SlideShare une entreprise Scribd logo
1  sur  31
Télécharger pour lire hors ligne
Cervical Screening
Ayman Ewies
Consultant Gynaecologist
The Ipswich Hospital
24th April 2009
Background: Natural History
3
Natural History of Cervical Carcinoma
 Cervical cancer is the 2nd commonest female cancer
worldwide (breast cancer is the commonest).
 It accounts for 12% of cancers in women worldwide.
o Worldwide 470,000 new cases and 233,000 deaths per year.
o 80% in developing countries.
o Only 5% of all cancer resources spent in 3rd world.
o Highest incidences in Madras (India) and Coli (Columbia)
– 48-52/100,000 women per year.
– 60-80% diagnosed with stage III/VI disease.
 Women with cervical cancer die at a younger age than
those with any other non-childhood cancer.
4
Natural History of Cervical Carcinoma
 It is, potentially , the most preventable major form of cancer, given the
long natural history of pre-cancer stage.
 Countries that introduced organized cervical screening programmes
have seen significant falls in the incidence and mortality associated
with cervical cancer.
 In the UK, the cumulative risk for cervical cancer is 1.4% up to age 80
years.
 2,800 cases per annum UK.
 1,100 deaths per annum UK.
 Bimodal age distribution peaks at 30-35 / 80+
21 women die each week
on average in the UK
Natural History of Cervical Carcinoma
Time
6
27
Deathsper100,000
Mortality in developing countries
Mortality in developed countries
Effect of health education, regular check-ups &
availability of appropriate management services
Introduction of screening
Effect of screening
6
Risk Factors For Cervical Cancer
1. HPV infection: RR 116
2. Early onset of sexual activity before age of 16:
- Intercourse within one year of menarche  RR 16
3. Multiple sexual partners (self or of the partner):
- ≥ 6 life time partners  RR 5
4. Low socio-economic status (irrespective of other factors): RR 3
5. Black race compared to white: RR 2
7
Risk Factors For Cervical Cancer
6. Heavy long-term tobacco smoking: RR 2
7. Use of COC:
 Using COC ≥5 years + HPV positivity  RR 3
 Death from cervical cancer among current and recent users (within
10 years)  RR 10
8. Immuno-compromise (e.g. organ transplant, lupus disease & HIV
infection)  RR 5
Sexual
activity
Normal
mucosa
CIN
Persistent
HPV
infection with
high risk
types
Invasive
cervical
cancer
“Seed, soil and nutrient” model for cervical carcinogenesis
Aetiology of Cervical Cancer
Co-factors:
Smoking
OC use
Other STD’s
Immunosuppression
Transient HPV
infection
9
Cervical Screening in The UK
 The NHS cervical screening programme is recognised
as world leading.1
 Cervical cancer incidence fell by 42% between 1988 and
1997 (England and Wales). This fall is believed to be
directly related to the cervical screening programme2
which was introduced in 1988.
1. http://cancerscreening.org.uk/cervical/publications/cervical-annual-review-2004.pdf Accessed 12/10/05
2. NHS. Cervical Screening pocket guide. 2004.
10
Cervical Screening in The UK
 Computerised call / recall since 1988 reduced deaths from cervical
cancer by 60% despite increased incidence CIN 2/3.
 Success of UK screening attributed to coverage of >80% of eligible
population.
 Almost 5000 deaths per year prevented by cervical screening in UK.
 England - incidence cervical cancer fallen from 15.4/ 100,000 to 9.6/
100,000
• Increased fall of mortality from 1-2% to 7% per year.
• Now decreased to 5% per year.
 England - screening of almost 4 million women per year
• Cost £150 million @ £37.5 per woman screened.
Dr Ayman Ewies - Cervical screening 2009
12
Cervical cancer incidence rates per 100,000
women, England and Wales, 1971-98
13
Cervical cancer mortality, England and Wales,
1971-2000
Screening Programmes
15
Screening programmes
 1949 first organised regional cervical screening programme.
– British Columbia
 1960’s further programmes.
– Scandinavia, USA, Scotland
Variation of current programmes:
– USA – screening at onset sexual activity.
– Holland – 5 yearly from 30 years.
16
Screening programmes - UK
 England and N. Ireland: 3 yearly 25-49  5 yearly 50-65.
 Wales: 3 yearly 20-65.
 Scotland: 3 yearly 20-60.
17
Screening programmes - UK
Outcome of cervical cytology %
90.55 negative
1.74 inadequate
3.95 borderline dyskaryosis
2.37 mild dyskaryosis
0.67 moderate dyskaryosis
0.59 severe dyskaryosis
0.04 ?invasion
0.08 abnormal glandular cells
Source - CSP Wales Jan – Jun 2006
18
Screening programmes
Developing Countries
 4.6 billion people living in developing countries  Only 5% of women
offered screening.
 900m adults illiterate and >1 billion live on <$1 US/ day.
 3rd world screening fails because
– Lack of organisation/ monitoring.
– Lack of motivation of staff having other disease priorities.
– Lack of professional awareness in public health.
– Poor coverage.
– Poor patient compliance/ understanding.
– Poor availability/ affordability/ sustainability.
19
Screening programmes
Developing Countries
 VIA and VILI are easy to teach but have limited reliability
 may be useful in resource poor countries.
 VIA: Sensitivity 79%, specificity 83%, PPV 12%, NPV
99%
– for detecting CIN 2/3
– >100,000 women from 25 studies.
 Performance VILI appears comparable.
 VILI could follow VIA for borderline cases.
 No magnification.
20
Screening programmes
Developing Countries
 See and treat patients offered cryotherapy for abnormal
results.
 VIA/ VILI less useful in postmenopausal women.
 Screening result:
– 1 visit @ 35 yrs  reduces lifetime risk cancer by 25-
36%.
– 2 visits @ 35-40 yrs  reduces risk by further 40%.
(Goldie et al, 2005)
Human Papilloma Virus (HPV)
22
HPV Infection
 HPV DNA is present in virtually all cervical tumours.
 It has been proposed as the first ever identified “necessary
cause” of a human cancer.
103 HPV genotypes known
35 infect the genital tract
20 carcinogenic
16 & 18 found in75% of cervical cancer cases
23
HPV Infection
HPV infection can be:
1- Sub-clinical (flat warts)
 Changes similar to CIN 1 that become apparent only with the
application of acetic acid.
 Satellite lesions may present outside the TZ.
2- Clinical (exophytic warts = condylomas)
 Visible on naked eye inspection.
 The viral type is usually non-oncogenic ( 6 or 11 in 90% of cases).
 Histological confirmation is important since they may mimic invasive
lesions.
24
HPV Infection
Exophytic warts
25
HPV Infection
 Reported incidence in developed countries varies between 10-30% in
the adolescent age group (16-24 years).
The incidence drops to 5% above age of 30 years.
An estimated 80% of sexually active women will be exposed to the virus
by age 50.
60-80%
Clear spontaneously
(within 1-2 years)
20-40%
CIN
(within 2-4 years)
26
HPV Infection
Women >30 years with high risk HPV positive and normal
smear  the risk of developing CIN 3 is 116 times higher
than women with an HPV negative and normal smear.
The progression rate of CIN in women with high risk HPV
positive is 5% per year.
27
HPV Vaccination
 In September 2008 national HPV vaccination programme
introduced using Cervarix (GSK), prophylactic vaccine
against HPV 16/18.
 Vaccination will target 12/13 year old girls.
 Catch-up programme over next 3 years:
– 18 years old girls vaccinated during 2008/9.
– 16/17 years old girls during 2009/10.
– 14/15 year old girls during 2010/11.
28
HPV Vaccination
 Case for HPV vaccination based on evidence from RCT
showing virus like particle (VLP) vaccine effectively
prevented HPV 16/18 specific high grade CIN.
 Evidence of cross protection against HPV 31/45 in the
longer term.
 Cervarix does not protect against genital warts.
 Cervarix will reduce incidence HPV 16 related VaIN/ VIN.
29
HPV Vaccination
 Since >60% CIN2/3 cases are HPV 16/18 related 
incidence is expected to ↓ over next 15 years.
 However, cervical screening will still be needed for
unvaccinated women and to prevent non HPV 16/18 related
cancer in vaccinated women.
 Further modelling studies/ trials to design changes to
screening programme are required.
• ? increasing screening intervals
30
HPV Vaccination
 The vaccine should be administered as 3 IM injections at months 0, 2
and 6.
 Each dose is 0.5ml.
 Presented in a pre-filled syringe with safety device.
 The vaccination schedule permits flexibility if necessary.
 Generally well-tolerated:
-The commonly reported adverse events were injection site
reactions and mild fever.
Dr Ayman Ewies - Cervical screening 2009

