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Recent Advances in Cervical Cancer
Recent Advances in Cervical Cancer
Abstract
Chapter 6
Screening Methods and Early Diagnose
in Cervical Cancers
Melek Ardahan
Early Diagnose in Cervical Cancer
Department of Public Health Nursing, Ege University,
Turkey
Corresponding Author: Melek Ardahan, Department
of Public Health Nursing, Ege University, Tel: (090) (232)
388-1103/5568; Email: [email protected]
*
First Published March 22, 2016
Copyright: © 2016 Melek Ardahan.
This article is distributed under the terms of the Creative
Commons Attribution 4.0 International License
(http://creativecommons.org/licenses/by/4.0/), which
permits unrestricted use, distribution, and reproduction
in any medium, provided you give appropriate credit to
the original author(s) and the source.
2
In this section, screening methods and early diagnose
in cervical cancers, the anatomic and pathologic basis of
visual inspection with acetic acid(VIAA) ,the results of
early diagnose studies with VIAA, nurse’s and midwife’s
role in protection and early diagnosehave been given.
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In recent years, although important improvements
have been made in cancer therapy early diagnose still remains its significance. In fact, to identify those cells that
can be turned into cancer before the illness is onset is
more important in terms of early diagnose and treatment
and this constitutes the most fundamental point in terms
of decreasing the cancer-related deaths [1-4].
Studies carried out on early diagnose of diseases in
population show that in many diseases the known case
count is lesser than the available case count. The term
“diseases are like icebergs” was used for all the diseases
that require early diagnose in population considering that
the much larger part of the icebergs remains under the
sea and is never visible. Because all the population cannot
be screened systematically when screening is made for the
purpose of early diagnose, if the screening is made by selecting those groups under risk, the success to be achieved
considerably increases. Besides, if the disease is seen in
population frequently, if its treatment takes longer time,
if there is a method to be used in screenings and if to pre-
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Recent Advances in Cervical Cancer
Recent Advances in Cervical Cancer
vent progression of the disease is possible then the efforts
to be made for early diagnose will be appropriate [1,5].
One of the leading cancer types where early diagnose
approach is very successful is cervical cancer. PAP-smear
test is a very simple and has very successful responsiveness-selectiveness in terms of early diagnose of this disease. Cervical cancer can be caught at the stage of “insitu” with the help of this method; to heal patients with
the therapy to be performed at this stage is possible. As
a result of advanced examinations when it is applied to
1.000 women for the purpose of early diagnose, 60 women
seem “test-positive”; of these individuals an in-situ cancer
is detected in 13 and invasive cervical cancer in 2 (Figure
1). In early diagnose intended studies the cost per person
is 13 US dollars for PAP-smear and along with advanced
examinations it reaches 34 US dollars; the therapy of an
advanced cervical cancer is estimated to be over one million dollars [5-7].
Those women, who involve sexual relationship at the
early age, make sex with individuals more than one and
having malfunctioning immunologic system are under
the cervical cancer risk. PAP-smear test must be applied
to risk groups more often, because those cells that show
alterations prior to cervical cancer turn into cancer after
a long time, such as 5 to 10 years. Besides, the cervical
cancer-related deaths decrease by 40 % in women who
has received smear test. In groups not under risk, smear
test is recommended once a year. If three tests performed
successively for three years are normal they may be performed less frequently [5,7].
In countries with lesser resources, alternative low-cost
early diagnostic methods are needed, since regular followups cannot be performed with expensive techniques. Visual Inspection with Acetic Acid (VIAA), with many features, is an attractive approach to be used in settings with
less resource, because VIAA’s cost is very low compared to
other early diagnostic methods [8-12].
The Anatomic and Pathologic Basis
of Visual Inspection with Acetic Acid
(VIAA)
Figure 1: The results of early diagnosis study in cervical
cancer.
