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Screening for cervical Screening for cervical neoplasia in Bangladesh neoplasia in Bangladesh

using visual inspection using visual inspection

with acetic acid with acetic acid

Chairperson: Chairperson:

Dr. Gopal Chandra Das Dr. Gopal Chandra Das

Assistant Professor Assistant Professor

Department of Obs & Gynae, Department of Obs & Gynae,

MMCMMC

Speaker:

Speaker:

Dr. Khurshida Jahan Dr. Khurshida Jahan

MS Obs & Gynae (Thesis part), MS Obs & Gynae (Thesis part),

MMC MMC

(2)

Auther:

Auther:

Nessa

Nessa A A, , HussainHussain MA MA, , RahmanRahman JN JN, , Rashid MH

Rashid MH, , MuwongeMuwonge R R, , Sankaranarayanan

Sankaranarayanan R R..

Department of Obstetrics & Gynecology, Bangabandhu Department of Obstetrics & Gynecology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh.

Sheikh Mujib Medical University, Dhaka, Bangladesh.

Source:

Source:

International Journal of Gynaecology & Obstetrics. 111(2010) 115- International Journal of Gynaecology & Obstetrics. 111(2010) 115-

118.

118.

(3)

Introduction Introduction

Cervical cancer constitutes 25% Cervical cancer constitutes 25%

of all cancer cases in women and of all cancer cases in women and

accounts for 13000 new cases accounts for 13000 new cases

and 8000 deaths annually in and 8000 deaths annually in

Bangladesh. More than 80% of Bangladesh. More than 80% of

patients diagnosed with this patients diagnosed with this

eminently preventable cancer eminently preventable cancer

present in clinically advanced, present in clinically advanced,

inoperable stages.

inoperable stages.

(4)

The aim of the present paper was The aim of the present paper was to briefly describe the

to briefly describe the

organization and functioning of organization and functioning of the VIA screening program and the VIA screening program and

discuss the early results, discuss the early results,

strengths and limitations of the strengths and limitations of the

pioneering effort in cervical pioneering effort in cervical

cancer prevention in Bangladesh.

cancer prevention in Bangladesh.

(5)

Objective:

Objective:

To report the organization and To report the organization and early results of a visual

early results of a visual

inspection with acetic acid inspection with acetic acid

(VIA) screening program for (VIA) screening program for

cervical cancer prevention in cervical cancer prevention in

Bangladesh.

Bangladesh.

(6)

Patients and Patients and

methods methods

The VIA screening program is provided The VIA screening program is provided through the existing healthcare

through the existing healthcare infrastructure in Bangladesh.

infrastructure in Bangladesh.

The target population for VIA screening The target population for VIA screening is apparently healthy, ambulant,

is apparently healthy, ambulant,

married women aged 30 years and married women aged 30 years and

above attending the healthcare above attending the healthcare

facilities at MCWCs, DHs, MCHs, facilities at MCWCs, DHs, MCHs,

BSMMU, UHFWCs, and UHCs.

BSMMU, UHFWCs, and UHCs.

(7)

It was an opportunistic screening program. It was an opportunistic screening program.

The screening algorithm involved a single The screening algorithm involved a single

visit for screen-negative women and 2-3 visit for screen-negative women and 2-3

visits for screen-positive women, visits for screen-positive women,

After counseling and informed consent, a After counseling and informed consent, a speculum examination was performed for speculum examination was performed for

direct visualization of the cervix and direct visualization of the cervix and

vagina to identify the squamocolumnar vagina to identify the squamocolumnar

junction (SCJ), inflammation, polyps, junction (SCJ), inflammation, polyps,

leukoplakia, and growth. Freshly prepared leukoplakia, and growth. Freshly prepared 5% 5% dilute acetic acid was applied to the dilute acetic acid was applied to the

cervix.

cervix.

(8)

Care was taken to avoid any Care was taken to avoid any

bleeding and results were reported 1 bleeding and results were reported 1

minute after application under 100- minute after application under 100-

watt illumina tion. VIA test was watt illumina tion. VIA test was

considered positive when a definite, considered positive when a definite,

well-defined acetowhitening was well-defined acetowhitening was

observed in the transformation zone observed in the transformation zone

in close proximity with the SCJ or in close proximity with the SCJ or

when a growth turned acetowhite;

when a growth turned acetowhite;

when in doubt the test was repeated.

when in doubt the test was repeated.