Contenu connexe

Tendances

HPV Vaccination & Ca. Cervix Screening Update Dr. Sharda Jain Dr. Jyoti A...
HPV Vaccination & Ca. Cervix Screening Update  Dr. Sharda Jain Dr. Jyoti A...HPV Vaccination & Ca. Cervix Screening Update  Dr. Sharda Jain Dr. Jyoti A...
HPV Vaccination & Ca. Cervix Screening Update Dr. Sharda Jain Dr. Jyoti A...Lifecare Centre
 
Cervical cancer prevention Dr Sharda Jain
Cervical cancer prevention Dr Sharda Jain Cervical cancer prevention Dr Sharda Jain
Cervical cancer prevention Dr Sharda Jain Lifecare Centre
 
HPV Infection , HPV Vaccination , Cervical cancer , Cancer in India , Dr. SHA...
HPV Infection , HPV Vaccination , Cervical cancer , Cancer in India , Dr. SHA...HPV Infection , HPV Vaccination , Cervical cancer , Cancer in India , Dr. SHA...
HPV Infection , HPV Vaccination , Cervical cancer , Cancer in India , Dr. SHA...Lifecare Centre
 
HPV Diseases More Than Cervical Cancer, Dr. Sharda Jain
HPV Diseases More Than Cervical Cancer, Dr. Sharda Jain HPV Diseases More Than Cervical Cancer, Dr. Sharda Jain
HPV Diseases More Than Cervical Cancer, Dr. Sharda Jain Lifecare Centre
 
Evidence Based Guide of Screening for Prevention of Cervical Cancer
Evidence Based Guide of Screening for Prevention of Cervical Cancer  Evidence Based Guide of Screening for Prevention of Cervical Cancer
Evidence Based Guide of Screening for Prevention of Cervical Cancer Lifecare Centre
 
Cervical cancer hpv-feb07
Cervical cancer hpv-feb07Cervical cancer hpv-feb07
Cervical cancer hpv-feb07Ules Abraham
 
Human papillomavirus (HPV) Vaccine
Human papillomavirus (HPV) VaccineHuman papillomavirus (HPV) Vaccine
Human papillomavirus (HPV) VaccineKeith Wassung
 
