Download Treatment options for precancerous lesions of the cervix

Treatment Options for Cervical Cancer in Low Income
Countries
Dr. Nelly R. Mugo
Obstetrician Gynaecologist/ Research Scientist
Kenya Medical Research Institute
2016 WE CAN African Breast and Cervical Cancer
Advocacy, Education and Outreach Summit
Fairview Hotel
22nd April 2016
Can we envision a world where women no longer die
from cervical cancer ?
Cervical cancer is a preventable disease, when
diagnosed early
We can treat in the outpatient clinic and effectively
prevent cancer events
Increased screening has greatly reduced the
incidence of cervical cancer in England
• Improvements in cervical screening coverage in England have
led to a 35% decrease in cervical cancer cases in under a decade
Age-standardized incidence of invasive cervical cancer
and coverage of screening, England 1971–1995
18
Covera
ge
14
12
10
0
Invasive cervical
cancer
National call-recall
introduced
Year
Percenta
ge
Incidence rate per
100,000
16
100
90
80
70
60
50
40
30
20
10
0
Quinn M, et al. Brit Med J 1999; 318:904–908.
Why we should invest in preventing
cervical cancer
• 500,000 incident cases of cervical cancer each
year
• 230,000 deaths each year
– 80% of women with cancer and experiencing cervical
cancer death reside in sub Saharan Africa
– SSA have less than 5% of cancer treatment resources
• Risk of Ca cervix for a woman in LIC is approx 24%
• Pap smear screening programs have markedly
reduced the incidence of ca cervix in Western
countries
Kenya situation:- Cancer
• Average age at presentation for invasive cancer is 42 years
• In most cases it is diagnosed late (>90% are stage IIB or worse)
• KNH is the only national hospital with radiotherapy
– Currently Nairobi city has three private hospitals (AGK, MP Shah, Nairobi Hospital)
with radiotherapy units
• Several regional hospices offer Palliative care
•
Situation expected to improve: 
– Ministry of Health
• See and treat approach
– VIA/VILLI and cryotherapy
• Colposcopy machines
• Collaboration with Partners
Treatment options for Pre-Malignant
Lesions of the Cervix
•
•
•
•
Cryotherapy
LEEP
Cone Biopsy
Hysterectomy
The mouth of the uterus (cervix) provides access
normal on naked eye exam
The early lesion is within a small
area of the cervix, can be seen
clearly with application of acetic
acid or lugols iodine, outlining
area for treatment
Pre-malignant
Cervix with acetic acid (VIA)
Lugols iodine
changes
Sqcolumnar
junction
Progression to Cervical Cancer
Years
Months
Normal
Epithelium
HPV Infection
ASCUS/LSIL
CIN1
CIN2
CIN3
Decades
Carcinoma
HSIL
Screening
Treatment
Persistent HPV infection
SIL = Squamous intraepithelial lesion - CIN : Cervical intraepithelial neoplasia
Treatment: LEEP
The wire quickly passed within the borders of the lesion,
completely removes the area with early changes- pre cancer
Done in the clinic, actual procedure very short
Visual Inspection with
Acetic Acid
Normal
VIA Positive: Aceto White Lesion
Instruments for Visual Inspection
No power, simple light, can be done in any level
of health care
Easily followed with cryoyotherapy
Suspicious of Cancer
Cryotherapy: freezing technique
freezing destroys the abnormal tissue
uses gas: nitrogen or carbon dioxide
does not require electricity
low cost
Appearance after Cryotherapy
2 wks later
Iceball-immediate
3 months later
One year later
Screen and Treat: is ideal
with no repeat visits
reduces both direct (facility) and indirect
costs (to clients-transport and time)
In Zambia:
>15 service points,
screened 20,000 women over a 2
year period
Utilize nurses, with a screen and
treat approach
Referral for none cryotherapy
eligible lesions
In Kenya, there over 10.3 million women at risk
for cervical cancer over the age of 15 years, with risk
of cervical cancer
we have the knowledge and tools to effectively
prevent the advent of cancer in their lives
15
A Team Approach To Cervical Cancer
Prevention And Control
• Cervical cancer control requires a multi- sectoral and multidisciplinary
effort.
• It also requires strong linkages and team work between providers at all
levels of health care system
– Target high risk women with a once or twice lifetime use of a highly
sensitive test
– Emphasis on high coverage (80%)
• Effective screening programme low resource settings require
– adequate financial resources
– adequate infrastructure
– Trained manpower
– Surveillance mechanisms for screening, treating, and follow up