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Inspection of cervical uterine with naked eye after
acetic acid of 4% was applied provides a simple test possibility for establishment of cervical precancerous lesions
and early term invasive cancer at the early period. The
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potential difficulties related to application of trauma tests
based on cervical cytology to the settings with insufficient
resources have led investigating the validity of alternative
tests with lower technology (such as VIAA) in detection of
cervical neoplasia [13,14]. VIAA results can be immediately obtained and do not require any laboratory support.
The categorization of VIAA results depends on the color
changes observed in cervix. To understood cervix’s anatomy, physiology and pathology clearly is highly important
in terms of understanding the essence of the screenings
made by using VIAA and interpreting the results obtained
through these tests [15,16].
Pathophysiology of VIAA
It is believed that application of acetic acid of 4% causes reversible coagulation or precipitation of cell-related
proteins. Besides, especiallyit leads to swelling of columnar, abnormal squamous epithelial regions and epithelial
tissues and dehydration of cells. Acetic acid application
helps cervix to clean mucus secretions and to coagulate.
The normal squamous epithelium seems pink and the columnar epithelium seems red due to the light reflections
coming from below the stroma rich in blood cells. If epithelium contains too many cellular proteins, acetic acid
coagulates these proteins that can eliminate the color of
stroma. The rest of the white cells are visible when the cervix is compared with normal pink color around the normal
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squamous epithelium; this effect can be seen with naked
eye. So, the effect of acetic acid depends on the amount of
cellular proteins available in epithelium. The region where
nuclear activity increased and DNA content show most of
the white alterations.
When acetic acid is applied to squamous epithelium
some coagulation occurs on the superficial cellular layer.
Despite deeper cells contain excessive nuclear proteins
acetic acid may not affect them because the result of precipitation is not enough for elimination of color under the
stroma. CIN area and invasive cancer undergo coagulation due to high nuclear protein content and block the
upcoming light by passing through epithelium. Consequently, lower epithelium vascular sample vanishes and
epithelium seems densely white.
White-cell appearance is not enough for early diagnose of CIN and cancer. Furthermore, there must be nuclear protein, squamous metaplasia, epitheliumcombined
with inflammation, condyloma and hyperkeratos. When
the white-cell appearance and CIN is combined and at the
beginning of invasive cancer the edges are smaller, opaque,
thin and denser.White cells are generally scattered within
cervix because of infection and regional change has not
been identified. Condyloma and hyperkeratosseem densely grayish-white after acetic acid was applied. The effect of
acetic acid reverses almost at the same slowness in CIN lesions, inflammation and squamous metaplasia and onset
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Recent Advances in Cervical Cancer
of preclinic invasive cancer. It may be three-five minutes
late in CIN 2-3 cases and invasive cancers [17-19].
The Results of Early Diagnose Studies
with VIAA
In many countries early detection of cervical cancer
by using acetic acid was attempted. When the studies carried out were scrutinized; in a study by Belinson et al.
(2001) sensitivity was 71% and specificity was 74%; Deny
et al. (2000) found the sensitivity as 67% and specificity
as 83%; In the scope of JHPIEGO (1999) project sensitivity was 77% and specificity was 64% [20-22]. The results
of other studies were explained in the following table in
detail [8-10,23,24]. When the studies performed were
examined, it also seems that applications were performed
by the personnel other than physicians. When other studies carried out by using acetic acid were scrutinized it
was observed that VIAA sensitivity has changed between
60.3% and 100% and specificity between 30.4% and 96.8%
[25-35].When the studies carried out in previous years
are considered, specificity of VIAA seems significantly reduced[8-10,20-22] (Table 1).
When the studies conducted in recent years are reviewed it appears that VIAA’s sensitivity is between 25.0%
and 94.4%, but its specificity has varied between 32,0%
and 99.1%[36-47] (Table 2). When the studies conducted
in previous years are considered it can be said that VIAA’s
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specificity has shown in increase. Consequently, developing countries’ seeking for cost-effective methods toward
early diagnose of the cervical cancer is gratifying. VIAA
can be used in developing countries as a low-cost, easily
applicable and immediately result obtainable method.