HPV Vaccination Update Grothuesmann
HPV Vaccination Update GrothuesmannHPV Vaccination Update Grothuesmann
HPV Vaccination Update GrothuesmannDr Dirk Grothuesmann
 
Cervical Cancer Screening Modalities
Cervical Cancer Screening ModalitiesCervical Cancer Screening Modalities
Cervical Cancer Screening ModalitiesDr. Rahul Shah
 
Cancer Biomarkers Research, HPV and Cancer, HPV Vaccine
Cancer Biomarkers Research, HPV and Cancer, HPV VaccineCancer Biomarkers Research, HPV and Cancer, HPV Vaccine
Cancer Biomarkers Research, HPV and Cancer, HPV VaccineJames Lyons-Weiler
 
Mission SAY No to Cervical Cancer With HPV Vaccination DR. SHARDA JAIN S...
Mission SAY No to Cervical Cancer   With HPV Vaccination DR. SHARDA JAIN  S...Mission SAY No to Cervical Cancer   With HPV Vaccination DR. SHARDA JAIN  S...
Mission SAY No to Cervical Cancer With HPV Vaccination DR. SHARDA JAIN S...Lifecare Centre
 
HPV and Cervical Cancer: Mechanisms
HPV and Cervical Cancer: MechanismsHPV and Cervical Cancer: Mechanisms
HPV and Cervical Cancer: Mechanismsbrandolina1
 
The incidence of significant lesions on cervical smears poster final edit
The incidence of significant lesions on cervical smears  poster final editThe incidence of significant lesions on cervical smears  poster final edit
The incidence of significant lesions on cervical smears poster final editGenevieve Warner Learmonth
 
Cervical Cancer Screening - HPV - www.jinekolojivegebelik.com
Cervical Cancer Screening - HPV - www.jinekolojivegebelik.comCervical Cancer Screening - HPV - www.jinekolojivegebelik.com
Cervical Cancer Screening - HPV - www.jinekolojivegebelik.comjinekolojivegebelik.com
 

Tendances (20)

HPV Vaccination & Ca. Cervix Screening Update Dr. Sharda Jain Dr. Jyoti A...
HPV Vaccination & Ca. Cervix Screening Update  Dr. Sharda Jain Dr. Jyoti A...HPV Vaccination & Ca. Cervix Screening Update  Dr. Sharda Jain Dr. Jyoti A...
HPV Vaccination & Ca. Cervix Screening Update Dr. Sharda Jain Dr. Jyoti A...
 
Cervical cancer prevention Dr Sharda Jain
Cervical cancer prevention Dr Sharda Jain Cervical cancer prevention Dr Sharda Jain
Cervical cancer prevention Dr Sharda Jain
 
HPV Infection , HPV Vaccination , Cervical cancer , Cancer in India , Dr. SHA...
HPV Infection , HPV Vaccination , Cervical cancer , Cancer in India , Dr. SHA...HPV Infection , HPV Vaccination , Cervical cancer , Cancer in India , Dr. SHA...
HPV Infection , HPV Vaccination , Cervical cancer , Cancer in India , Dr. SHA...
 
HPV Diseases More Than Cervical Cancer, Dr. Sharda Jain
HPV Diseases More Than Cervical Cancer, Dr. Sharda Jain HPV Diseases More Than Cervical Cancer, Dr. Sharda Jain
HPV Diseases More Than Cervical Cancer, Dr. Sharda Jain
 
Evidence Based Guide of Screening for Prevention of Cervical Cancer
Evidence Based Guide of Screening for Prevention of Cervical Cancer  Evidence Based Guide of Screening for Prevention of Cervical Cancer
Evidence Based Guide of Screening for Prevention of Cervical Cancer
 
Cervical cancer hpv-feb07
Cervical cancer hpv-feb07Cervical cancer hpv-feb07
Cervical cancer hpv-feb07
 
Human papillomavirus (HPV) Vaccine
Human papillomavirus (HPV) VaccineHuman papillomavirus (HPV) Vaccine
Human papillomavirus (HPV) Vaccine
 
HPV Vaccination Update Grothuesmann
HPV Vaccination Update GrothuesmannHPV Vaccination Update Grothuesmann
HPV Vaccination Update Grothuesmann
 
HPV and Cervical Cancer
HPV and Cervical CancerHPV and Cervical Cancer
HPV and Cervical Cancer
 
Cervical Cancer Screening Modalities
Cervical Cancer Screening ModalitiesCervical Cancer Screening Modalities
Cervical Cancer Screening Modalities
 
Cancer Biomarkers Research, HPV and Cancer, HPV Vaccine
Cancer Biomarkers Research, HPV and Cancer, HPV VaccineCancer Biomarkers Research, HPV and Cancer, HPV Vaccine
Cancer Biomarkers Research, HPV and Cancer, HPV Vaccine
 
Hpv vaccination
Hpv vaccination  Hpv vaccination
Hpv vaccination
 
Cervical cancer hpv
Cervical cancer hpvCervical cancer hpv
Cervical cancer hpv
 
Hpv vaccine
Hpv vaccineHpv vaccine
Hpv vaccine
 
Mission SAY No to Cervical Cancer With HPV Vaccination DR. SHARDA JAIN S...
Mission SAY No to Cervical Cancer   With HPV Vaccination DR. SHARDA JAIN  S...Mission SAY No to Cervical Cancer   With HPV Vaccination DR. SHARDA JAIN  S...
Mission SAY No to Cervical Cancer With HPV Vaccination DR. SHARDA JAIN S...
 