(9)

All VIA-positive women were referred All VIA-positive women were referred with a pink referral card to the

with a pink referral card to the

colposcopy clinics at BSMMU or nearby colposcopy clinics at BSMMU or nearby

medical college hospitals. Women with medical college hospitals. Women with

negative VIA were given a blue card negative VIA were given a blue card

and advised to come back after 3 years.

and advised to come back after 3 years.

A manual register is kept at each VIA A manual register is kept at each VIA

screening center that provides the screening center that provides the

number of women screened, tested number of women screened, tested

positive, and tested negative.

positive, and tested negative.

(10)

Colposcopy was performed by the trained Colposcopy was performed by the trained colposcopist when the screen-positive

colposcopist when the screen-positive

women reported at the colposcopy clinics women reported at the colposcopy clinics

at medical college hospitals or BSMMU.

at medical college hospitals or BSMMU.

All women with suspected CIN and All women with suspected CIN and

cancer had colposcopy-directed cervical cancer had colposcopy-directed cervical biopsy and the specimens were given to biopsy and the specimens were given to

the women or their attendants to submit the women or their attendants to submit

to the histopathology department. The to the histopathology department. The

colposcopic findings were documented in colposcopic findings were documented in

a form.

a form.

(11)

Women with normal histology and CIN 1 reports Women with normal histology and CIN 1 reports were advised to return for follow-up after 6-12 were advised to return for follow-up after 6-12

months. Women with CIN 1 who wanted months. Women with CIN 1 who wanted

immediate treatment or who were unlikely to immediate treatment or who were unlikely to report for follow-up and those above 35 years report for follow-up and those above 35 years

were treated with cryotherapy or LEEP. Women were treated with cryotherapy or LEEP. Women with histologically confirmed CIN 2 or 3 lesions with histologically confirmed CIN 2 or 3 lesions

were treated with LEEP or cryotherapy and were were treated with LEEP or cryotherapy and were

advised to return for follow-up after 6 months.

advised to return for follow-up after 6 months.

Women with cervical cancer were referred to Women with cervical cancer were referred to

cancer treatment facilities for further cancer treatment facilities for further

investigations and treatment.

investigations and treatment.

The final diagnosis was based on the The final diagnosis was based on the

histopathology or colposcopy if no or an histopathology or colposcopy if no or an

inadequate biopsy sample was taken.

inadequate biopsy sample was taken.

(12)

Results Results

From January 1, 2005, to June 30, From January 1, 2005, to June 30, 2008, VIA screening was provided 2008, VIA screening was provided

for 104 098 women in 44 districts in for 104 098 women in 44 districts in

Bangladesh. The average number of Bangladesh. The average number of

women screened in most districts women screened in most districts

ranged from 800-4000 women.

ranged from 800-4000 women.

(13)

Table 1: Number of women screened & those tested

positive

Year of screening Number screened Screen positive (%)

2005 11693 548 (4.7)

2006 21609 925(4.3)

2007 40785 1918(4.7)

2008 until June 30011 1622(5.4)

Total 104098 5013(4.8)

(14)

Of the women screened, 5013 (4.8%) Of the women screened, 5013 (4.8%) were positive on VIA and were

were positive on VIA and were referred to colposcopy clinics at referred to colposcopy clinics at

BSMMU or nearby medical college BSMMU or nearby medical college

hospitals.

hospitals.

Overall, 4371 (87.2%) of screen Overall, 4371 (87.2%) of screen positive women underwent

positive women underwent colposcopy.

colposcopy.

(15)

Table 2: Distribution of women Table 2: Distribution of women

attending different colposcopy clinics.

attending different colposcopy clinics.

Institutes with colposcopy clinics No. (%) of women

Bangabandhu Sheikh Mujib Medical University (BSMMU) 2188 (43.6) Chittagong Medical"College Hospital (CMCH) 747 (14.9) Rajshahi Medical College Hospital (RjMCH) 442 (8.8) Mymensingh Medical College Hospital (MMCH) 341 (6.8)

Ktmlna Medical College Hospital (KMCH) 277 (5.5)

Sylhet MAG Osmani Medical College Hospital (SMAGOMCH) 210 (4.2)

Dhaka Medical College Hospital (DMCH) 132 (2.6)

Rangpur Medical College Hospital (RMCH) 34 (0.7)

Women who did not attend 642 (12.8)

Total 5013 (100.0)

(16)