Nurse’s and Midwife’s Role in
Protection and Early Diagnose
Nurse’s/midwife’s role in protection and early diagnose can be categorized under three topics; primary, secondary and tertiary. Primary protection can be achieved
through staying away from risk factors and carcinogens
and through vaccination methods and health training
[48-50]. Health training which is one of the fundamental
responsibilities of nurse/midwife has an important place
in primary protection. Nurses and midwives who communicate with community and individuals constantly,
should inform individuals concerning health habits by
proving medical advice and collecting appropriate data
[51]. In this context, informing population and especially
individuals under risk concerning protection from cancer
and symptoms of early diagnose is very important [52].
Usually humans do not go to overall health control unless they have a complaint. However, individuals under
risk visit health institutes when they are warned by health
personnel and they shift from passive role to active role
[53,54].
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The Organization for Prevention of Cervical Cancers,
cooperate with five international organizations including
WHO, stated that all health personnel working in information and training services should provide women with
training related to protection from cervical cancers wherever and whenever they reach them [55].
Table 1: The Results of Early Diagnose Studies with VIAA.
Author (s) (Year)
No. of
Sensitivity Specificity Research Makers
Women
Nairobi (Kenya )
853
(%)
73.3
(%)
80.0
Not notified
Iran
200
95.7
44.0
Gynecologists
Cameroon
New Delphi
Brazil
4813
400
1154
70.4
96.7
100
77.6
36.4
78
Nurse+ obstetricians
Paramedical
Nurse + physicians
India
18.675
60.3
86.8
et al. (2004) [32]
Bhatla et al. (2004)
[25]
Independent health
carepersonnel
India
100
100
53
Nurses
Ghaemmaghami et al.
Iran
1200
87.5
74.3
63
94
Physicians
Gynecologists
(2004) [30]
El Shalakany et al.
Egypt
2049
85.5
96.8
Gynecologists
China
Pakistan
1997
501
70.9
93.9
74.3
30.4
Oncology experts
Gynecologists r
Vuyst et al. (2005)
[34]
Eftekhar et al. (2005)
[28]
Doh et al. (2005) [27]
Goel et al. (2005) [31]
Bomfim et al. (2005)
[26]
Sankaranarayanan
(2004) [29]
Wu et al. (2003) [35]
Tayyeb et al. (2003)
[33]
Belinson et al. (2001)
[20]
Deny et al. (2000)
Zimbabve Üniversitesi
JHPIEGO (1999)
Sankarananayanan et
al. (1999)
Sankarananayanan et
al. (1998)
Londhe et al. (1997)
[24]
Megevand et al.
(1996) [18]
Cechini et al. (1993)
Slawson (1992)
10
Country
China
1.977
71
74
Africa
Zimbabwe
2.944
2.203
67
77
83
64
Gynecologic oncologist
Nurse
Nurse-obstetrician
India
1.351
96
68
Nurse
India
3000
90
92
Cytology technician
India
372
72
54
Not indicated
South Africa
2.426
65
98
Nurse
Italy
United States
2.105
2.827
83
29
83
97
Obstetricians
Clinicians
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In secondary protection, nurse/midwife should tell individuals the importance of regular health screenings and
early diagnose [51]. Thereby, early diagnose is achieved.
Early diagnose is define as “all kinds of health activities
carried out in order to catch a certain disease before its
symptoms and findings appear by targeting whole of the
healthy population or a part of it accepted to be under
risk”[56]. The cervical cancer is at the forefront of the cancers preventable through screening. The reason for this is
the presence of well-defined prolonged preinvasive period
in cervical cancer [57].
Table 2: The Results of Early Diagnose Studies with VIAA
in Last Year.
Author (s) (Year)
Country
Women
(%)
(%)
Khodakarami et al. (2011)
[36]
Lewis et al. (2011) [37]
Ibrahim et al. (2012) [38]
Albert et al. (2012) [39]
Sahasrabuddhe et al.