HPV Vaccine Recommendations (AAP)
HPV Vaccine Recommendations (AAP)HPV Vaccine Recommendations (AAP)
HPV Vaccine Recommendations (AAP)
 
Introducing HPV Vaccine
Introducing HPV VaccineIntroducing HPV Vaccine
Introducing HPV Vaccine
 
HPV and Cervical Cancer: Mechanisms
HPV and Cervical Cancer: MechanismsHPV and Cervical Cancer: Mechanisms
HPV and Cervical Cancer: Mechanisms
 
The incidence of significant lesions on cervical smears poster final edit
The incidence of significant lesions on cervical smears  poster final editThe incidence of significant lesions on cervical smears  poster final edit
The incidence of significant lesions on cervical smears poster final edit
 
Cervical Cancer Screening - HPV - www.jinekolojivegebelik.com
Cervical Cancer Screening - HPV - www.jinekolojivegebelik.comCervical Cancer Screening - HPV - www.jinekolojivegebelik.com
Cervical Cancer Screening - HPV - www.jinekolojivegebelik.com
 

Similaire à Dr Ayman Ewies - Cervical screening 2009

Cervical cancer Dr.Alia
Cervical cancer Dr.Alia Cervical cancer Dr.Alia
Cervical cancer Dr.Alia HanaEtbiga
 
201405724 american-cancer-society
201405724 american-cancer-society201405724 american-cancer-society
201405724 american-cancer-societyhomeworkping4
 
Cervical cancer screening modalities
Cervical cancer screening modalitiesCervical cancer screening modalities
Cervical cancer screening modalitieschaimingcheng
 
18- dr. ghazi alsbeih kau 13 may 2015
 18- dr. ghazi alsbeih kau 13 may 2015 18- dr. ghazi alsbeih kau 13 may 2015
18- dr. ghazi alsbeih kau 13 may 2015Basalama Ali
 
Article on Cervical cancer.Daily News
Article on Cervical cancer.Daily NewsArticle on Cervical cancer.Daily News
Article on Cervical cancer.Daily NewsShantha Hettiarachchi
 
Vulvar and vaginal cancer epidemiology and molecular pathogenesis
Vulvar and vaginal cancer epidemiology and molecular pathogenesisVulvar and vaginal cancer epidemiology and molecular pathogenesis
Vulvar and vaginal cancer epidemiology and molecular pathogenesisSravanthi Nuthalapati
 
CERVICAL CANCER presentation for the clinic
CERVICAL CANCER presentation for the clinicCERVICAL CANCER presentation for the clinic
CERVICAL CANCER presentation for the clinicShadreckChipapi1
 
Gynaecology cancer awareness
Gynaecology cancer awarenessGynaecology cancer awareness
Gynaecology cancer awarenesslimgengyan
 
Gynaecology cancer awareness
Gynaecology cancer awarenessGynaecology cancer awareness
Gynaecology cancer awarenesslimgengyan
 
Gynaecology cancer awareness
Gynaecology cancer awarenessGynaecology cancer awareness
Gynaecology cancer awarenesschaimingcheng
 
Cervical Cancer Case Study
Cervical Cancer Case StudyCervical Cancer Case Study
Cervical Cancer Case StudyBrandy Grant
 
screening_and_prevention protocols for_cervix.ppt
screening_and_prevention protocols for_cervix.pptscreening_and_prevention protocols for_cervix.ppt
screening_and_prevention protocols for_cervix.pptPriyankaSinha406376
 
The Relationship Between Hpv And Cervical Neoplasia
The Relationship Between Hpv And Cervical NeoplasiaThe Relationship Between Hpv And Cervical Neoplasia
The Relationship Between Hpv And Cervical NeoplasiaNora Hernandez
 
Human papilloma virus vaccine - Egypt
Human papilloma virus vaccine - EgyptHuman papilloma virus vaccine - Egypt
Human papilloma virus vaccine - EgyptMoustapha Ramadan
 

Similaire à Dr Ayman Ewies - Cervical screening 2009 (20)

Cervical cancer Dr.Alia
Cervical cancer Dr.Alia Cervical cancer Dr.Alia
Cervical cancer Dr.Alia
 
201405724 american-cancer-society
201405724 american-cancer-society201405724 american-cancer-society
201405724 american-cancer-society
 
Cervical cancer screening modalities
Cervical cancer screening modalitiesCervical cancer screening modalities
Cervical cancer screening modalities
 
Human papiloma virus
Human papiloma virusHuman papiloma virus
Human papiloma virus
 
18- dr. ghazi alsbeih kau 13 may 2015
 18- dr. ghazi alsbeih kau 13 may 2015 18- dr. ghazi alsbeih kau 13 may 2015
18- dr. ghazi alsbeih kau 13 may 2015
 
Cervical cancer
Cervical cancerCervical cancer
Cervical cancer
 
Article on Cervical cancer.Daily News
Article on Cervical cancer.Daily NewsArticle on Cervical cancer.Daily News
Article on Cervical cancer.Daily News
 
Vulvar and vaginal cancer epidemiology and molecular pathogenesis
Vulvar and vaginal cancer epidemiology and molecular pathogenesisVulvar and vaginal cancer epidemiology and molecular pathogenesis
Vulvar and vaginal cancer epidemiology and molecular pathogenesis
 
Cervical Cancer
Cervical CancerCervical Cancer
Cervical Cancer
 
CERVICAL CANCER presentation for the clinic
CERVICAL CANCER presentation for the clinicCERVICAL CANCER presentation for the clinic
CERVICAL CANCER presentation for the clinic
 
