Lesions extends >75% of the ectocervix
-Endocervical sample indicates high grade CIN or
glandular neoplasia
- Persistence/ recurrence of high grade CIN post therapy
 ADVANTAGE: Provided tissue for HPE
 DIAGNOSTIC EXCISION-Invasive lesion not ruled out by
colposcopy
 THERAPEUTIC EXCISION- for CIN diagnosed by HPE
and colposcopy

57. LEEP/ LLETZ COLD KNIFE CONISATION
ADVANTAGES
- Better safety profile
- Easy
- OPD procedure
- Cheaper
- Tissue available for HPE
- Patient anesthetised
- No margin compromise
- Better patient support in
case of haemorrhage
DISADVANTAGES
- Thermal damage may
obscure margin status
- Training required
- Postprocedure bleeding
- Haemorrhagge
- Longer time
- Post-op discomfort
- GA/ RA needed
- OT needed
- Costlier
- Larger amount of stroma
removed
- Poorer reproductive
outcome

58. LEEP/ LLETZ

59. CONISATION

60. CONISATION
 Indications-
 Abnormal endo cervical curettage (ECC)
 CIN-2 or CIN-3
 Lesion extends to ECC and extent not possible
to confirm
 Extent exceeds capability of LEEP(1.5 cm )
 Cytology shows atypical glandular cells
 Colposcopy suggest glandular dysplasia or
adenocarcinoma in situ
 Invasive cancer cannot be ruled out
 Suspected micro invasion
 Lack of correlation between cytology, biopsy,
and colposcopy results

61. MANAGEMENT
OF INVASIVE
CERVICAL
CANCER
EARLY DISEASE ADVANCED DISEASE
 Irregular spotting/
bleeding PV
 Postmenopausal
bleeding
 Post coital bleeding
 Copious/ foul smelling
discharge PV
 Loss of weight/ appetite
 Persistent leg/ back/
pelvic pain
 Lower limb swelling
 Decreased urine output
General physical examination especially to examine the
supraclavicular, axillary, inguinofemoral lymph nodes
Per speculum examination of the cervix and vagina
Digital examination of the cervix
Per rectal examination
TERTIARY PREVENTION

62. EXAMINATION
 DIAGNOSIS- histopathological
 STAGING- based on tumour size and spread of the
disease
 TREATMENT OPTIONS-
 Surgery
Radiotherapy
Chemotherapy
Palliative

63. NATIONAL
CANCERGRID
OF INDIA
CONSENSUS
ON
MANAGEMENT
OFCARCINOMA
CERIVX
FIGO STAGE OPTIMALTREATMENT REMARKS
IA1 Type 1 radical
hysterectomy
Conisation/ radical trachelectomy
if fertility sparing
IA2 Type 2 radical
hysterectomy+ pelvic
lymphadenectomy
Radical trachelectomy+ RPLND
if fertility sparing
IB1-IIA1 Type 3 radical
hysterectomy+ pelvic
lymphadenectomy
Adjuvant RT/CT
IB2 Concurrent pelvic
chemoradiation+ BT
Extended field RT if paraaortic
nodes positive
IIA2-IIIB Concurrent pelvic
chemoradiation+ BT
Extended field RT if paraaortic
nodes positive
IVA NACT + concurrent
chemoradiation
IVB Pallaitve
Chemoradiotherapy
NATIONAL CANCER GRID: RESOURCE
STRATIFIED GUIDELINES_2019

64. GLOBAL
STRATEGYTO
ACCELERATE
THE
ELIMINATION
OFCERVICAL
CANCERASA
PUBLIC
HEALTH
PROBLEM

67. WHO
RESPONSE
Adapted from the WORLD HEALTH ASSEMBLY to
accelerate the elimination of cervical cancer as public
health problem
ELIMINATION- a country reaching a threshold of <4
cases per 100000 women per year
90-70-90TARGETS to be reached by 2030 and
maintained
>90% of the girls fully vaccinated by the age of 15
years
70% of them women screened by a high performance
test by the age of 35years and repeated by the age of
45 years
90% of the patients identified with cervical disease
managed for the same

69. ACHIEVINGTHE 90-70-90

70. PREVENTIVE
STRATEGIES
INVAGINAL
ANDVULVAL
CANCER
VAGINAL
CANCER
VULVAL
CANCER
PRIMORDIAL
PREVENTION
-Hpv infection (65%) ->65 yr
-Hpv infection
-Lichen sclerosis
PRIMARY
PREVENTION
- Hpv vaccination - Hpv vaccination
SECONDARY
PREVENTION
- Biopsy/ ecc/ emc
- Cystoscopy
- Proctoscopy
- Imaging
- Early diagnosis
- Vulvoscopy
- Cystoscopy
- Proctoscopy
- Imaging
TERTIARY
PREVENTION
- Surgery
- Radiotherapy +/-
concurrent
chemotherapy
- Wide local excision
- Vulvectomy

71. WHAT ISTHE
BEST
PREVENTIVE
STRATEGY?

73. THANK
YOU