(2012) [40]
Begum et al. (2012) [41]
-
100
62.5
98.8
Nairobi (Kenya )
Sudan
Zaria
India
490
934
351
303
93.0
74.2
60.0
80.0
32.0
41.9
94.4
82.6
Bangabandhu Sheikh
Mujib Medical University Nairobi (Kenya)
-
300
94.4
97.8
500
3629
92.7
93.0
99.1
91.0
Karachi
Cameroon
Iran
500
540
1000
93.5
36.4
71.4
95.8
90.4
50.0
Africa
259
25.0
74.2
Chung et al. (2013 ) [42]
Pimple and Shastri (2014)
[43]
Khan et al. (2015) [44]
Tebeu et al. (2015) [45]
Paurasad-Shahrak et al.
(2015) [46]
Bigoni et al. (2015) [47]
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No. of
Sensitivity
Specificity
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In screening studies carried out for the purpose of
early diagnose, screening only those groups under risk
instead of whole population provided more successful
results. Women under high risk are known as those who
become sexually active during adolescent period and have
predisposition to be polygamy [58].
In the scope of tertiary protection program nurses/
midwives may prevent complications by training patients
and monitoring regularly. Moreover, they can reduce disabilities by providing symptom control and paying immediate attention to complications [59].
Conclusion
Various methods are used in the diagnosis of early
cervical cancer.Some of the most inexpensive and simplemethod is VIAA. VIAA is a method that can be used
easily in developing countries. In addition, the methods
used in the diagnosis of early cervical cancer nurse and
midwife important roles in interested in.
References
1. Ergör G.Strategy For Population Based Screenings. The First Regional Meeting of the Asian Pacific Organization for Cancer Prevention. Izmir:
Ege University MÖTBE Hall. 2003.
2. Hoffman MS, Cavanagh D. Cervical Cancer:
Screening and Prevention of Invasive Disease.
Cancer Control. 1995; 2: 503-509.
12
www.avidscience.com
3. Schneider V, Henry MR, Jimenez-Ayala M, Turnbull LS, Wright TC. Cervical Cancer Screening,
Screening Errors and Reporting. Acta Cytol. 2001;
45: 493-498.
4. Taşkın L. Childbirth and Women’s Health Nursing. 8. Edition. Ankara: System Offset Publishing
House. 2007; 15: 607-616.
5. BilirN, HarmancıH. Current Approaches in Protection from Cancer. 8. National Community
Health Congress. Congress Book. Diyarbakır.
2002; 147-152.
6. Nygard JF, Skare GB, Thoresen SO. The Cervical
Cancer Screening Programme in Norway, 19922000: Changes in Pap Smear Coverage and Incidance of Cervix Cancer, J Med Scree. 2002; 9: 86-91.
7. O’Meara AT. Present Standarts for Cervical Cancer Screenig. Curr Opin Oncol. 2002; 14: 505-511.
8. Gates B, Gates M. Visual Screening Approaches:
Promising Alternative Screening Strategies. Alliance Cervical Cancer Prevention. 2003.
9. Gates B, Gates M. Pap Smears: An Important But
Imperfect Screening Method, Alliance Cervical
Cancer Prevention. 2003.
10.Gates B, Gates M. Treating Precancerous Cervical Lesions. Alliance Cervical Cancer Prevention.
2003.
www.avidscience.com
13
Recent Advances in Cervical Cancer
Recent Advances in Cervical Cancer
17.Denny L, Kuhn L, Pollack A, Wright TC Jr. Direct
Visual Inspection for Cervical Cancer Screening:
An Analysis of Factors Influencing Test Performance. Cancer. 2002; 94: 1699-1707.
12.Tayyeb R, Khawaja NP, Malik N. Comparison of
Visual Inspection of Cervix and Pap Smear for
Cervical Cancer Screening. J Coll Physicians Surg
Pak. 2003; 13: 201-203.
18.Megevand E, Denny L, Dehaeck K, Soeters R,
Bloch B. Acetic Acid Visualization of the Cervix:
An Alternative to Cytologic Screening. Obstet
Gynecol. 1996; 88: 383-386.