Gynaecology cancer awareness
Gynaecology cancer awarenessGynaecology cancer awareness
Gynaecology cancer awareness
 
Gynaecology cancer awareness
Gynaecology cancer awarenessGynaecology cancer awareness
Gynaecology cancer awareness
 
Gynaecology cancer awareness
Gynaecology cancer awarenessGynaecology cancer awareness
Gynaecology cancer awareness
 
Cervical Cancer Case Study
Cervical Cancer Case StudyCervical Cancer Case Study
Cervical Cancer Case Study
 
Cervical cancer
Cervical cancer Cervical cancer
Cervical cancer
 
screening_and_prevention protocols for_cervix.ppt
screening_and_prevention protocols for_cervix.pptscreening_and_prevention protocols for_cervix.ppt
screening_and_prevention protocols for_cervix.ppt
 
The Relationship Between Hpv And Cervical Neoplasia
The Relationship Between Hpv And Cervical NeoplasiaThe Relationship Between Hpv And Cervical Neoplasia
The Relationship Between Hpv And Cervical Neoplasia
 
Road map to eliminate Cervical Cancer in the Indian subcontinent 2023 Dr V ...
Road map to eliminate  Cervical Cancer in the Indian subcontinent  2023 Dr V ...Road map to eliminate  Cervical Cancer in the Indian subcontinent  2023 Dr V ...
Road map to eliminate Cervical Cancer in the Indian subcontinent 2023 Dr V ...
 
1 dr mario sideri
1  dr mario sideri 1  dr mario sideri
1 dr mario sideri
 
Human papilloma virus vaccine - Egypt
Human papilloma virus vaccine - EgyptHuman papilloma virus vaccine - Egypt
Human papilloma virus vaccine - Egypt
 

Plus de AymanEwies

Dr Ayman Ewies - Topical Vaginal Oestrogen in the management of postmenopausa...
Dr Ayman Ewies - Topical Vaginal Oestrogen in the management of postmenopausa...Dr Ayman Ewies - Topical Vaginal Oestrogen in the management of postmenopausa...
Dr Ayman Ewies - Topical Vaginal Oestrogen in the management of postmenopausa...AymanEwies
 
Dr Ayman Ewies - Principles of Safe Laparoscopic Entry
Dr Ayman Ewies - Principles of Safe Laparoscopic EntryDr Ayman Ewies - Principles of Safe Laparoscopic Entry
Dr Ayman Ewies - Principles of Safe Laparoscopic EntryAymanEwies
 
Dr Ayman Ewies - Principles of Hysteroscopy
Dr Ayman Ewies - Principles of HysteroscopyDr Ayman Ewies - Principles of Hysteroscopy
Dr Ayman Ewies - Principles of HysteroscopyAymanEwies
 
Dr Ayman Ewies - Prevalence of hyperplasia and cancer in endometrial polyps i...
Dr Ayman Ewies - Prevalence of hyperplasia and cancer in endometrial polyps i...Dr Ayman Ewies - Prevalence of hyperplasia and cancer in endometrial polyps i...
Dr Ayman Ewies - Prevalence of hyperplasia and cancer in endometrial polyps i...AymanEwies
 
Dr Ayman Ewies - Operative Hysteroscoy Practical Tips
Dr Ayman Ewies - Operative Hysteroscoy Practical TipsDr Ayman Ewies - Operative Hysteroscoy Practical Tips
Dr Ayman Ewies - Operative Hysteroscoy Practical TipsAymanEwies
 
Dr Ayman Ewies - Mirena: why 50% of women dislike it?
Dr Ayman Ewies - Mirena: why 50% of women dislike it?Dr Ayman Ewies - Mirena: why 50% of women dislike it?
Dr Ayman Ewies - Mirena: why 50% of women dislike it?AymanEwies
 
Dr Mona Elshafie and Dr Ayman Ewies - The Effect Of Leptin On Maturation Of T...
Dr Mona Elshafie and Dr Ayman Ewies - The Effect Of Leptin On Maturation Of T...Dr Mona Elshafie and Dr Ayman Ewies - The Effect Of Leptin On Maturation Of T...
Dr Mona Elshafie and Dr Ayman Ewies - The Effect Of Leptin On Maturation Of T...AymanEwies
 
Dr Ayman Ewies - Endometrial Polyps in Postmenopausal Women
Dr Ayman Ewies - Endometrial Polyps in Postmenopausal WomenDr Ayman Ewies - Endometrial Polyps in Postmenopausal Women
Dr Ayman Ewies - Endometrial Polyps in Postmenopausal WomenAymanEwies
 
Dr Ayman Ewies - What makes an effective e-tutorial?
Dr Ayman Ewies - What makes an effective e-tutorial?Dr Ayman Ewies - What makes an effective e-tutorial?
Dr Ayman Ewies - What makes an effective e-tutorial?AymanEwies
 
Dr Ayman Ewies - Best Oral Presentation
Dr Ayman Ewies - Best Oral PresentationDr Ayman Ewies - Best Oral Presentation
Dr Ayman Ewies - Best Oral PresentationAymanEwies
 
Dr Ayman Ewies and Dr Seu Gunasekera Best Oral Presentation
Dr Ayman Ewies and Dr Seu Gunasekera Best Oral PresentationDr Ayman Ewies and Dr Seu Gunasekera Best Oral Presentation
Dr Ayman Ewies and Dr Seu Gunasekera Best Oral PresentationAymanEwies
 