Total women underwent colposcopy – 4371 Total women underwent colposcopy – 4371

Women attended at BSMMU (VIA +ve cases) – Women attended at BSMMU (VIA +ve cases) – 2188

2188

Normal colposcopic findings – 1044 (47.7%) Normal colposcopic findings – 1044 (47.7%)

Colposcopic abnormalities Colposcopic abnormalities

Suggestive of CIN or cancer Suggestive of CIN or cancer =1144 =1144

CIN I CIN I = 682 = 682

CIN IICIN II = 149 = 149

CIN III CIN III = 29 = 29

Invasive Invasive = 134 = 134

Unsatisfactory Unsatisfactory = 150 = 150

(17)

Histopathology results of cases Histopathology results of cases with colposcopic abnormalities with colposcopic abnormalities

CINI CINI = 369 = 369

CIN II CIN II = 127 = 127

CIN III CIN III = 30 = 30

Invasive cancer Invasive cancer = 123 = 123

(18)

Of the 4371 women who underwent Of the 4371 women who underwent

colposcopy, 2188 attended the colposcopy colposcopy, 2188 attended the colposcopy

clinic at BSMMU. The results of colposcopy clinic at BSMMU. The results of colposcopy

and histology are given in Table 3. No and histology are given in Table 3. No

colposcopic abnormalities were detected in colposcopic abnormalities were detected in

1044 (47.7%) women, whereas directed 1044 (47.7%) women, whereas directed

biopsies in 1144; women showed biopsies in 1144; women showed

colposcopic abnormalities suggestive of CIN colposcopic abnormalities suggestive of CIN

or cancer. On histology, 369 women were or cancer. On histology, 369 women were

diagnosed with CIN 1, 127 with CIN 2, 30 diagnosed with CIN 1, 127 with CIN 2, 30 with CIN 3, and 123 with invasive cancer.

with CIN 3, and 123 with invasive cancer.

(19)

VIA repeated by gynecologists in 2188 VIA repeated by gynecologists in 2188 women before they underwent

women before they underwent

colposcopy was positive in 1060 and colposcopy was positive in 1060 and

negative in 1128 women; the final negative in 1128 women; the final

diagnosis among these 1128 VIA- diagnosis among these 1128 VIA-

negative women was as. follows: no negative women was as. follows: no

lesion (n = 1091); CIN 1 (n = 22); CIN lesion (n = 1091); CIN 1 (n = 22); CIN 2-3 (n = 10); and invasive cancer (n = 2-3 (n = 10); and invasive cancer (n = 5). 5).

(20)

The sensitivity, specificity, and positive The sensitivity, specificity, and positive predictive value of VIA to detect CIN 2 predictive value of VIA to detect CIN 2

and 3 lesions after excluding the 123 and 3 lesions after excluding the 123 invasive cancer cases in this selected invasive cancer cases in this selected

sample of women were 93.6%, 58.3%, sample of women were 93.6%, 58.3%,

and 15.6%, respectively (Table 4).

and 15.6%, respectively (Table 4).

Forty-one women (11%) with CIN 1 Forty-one women (11%) with CIN 1 and 80 women (50%) with CIN 2-3 and 80 women (50%) with CIN 2-3

lesions received treatment with LEEP lesions received treatment with LEEP

(n = 105), cryotherapy (n = 6), or (n = 105), cryotherapy (n = 6), or hysterectomy (n= 10) at BSMMU.

hysterectomy (n= 10) at BSMMU.

(21)

Table 3 Accuracy of visual screening with Table 3 Accuracy of visual screening with acetic acid to detect CIN 2-3 lesions among acetic acid to detect CIN 2-3 lesions among 2065 women attending colposcopy services 2065 women attending colposcopy services

at BSMMU.

at BSMMU.

VIA result Women detected

with CIN 2-3 lesions Women with normal

cervix or CIN 1 lesions Total

Positive 147 795 942

Negative 10 1113 1123

Total 157 1908 2065

Sensitivity: 93.6% (95% CI, 88.6-96.9);

Specificity: 58.3% (95% CI, 56.1-60.6); Positive predictive value: 15.6% (95% CI, 13.3-18.1);

Negative predictive value: 99.1% (95% CI, 98.4- 99.6).