13.Basu PS, Sankaranarayanan R, Mandal R, Roy C,
Das P, et al. Visual Inspection with Acetic Acid
and Cytology in the Early Detection of Cervical
Neoplasia in Kolkata. INDIA. Int. J. Gynecol Cancer. 2003; 13: 626-632.
19.Wright TC, Denny L, Kuhn L, Goldie S. Use of
Visual Screening Methods for Cervical Cancer
Screening. Obstet Gynecol Clin North Am. 2002;
29:701-734.
14.Basu PS, Sankaranarayanan R, Mandal R, Roy C,
Das P, et al. Evaluation of Downstaging in the Detection of Cervical Neoplasia in Kolkata. INDIA.
Int. J. Cancer. 2002; 100: 92-96.
15.Claeys P, Vuyst D, Gonzalez C, Garcia A, Bello RE,
et al. Performance of the Acetic Acid Test When
Used in Field Conditions as a Screening Test for
Cervical Cancer.Tropical Medicine & International Health. 2003; 8: 704.
16.Sankaranarayanan R, Ramani S, Wesley MD. A
Practical Manual on Visual Screening for Cervical
Neoplasia. World Health Organization. France.
14
2003.
11.Sing V, Schgal A, Parashari A, Sodhani P,
Satyanarayana L. Early Detection of Cervical
Cancer through Acetic Acid Application an Aided
Visual Inspection. Singapore Med J. 2001; 42: 351354.
www.avidscience.com
20.Belinson JL, Pretorius RG, Zhang WH, Wu LY,
Qiao YL, et al. Cervical Cancer Screening by Simple Visual Inspection after Acetic Acid. Obstet
Gynecol. 2001; 98: 441-444.
21.Cecchini S, Bonardi R,Iossa A, Zappa M, Ciatto S.
Colposcopy as a Primary Screening Test for Cervical Cancer. Tumori. 1997; 83: 810-813.
22.Denny L, Kuhn L, Pollack A, Wainwright H,
Wright TC Jr. Evaluation of Alternative Methods
of Cervical Cancer Screening for Resource-Poor
Settings. Cancer. 2000; 89: 826-833.
23.JHPIEGO Cervical Cancer Project. Visual Inspection with Acetic Acid for Cervical Cancer Screenwww.avidscience.com
15
Recent Advances in Cervical Cancer
Recent Advances in Cervical Cancer
ing: Test Qualities in a Primary Care Setting.Lancet.1999; 353: 869-873.
of the Cervix for the Detection of Premalignant
Lesions.J Low Genit Tract Dis. 2004; 8:16-20.
24.Londhe M, George SS, Seshadri L. Detection of
CIN by Naked Eye Visualization after Application
of Acetic Acid.Indian J Cancer. 1997; 34: 88-91.
30.Ghaemmaghami F, Behtash N, Modares GM,
Mousavi A, Marjani M, et al. Visual Inspection
with Acetic Acid as a Feasible Screening Test for
Cervical Neoplasia in Iran. Int J Gynecol Cancer.
2004; 14: 465-469.
25.Bhatla N, Mukhopadhyay A, Joshi S, Kumar A,
Kriplani A, et al. Visual Inspection for Cervical
Cancer Screening: Evaluation by Doctor Versus
Paramedical Worker. Indian J Cancer. 2004; 41:
32-36.
26.Bomfim S, Santana-Franco E, Bahamondes L.
Visual Inspection with Acedic Acid for Cervical
Cancer Detection. International Journal of Gynecology& Obstetrics. 2005; 88: 65-66.
27.Doh AS, Nkele NN, Achu P, Essimbi F, Essame O,
et al. Visual Inspection with Acetic Acid and Cytology as Screening Methods for Cervical Lesions
in Cameroon. International Journal of Gynecology & Obstetrics. 2005; 89: 167-173.