Dr Ayman Ewies - Recurrent PMB
Dr Ayman Ewies - Recurrent PMBDr Ayman Ewies - Recurrent PMB
Dr Ayman Ewies - Recurrent PMBAymanEwies
 
Dr Ayman Ewies - Doctors versus nurses in managing women with PMB
Dr Ayman Ewies - Doctors versus nurses in managing women with PMBDr Ayman Ewies - Doctors versus nurses in managing women with PMB
Dr Ayman Ewies - Doctors versus nurses in managing women with PMBAymanEwies
 
Dr Ayman Ewies - Body fat percentage in women with PMB
Dr Ayman Ewies - Body fat percentage in women with PMBDr Ayman Ewies - Body fat percentage in women with PMB
Dr Ayman Ewies - Body fat percentage in women with PMBAymanEwies
 
Dr Ayman Ewies - Thickened Endometrium in absence of PMB
Dr Ayman Ewies - Thickened Endometrium in absence of PMBDr Ayman Ewies - Thickened Endometrium in absence of PMB
Dr Ayman Ewies - Thickened Endometrium in absence of PMBAymanEwies
 
Dr Ayman Ewies - Are animal laboratory models superior to virtual reality sim...
Dr Ayman Ewies - Are animal laboratory models superior to virtual reality sim...Dr Ayman Ewies - Are animal laboratory models superior to virtual reality sim...
Dr Ayman Ewies - Are animal laboratory models superior to virtual reality sim...AymanEwies
 
Dr Ayman Ewies - Office operative hysteroscopy service: remarkable clinical s...
Dr Ayman Ewies - Office operative hysteroscopy service: remarkable clinical s...Dr Ayman Ewies - Office operative hysteroscopy service: remarkable clinical s...
Dr Ayman Ewies - Office operative hysteroscopy service: remarkable clinical s...AymanEwies
 
Dr Ayman Ewies - Abnormal Uterine Bleeding in Pre-menopausal Women: When Shou...
Dr Ayman Ewies - Abnormal Uterine Bleeding in Pre-menopausal Women: When Shou...Dr Ayman Ewies - Abnormal Uterine Bleeding in Pre-menopausal Women: When Shou...
Dr Ayman Ewies - Abnormal Uterine Bleeding in Pre-menopausal Women: When Shou...AymanEwies
 
Dr Ayman Ewies - Colposcopy and STI Survey
Dr Ayman Ewies - Colposcopy and STI SurveyDr Ayman Ewies - Colposcopy and STI Survey
Dr Ayman Ewies - Colposcopy and STI SurveyAymanEwies
 
Dr Ayman Ewies - Postcoital Bleeding National Survey
Dr Ayman Ewies - Postcoital Bleeding National SurveyDr Ayman Ewies - Postcoital Bleeding National Survey
Dr Ayman Ewies - Postcoital Bleeding National SurveyAymanEwies
 

Plus de AymanEwies (20)

Dr Ayman Ewies - Topical Vaginal Oestrogen in the management of postmenopausa...
Dr Ayman Ewies - Topical Vaginal Oestrogen in the management of postmenopausa...Dr Ayman Ewies - Topical Vaginal Oestrogen in the management of postmenopausa...
Dr Ayman Ewies - Topical Vaginal Oestrogen in the management of postmenopausa...
 
Dr Ayman Ewies - Principles of Safe Laparoscopic Entry
Dr Ayman Ewies - Principles of Safe Laparoscopic EntryDr Ayman Ewies - Principles of Safe Laparoscopic Entry
Dr Ayman Ewies - Principles of Safe Laparoscopic Entry
 
Dr Ayman Ewies - Principles of Hysteroscopy
Dr Ayman Ewies - Principles of HysteroscopyDr Ayman Ewies - Principles of Hysteroscopy
Dr Ayman Ewies - Principles of Hysteroscopy
 
Dr Ayman Ewies - Prevalence of hyperplasia and cancer in endometrial polyps i...
Dr Ayman Ewies - Prevalence of hyperplasia and cancer in endometrial polyps i...Dr Ayman Ewies - Prevalence of hyperplasia and cancer in endometrial polyps i...
Dr Ayman Ewies - Prevalence of hyperplasia and cancer in endometrial polyps i...
 
Dr Ayman Ewies - Operative Hysteroscoy Practical Tips
Dr Ayman Ewies - Operative Hysteroscoy Practical TipsDr Ayman Ewies - Operative Hysteroscoy Practical Tips
Dr Ayman Ewies - Operative Hysteroscoy Practical Tips
 
Dr Ayman Ewies - Mirena: why 50% of women dislike it?
Dr Ayman Ewies - Mirena: why 50% of women dislike it?Dr Ayman Ewies - Mirena: why 50% of women dislike it?
Dr Ayman Ewies - Mirena: why 50% of women dislike it?
 
Dr Mona Elshafie and Dr Ayman Ewies - The Effect Of Leptin On Maturation Of T...
Dr Mona Elshafie and Dr Ayman Ewies - The Effect Of Leptin On Maturation Of T...Dr Mona Elshafie and Dr Ayman Ewies - The Effect Of Leptin On Maturation Of T...
Dr Mona Elshafie and Dr Ayman Ewies - The Effect Of Leptin On Maturation Of T...
 
