Chapter One: Introduction

Magnitude of the Problem

 Third most common cancer in women

 Affects 1.4 million women worldwide
 Each year, 460,000 new cases occur
 Each year, 231,000 women die of the disease
 About 80% of new cases are in developing
countries

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 Background

 99.7% of cervical cancers directly linked to previous

infection with human papillomavirus (HPV)
 Of more than 50 types of HPV that infect genital tract,
15–20 types linked to cervical cancer
 Four of these types are most often detected in cervical
cancer
 HPV infections often cause no symptoms
 Most common signs of infection are small pink or red
warts, itching and burning in genital area

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 Background (cont.)

 After woman becomes infected with HPV:

 Infection may remain stable
 Infection may regress spontaneously
 If cervix infected, may develop into low-grade
squamous intraepithelial lesions (LGSILs), also called
mild cervical intraepithelial neoplasia
(CIN I) or early dysplasia

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 Background (cont.)

 For every 1 million women affected, 10%

(100,000) will develop precancerous changes in
cervical tissue:
 These changes are usually in women ages 30–40
 About 8% of these women will develop precancer
limited to outer layers of cervix (carcinoma in situ)
(CIS)
 About 1.6% will develop invasive cancer unless CIS
detected and treated

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 Background (cont.)

 Progression to cervical cancer from high-grade

squamous intraepithelial lesions (HGSILs)
usually occurs over 10–20 years
 Although rare, some precancer lesions become
cancerous within a year or two

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 HIV/AIDS, HPV Infection, and
Cervical Cancer
 39.5 million people living with HIV/AIDS in 2006;
almost half women
 Heterosexual contact main mode of transmission
in new cases
 In HIV-infected women:
 HPV detected more frequently; resolves more slowly
 HPV-associated diseases more difficult to treat
 Progression of precancer accelerated

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 HIV/AIDS, HPV Infection, and
Cervical Cancer (cont.)
 Cervical cancer screening important in this
population:
 Where HIV endemic, 15–20% women positive for
precancer
 Cervical squamous cell cancer now an “AIDS-
defining illness”
 Antiretroviral drugs improve quality of life; effect
on progression of precancer not known

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 Risk Factors for HPV and
Cervical Cancer
 Sexual activity before age 20
 Multiple sexual partners
 Exposure to sexually transmitted infections (STIs)
 Mother or sister with cervical cancer
 Previous abnormal Pap smear
 Smoking
 Immunosuppression:
 HIV/AIDS
 Chronic corticosteroid use

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 Preventing Cervical Cancer

 Preventing HPV infection will prevent cervical

cancer
 No conclusive evidence that condoms reduce
the risk of HPV infection, although they may
provide some protection against HPV-associated
diseases

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 Primary Prevention:
Development of a Vaccine
 A vaccine would be the most effective way to
prevent cervical cancer
 Vaccine would protect woman against only some
types of HPV
 Vaccine would need to contain mixture of
virus types
 At least two vaccines currently being tested

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 Secondary Prevention

 Women already infected should be screened to

determine whether they have early, easily treatable
precancerous lesions
 Pap smear is most well-established screening method
 Other screening methods:
 Visual screening
 HPV tests
 Automated cytology screening
 Pap smear, with its many steps, is problematic in low-
resource settings

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 Screening:
Visual Inspection with Acetic Acid (VIA)
 VIA is at least as effective as Pap smear in
detecting disease
 VIA has fewer logistic and technical constraints
 Studies in South Africa, India and Zimbabwe in
1990s showed VIA as a good alternative to Pap
smear
 Later studies confirmed that VIA is viable option
for screening in low-resource settings

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 Value of VIA in Low-Resource Settings

 Can effectively identify most precancerous lesions

 Is non-invasive, easy to perform and inexpensive
 Can be performed by all levels of health care workers in
almost any setting
 Provides immediate results that can be used to inform
decisions and actions regarding treatment
 Requires supplies and equipment that are readily
available locally

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 Treatment

 Testing should be linked to appropriate treatment for any

precancerous lesions detected
 High-grade (CIN II–III) lesions should be treated
because they are more likely than low-grade (CIN I)
lesions to progress to cancer
 Most CIN I lesions regress spontaneously and do not
progress to cancer
 When close followup or confirmation is not possible,
treatment of acetowhite lesions may be advisable

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 Factors Affecting Choice of Treatment
 Effect on fertility
 Safety in pregnancy
 Method effectiveness
 Safety and potential side effects
 Who is allowed to provide treatment, and what training
they need
 Size, extent, severity and site of the lesion
 Acceptability of treatment offered
 Equipment and supplies needed
 Availability of method
 Cost or affordability of method

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 Managing Precancerous Cervical Disease
with Single Visit Approach
 Single visit approach:
 Modified version of screen-and-treat approach
 Links VIA with treatment using cryotherapy
 Women with VIA-positive results and for whom
cryotherapy is indicated are offered treatment

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 Advantages and Disadvantages of the
Single Visit Approach
 Advantages:
 Reduces the number of women lost to followup
 Can occur at lowest level of health care system
 Disadvantages:
 VIA has considerable false-positive rate
 Proportion of women who are VIA-positive do not
have precancerous lesions

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Treating Women with Unconfirmed Disease

 Positive predictive value of VIA is between 10%

and 35%
 Using single visit approach, between 6.5 to 9 of
every 10 women who test positive on VIA do not
have high-grade lesion and would be offered
immediate treatment

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Treating Women with Unconfirmed Disease
(cont.)
 Because of low morbidity associated with
cryotherapy, treatment of all women with VIA-
positive result may be cost-effective by
preventing disease from progressing to cervical
cancer
 Cryotherapy has the potential to significantly
reduce the probability of developing cancer or
precancerous lesions

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Links to Other Reproductive Health Services

 Linking cervical cancer screening and treatment

to other services is essential and logical
 These services are usually separate, leaving
women without access to care and contributing
to women’s poor health status
 Cervical cancer prevention must be integrated
with existing reproductive health care services

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Links to Other Reproductive Health Services
(cont.)
 District-based implementation of interventions
will ensure that health services are available
close to where people live
 Nurse or midwife who works in the community is
usually the best person to provide community-
based, appropriate, safe and cost-effective care

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