28.Eftekhar Z, Rahimi M, Yarandi F, Brojerdi R. Accuracy of Visual Inspection with Acedic Acid
(VIA) for Early Detection of Cervical Dysplasia
in Tehran. IRAN. Asian Pac J Cancer Prev. 2005;
6: 69-71.
29.El-Shalakany A, Hassan SS, Ammar E, Ibrahim
MA, Salam MA,et al. Direct Visual Inspection
16
www.avidscience.com
31.Goel A, Gandhi G, Batra S, Bhambhani S, Zutshi V, et al. Visual Inspection of the Cervix with
Acedic Acid for Cervical Intraepithelial Lesions.
Int J Gynaecol Obstet. 2005; 88: 25-30.
32.Sankaranarayanan R, Shastri SS, Basu P, Mahé C,
Mandal R, et al. The Role of Low-level Magnification in Visual Inspection with Acetic Acid for
the Early Detection of Cervical Neoplasia. Cancer
Detect Prev. 2004; 28: 345-351.
33.Tayyeb R, Khawaja NP, Malik N. Comparison of
Visual Inspection of Cervix and Pap Smear for
Cervical Cancer Screening.J Coll Physicians Surg
Pak. 2003; 13: 201-203.
34.Vuyst DH, Claeys P, Njiru S, Muchiri L, Steyaert
S,et al. Comparison of Pap Smear.Visual Inspection with Acedic Acid. Human Papilloma virus
DNA-PCR Testing and Cervicography. Int J Gynaecol Obstet. 2005; 89: 120-126.
35.Wu LY, Li N, Zhang WH, Li L, Pan QJ, et al. Valwww.avidscience.com
17
Recent Advances in Cervical Cancer
Recent Advances in Cervical Cancer
ue of Acetic Acid Smear Test for Cervical Cancer
Screening. Ai Zheng. 2003; 22: 1096-1098.
among HIV-infected women in India. Int J Cancer. 2012; 130: 234-240.
36.Khodakarami N, Farzaneh F, Aslani F, Alizadeh K.
Comparison of Pap smear, visual inspection with
acetic acid, and digital cervicography as cervical
screening strategies. Arch Gynecol Obstet. 2011;
284: 1247-1252.
41.Begum SA, Rashid MH, Nessa A, Aziz MA, Zakaria SM, et al. Comparative study between Pap
smear and visual inspection using acetic acid as a
method of cervical cancer screening. Mymensingh Med J. 2012; 21: 145-150.
37.Lewis KC, Tsu VD, Dawa A, Kidula NA, Chami
IN, et al. A comparison of triage methods for Kenyan women who screen positive for cervical intraepithelial neoplasia by visual inspection of the
cervix with acetic acid. Afr Health Sci. 2011; 11:
362-369.
42.Chung MH, McKenzie KP, De Vuyst H, Richardson BA, Rana F, et al. Comparing Papanicolau smear, visual inspection with acetic acid and
human papillomavirus cervical cancer screening
methods among HIV-positive women by immune
status and antiretroviral therapy. AIDS. 2013; 27:
2909-2919.
38.Ibrahim A, Aro AR, Rasch V, Pukkala E. Cervical
cancer screening in primary health care setting in
Sudan: a comparative study of visual inspection
with acetic acid and Pap smear. Int J Womens
Health. 2012; 4: 67-73.
39.Albert S, Oguntayo O, Samaila M. Comparative
study of visual inspection of the cervix using acetic acid VIA) and Papanicolaou (Pap) smears for
cervical cancer screening. Ecancermedicalscience. 2012; 6: 262.
40.Sahasrabuddhe VV, Bhosale RA, Kavatkar AN,
Nagwanshi CA, Joshi SN, et al. Comparison of
visual inspection with acetic acid and cervical
cytology to detect high-grade cervical neoplasia
18
www.avidscience.com
43.Pimple S, Shastri SS. Comparative evaluation
of human papilloma virus-DNA test verses colposcopy as secondary cervical cancer screening
test to triage screen positive women on primary
screening by visual inspection with 5% acetic acid.
Indian J Cancer. 2014; 51: 117-123.