Dr Ayman Ewies - Endometrial Polyps in Postmenopausal Women
Dr Ayman Ewies - Endometrial Polyps in Postmenopausal WomenDr Ayman Ewies - Endometrial Polyps in Postmenopausal Women
Dr Ayman Ewies - Endometrial Polyps in Postmenopausal Women
 
Dr Ayman Ewies - What makes an effective e-tutorial?
Dr Ayman Ewies - What makes an effective e-tutorial?Dr Ayman Ewies - What makes an effective e-tutorial?
Dr Ayman Ewies - What makes an effective e-tutorial?
 
Dr Ayman Ewies - Best Oral Presentation
Dr Ayman Ewies - Best Oral PresentationDr Ayman Ewies - Best Oral Presentation
Dr Ayman Ewies - Best Oral Presentation
 
Dr Ayman Ewies and Dr Seu Gunasekera Best Oral Presentation
Dr Ayman Ewies and Dr Seu Gunasekera Best Oral PresentationDr Ayman Ewies and Dr Seu Gunasekera Best Oral Presentation
Dr Ayman Ewies and Dr Seu Gunasekera Best Oral Presentation
 
Dr Ayman Ewies - Recurrent PMB
Dr Ayman Ewies - Recurrent PMBDr Ayman Ewies - Recurrent PMB
Dr Ayman Ewies - Recurrent PMB
 
Dr Ayman Ewies - Doctors versus nurses in managing women with PMB
Dr Ayman Ewies - Doctors versus nurses in managing women with PMBDr Ayman Ewies - Doctors versus nurses in managing women with PMB
Dr Ayman Ewies - Doctors versus nurses in managing women with PMB
 
Dr Ayman Ewies - Body fat percentage in women with PMB
Dr Ayman Ewies - Body fat percentage in women with PMBDr Ayman Ewies - Body fat percentage in women with PMB
Dr Ayman Ewies - Body fat percentage in women with PMB
 
Dr Ayman Ewies - Thickened Endometrium in absence of PMB
Dr Ayman Ewies - Thickened Endometrium in absence of PMBDr Ayman Ewies - Thickened Endometrium in absence of PMB
Dr Ayman Ewies - Thickened Endometrium in absence of PMB
 
Dr Ayman Ewies - Are animal laboratory models superior to virtual reality sim...
Dr Ayman Ewies - Are animal laboratory models superior to virtual reality sim...Dr Ayman Ewies - Are animal laboratory models superior to virtual reality sim...
Dr Ayman Ewies - Are animal laboratory models superior to virtual reality sim...
 
Dr Ayman Ewies - Office operative hysteroscopy service: remarkable clinical s...
Dr Ayman Ewies - Office operative hysteroscopy service: remarkable clinical s...Dr Ayman Ewies - Office operative hysteroscopy service: remarkable clinical s...
Dr Ayman Ewies - Office operative hysteroscopy service: remarkable clinical s...
 
Dr Ayman Ewies - Abnormal Uterine Bleeding in Pre-menopausal Women: When Shou...
Dr Ayman Ewies - Abnormal Uterine Bleeding in Pre-menopausal Women: When Shou...Dr Ayman Ewies - Abnormal Uterine Bleeding in Pre-menopausal Women: When Shou...
Dr Ayman Ewies - Abnormal Uterine Bleeding in Pre-menopausal Women: When Shou...
 
Dr Ayman Ewies - Colposcopy and STI Survey
Dr Ayman Ewies - Colposcopy and STI SurveyDr Ayman Ewies - Colposcopy and STI Survey
Dr Ayman Ewies - Colposcopy and STI Survey
 
Dr Ayman Ewies - Postcoital Bleeding National Survey
Dr Ayman Ewies - Postcoital Bleeding National SurveyDr Ayman Ewies - Postcoital Bleeding National Survey
Dr Ayman Ewies - Postcoital Bleeding National Survey
 

Dernier

Neurological history taking (2024) .
Neurological  history  taking  (2024)  .Neurological  history  taking  (2024)  .
Neurological history taking (2024) .Mohamed Rizk Khodair
 
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...Shubhanshu Gaurav
 
EXERCISE PERFORMANCE.pptx, Lung function
EXERCISE PERFORMANCE.pptx, Lung functionEXERCISE PERFORMANCE.pptx, Lung function
EXERCISE PERFORMANCE.pptx, Lung functionkrishnareddy157915
 
MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.whalesdesign
 
Pharmacokinetic Models by Dr. Ram D. Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D.  Bawankar.pptPharmacokinetic Models by Dr. Ram D.  Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D. Bawankar.pptRamDBawankar1
 
Trustworthiness of AI based predictions Aachen 2024
Trustworthiness of AI based predictions Aachen 2024Trustworthiness of AI based predictions Aachen 2024
Trustworthiness of AI based predictions Aachen 2024EwoutSteyerberg1
 
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdfSGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdfHongBiThi1
 
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdfSGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdfHongBiThi1
 
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA .pdf
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA    .pdfSGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA    .pdf
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA .pdfHongBiThi1
 
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdfCONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdfDolisha Warbi
 
Using Data Visualization in Public Health Communications
Using Data Visualization in Public Health CommunicationsUsing Data Visualization in Public Health Communications
Using Data Visualization in Public Health Communicationskatiequigley33
 
AUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functionsAUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functionsMedicoseAcademics
 
power point presentation of Clinical evaluation of strabismus
power point presentation of Clinical evaluation  of strabismuspower point presentation of Clinical evaluation  of strabismus
power point presentation of Clinical evaluation of strabismusChandrasekar Reddy
 
Role of Soap based and synthetic or syndets bar
Role of  Soap based and synthetic or syndets barRole of  Soap based and synthetic or syndets bar
Role of Soap based and synthetic or syndets barmohitRahangdale
 
Basic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptxBasic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptxkomalt2001
 
High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)kishan singh tomar
 
"Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio..."Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio...Sujoy Dasgupta
 

Dernier (20)

Neurological history taking (2024) .
Neurological  history  taking  (2024)  .Neurological  history  taking  (2024)  .
Neurological history taking (2024) .
 