(22)

Discussion Discussion

Among the cancers, cervical cancer Among the cancers, cervical cancer

accounts for almost one fifth of cases in accounts for almost one fifth of cases in

women. The cervical cancer burden is closer women. The cervical cancer burden is closer

to that of maternal deaths (13 000 deaths) to that of maternal deaths (13 000 deaths)

in Bangladesh. Currently, 32 million women in Bangladesh. Currently, 32 million women are aged between 30 and 60 years and less are aged between 30 and 60 years and less

than 0.4% are screened annually with a Pap than 0.4% are screened annually with a Pap

smear. It is not feasible to introduce smear. It is not feasible to introduce

cytology screening for cervical cancer cytology screening for cervical cancer

control in Bangladesh given the resource control in Bangladesh given the resource

(23)

The VIA test positivity of around 5% in this The VIA test positivity of around 5% in this program was at the lower range of test

program was at the lower range of test

positivity reported in other VIA studies in positivity reported in other VIA studies in

Asia and Africa.

Asia and Africa.

On repeat VIA performed before colposcopy, On repeat VIA performed before colposcopy, a little more than half of the women were

a little more than half of the women were

scored as negative, which indicates the wide scored as negative, which indicates the wide variability between the test providers due to variability between the test providers due to

the subjective interpretation of the test.

the subjective interpretation of the test.

If we extrapolate this finding to the entire If we extrapolate this finding to the entire study, the test-positive rates are likely to be study, the test-positive rates are likely to be

even lower than 5%.

even lower than 5%.

(24)

Treatment coverage of women with high-Treatment coverage of women with high- grade cervical cancer precursors is

grade cervical cancer precursors is

inadequate: half of such women received inadequate: half of such women received

treatment at the BSMMU colposcopy clinic.

treatment at the BSMMU colposcopy clinic.

The treatment rates can be improved if The treatment rates can be improved if cryotherapy or LEEP are offered

cryotherapy or LEEP are offered

immediately following colposcopy at the immediately following colposcopy at the first visit instead of receiving treatment first visit instead of receiving treatment

after histopathology confirmation of punch after histopathology confirmation of punch

biopsy specimens at the second visit.

biopsy specimens at the second visit.

(25)

Moreover, the current VIA-based program Moreover, the current VIA-based program would facilitate the devel opment of

would facilitate the devel opment of screening, diagnosis, and treatment screening, diagnosis, and treatment

infrastructure in health services, improve infrastructure in health services, improve

awareness of cervical cancer prevention awareness of cervical cancer prevention

among the population, and enable among the population, and enable

incorporation of new developments such incorporation of new developments such

as the more accurate, objective &

as the more accurate, objective &

affordable HPV testing technologies when affordable HPV testing technologies when

these technologies are commercially these technologies are commercially

available & affordable for wider use in available & affordable for wider use in

public health services.

public health services.

(26)

CONCLUSION:

CONCLUSION:

A VIA-based program would A VIA-based program would facilitate the development of facilitate the development of

screening, diagnosis, and screening, diagnosis, and

treatment of cervical neoplasia treatment of cervical neoplasia

and improve awareness of cervical and improve awareness of cervical

cancer prevention in Bangladesh.

cancer prevention in Bangladesh.

(27)
(28)

Approximate rates of spontaneous Approximate rates of spontaneous

regression, persistence &

regression, persistence &

progression of CIN progression of CIN

CINI

CINI CINII CINII CINIII CINIII

Regression to normal Regression to normal 60% 60% 40% 40% 30% 30%

Persistence Persistence 30% 30% 35% 35% 48% 48%

Progression to CINIII Progression to CINIII 10% 10% 20% 20% - -

Progress to carcinoma Progress to carcinoma <1% <1% 5% 5% 22% 22%

(29)

VIA & Colposcopy in MMCH VIA & Colposcopy in MMCH

2010 2010

Total VIA done Total VIA done - 3214 - 3214

VIA –ve VIA –ve - 3139 - 3139

VIA +ve VIA +ve - 75 - 75

Total colposcopy done Total colposcopy done - 433 - 433

Normal Normal - 200 - 200

CINI CINI - 172 - 172

CINII CINII - 22 - 22

CINIII CINIII - 08 - 08

Unsatisfactory Unsatisfactory - 11 - 11

Invasive Invasive - 20- 20

(30)

Histopathology results of Histopathology results of

cases with colposcopic cases with colposcopic abnormalities in MMCH abnormalities in MMCH

CIN I CIN I 92 92

CIN II CIN II 4545

CIN III CIN III 15 15

Invasive carcinoma Invasive carcinoma 15 15

(31)

Squamous epithelium Columnar epithelium

(32)
(33)

Colpoccopy – Abnormal Findings

(34)

References

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