44.Khan M, Sultana SS, Jabeen N, Arain U, Khans
S. Visual inspection of cervix with acetic acid: a
good alternative to pap smear for cervical cancer
screening in resource-limited setting. J Pak Med
Assoc. 2015; 5: 192-195.
45.Tebeu PM, Fokom-Domgue J, Crofts V, Flahaut E,
Catarino R, et al. Effectiveness of a two-stage stratwww.avidscience.com
19
Recent Advances in Cervical Cancer
Recent Advances in Cervical Cancer
egy with HPV testing followed by visual inspection with acetic acid for cervical cancer screening
in a low-income setting. Int J Cancer. 2015; 136:
743-750.
46.Pourasad-Shahrak S, Salehi-Pourmehr H, Mostafa-Garebaghi P, Asghari-Jafarabadi M, Malakouti
J, et al. Comparing the results of Pap smear and
Direct Visual Inspection (DVI) with 5% acetic
acid in cervical cancer screening. Niger Med J.
2015; 56: 35-38.
47.Bigoni J, Gundar M, Tebeu PM, Bongoe A, Schäfer
S, et al. Cervical cancer screening in sub-Sahara
Africa: a randomized trial of VIA versus cytology
for triage of HPV-positive women. Int J Cancer.
2015; 137: 127-134.
48.Arvas M, GezerA. Management of Familial (Hereditary) Ovary Cancers; Prevention ofOvary
Cancers – Surgical Approaches and Chemoprevention. Turkish Gynecologic Oncology Journal.
2004; 7: 89-98.
49.Lopez Ma L, Garcia–Cueto E, Fernandez JM,
Lopez S, Del Valle Ma del O, et al. Validation of a
questionnaire to evaluate the attitude towards primary prevention advice from the Europeon code
against cancer. European Journal of Cancer Prevention. 2003; 12: 157-164.
50.Turgay A, Sarı D, Türkistanlı Ç. Knowledge atti20
www.avidscience.com
tudes, risk factors, and early detection of cancer
relevant to the school teachers in İzmir, Turkey.
Preventive Medicine. 2005; 40: 636-641.
51.Pınar G, Algier L, Doğan N,Kaya N. Determining Risk Factors in Individuals with Gynecologic Cancer. International Hematology-Oncology
Journal. 2008; 18: 208-216.
52.Nural N, Akdemir N. The Cancer Risk Factors in
Patients Staying Internal Diseases Services and
Identifying the Symptoms of Early Diagnose. C.U.
Higher School of Nursing Journal. 2000; 4: 1-13.
53.Akbayrak N, Akdemir N. Determining Nurse’s Effect on Early Diagnose and Prevention of Cancers.
Nursing Forum.1998; 1: 226-229.
54.Croghan IV, Omoto MK. Cancer Prevention and
Risk Reduction. In: SB Baird, ed. A cancer source
book for nurses. 6th ed. By The American Cancer
Society Printed in the United States of America.
1991; 31-40.
55.Alliance for Cervical Cancer Prevention (ACCP).
Planning and implementing cervical cancer prevention and control programs: A manuel for managers. Seattle: ACCP. 2004; 13: 130-146.
56.Fidaner C. Catching Cancer Early: Early Diagnose
and Screenings. In: Tuncer, A.M. Editor. The Cancer Control in Turkey. Ankara: Onur Publishing
House. 2007; 319-331.
www.avidscience.com
21
Recent Advances in Cervical Cancer
57.TuncerZS. Human Papilloma Virus Infection in
terms of Gynecology. Hacettepe Medical Journal.
2007; 38: 8-14.
58.World Health Organization. National Cancer
Control Programmes Policies and Managerial
Guidelines. 2nd edition. Geneva: WHO. 2002.
59.Platin N. Cancer Handbook for Nurses. The
American Cancer Association. T.R. Ministry of
Health, Head of Cancer Administration and Oncology Nursing Association Journal. 2. Edition.
Ankara: Evening Art School Print Shop. 1998.
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