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
 
EXERCISE PERFORMANCE.pptx, Lung function
EXERCISE PERFORMANCE.pptx, Lung functionEXERCISE PERFORMANCE.pptx, Lung function
EXERCISE PERFORMANCE.pptx, Lung function
 
MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.
 
Pharmacokinetic Models by Dr. Ram D. Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D.  Bawankar.pptPharmacokinetic Models by Dr. Ram D.  Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D. Bawankar.ppt
 
Trustworthiness of AI based predictions Aachen 2024
Trustworthiness of AI based predictions Aachen 2024Trustworthiness of AI based predictions Aachen 2024
Trustworthiness of AI based predictions Aachen 2024
 
Rheumatoid arthritis Part 1, case based approach with application of the late...
Rheumatoid arthritis Part 1, case based approach with application of the late...Rheumatoid arthritis Part 1, case based approach with application of the late...
Rheumatoid arthritis Part 1, case based approach with application of the late...
 
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdfSGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdf
 
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdfSGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
 
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA .pdf
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA    .pdfSGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA    .pdf
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA .pdf
 
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdfCONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
 
Using Data Visualization in Public Health Communications
Using Data Visualization in Public Health CommunicationsUsing Data Visualization in Public Health Communications
Using Data Visualization in Public Health Communications
 
AUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functionsAUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functions
 
power point presentation of Clinical evaluation of strabismus
power point presentation of Clinical evaluation  of strabismuspower point presentation of Clinical evaluation  of strabismus
power point presentation of Clinical evaluation of strabismus
 
How to master Steroid (glucocorticoids) prescription, different scenarios, ca...
How to master Steroid (glucocorticoids) prescription, different scenarios, ca...How to master Steroid (glucocorticoids) prescription, different scenarios, ca...
How to master Steroid (glucocorticoids) prescription, different scenarios, ca...
 
Role of Soap based and synthetic or syndets bar
Role of  Soap based and synthetic or syndets barRole of  Soap based and synthetic or syndets bar
Role of Soap based and synthetic or syndets bar
 
Biologic therapy ice breaking in rheumatology, Case based approach with appli...
Biologic therapy ice breaking in rheumatology, Case based approach with appli...Biologic therapy ice breaking in rheumatology, Case based approach with appli...
Biologic therapy ice breaking in rheumatology, Case based approach with appli...
 
Basic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptxBasic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptx
 
High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)
 
"Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio..."Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio...
 

Dr Ayman Ewies - Cervical screening 2009

  • 1. Cervical Screening Ayman Ewies Consultant Gynaecologist The Ipswich Hospital 24th April 2009
  • 3. 3 Natural History of Cervical Carcinoma  Cervical cancer is the 2nd commonest female cancer worldwide (breast cancer is the commonest).  It accounts for 12% of cancers in women worldwide. o Worldwide 470,000 new cases and 233,000 deaths per year. o 80% in developing countries. o Only 5% of all cancer resources spent in 3rd world. o Highest incidences in Madras (India) and Coli (Columbia) – 48-52/100,000 women per year. – 60-80% diagnosed with stage III/VI disease.  Women with cervical cancer die at a younger age than those with any other non-childhood cancer.
  • 4. 4 Natural History of Cervical Carcinoma  It is, potentially , the most preventable major form of cancer, given the long natural history of pre-cancer stage.  Countries that introduced organized cervical screening programmes have seen significant falls in the incidence and mortality associated with cervical cancer.  In the UK, the cumulative risk for cervical cancer is 1.4% up to age 80 years.  2,800 cases per annum UK.  1,100 deaths per annum UK.  Bimodal age distribution peaks at 30-35 / 80+ 21 women die each week on average in the UK
  • 5. Natural History of Cervical Carcinoma Time 6 27 Deathsper100,000 Mortality in developing countries Mortality in developed countries Effect of health education, regular check-ups & availability of appropriate management services Introduction of screening Effect of screening
  • 6. 6 Risk Factors For Cervical Cancer 1. HPV infection: RR 116 2. Early onset of sexual activity before age of 16: - Intercourse within one year of menarche  RR 16 3. Multiple sexual partners (self or of the partner): - ≥ 6 life time partners  RR 5 4. Low socio-economic status (irrespective of other factors): RR 3 5. Black race compared to white: RR 2
  • 7. 7 Risk Factors For Cervical Cancer 6. Heavy long-term tobacco smoking: RR 2 7. Use of COC:  Using COC ≥5 years + HPV positivity  RR 3  Death from cervical cancer among current and recent users (within 10 years)  RR 10 8. Immuno-compromise (e.g. organ transplant, lupus disease & HIV infection)  RR 5
  • 8. Sexual activity Normal mucosa CIN Persistent HPV infection with high risk types Invasive cervical cancer “Seed, soil and nutrient” model for cervical carcinogenesis Aetiology of Cervical Cancer Co-factors: Smoking OC use Other STD’s Immunosuppression Transient HPV infection
  • 9. 9 Cervical Screening in The UK  The NHS cervical screening programme is recognised as world leading.1  Cervical cancer incidence fell by 42% between 1988 and 1997 (England and Wales). This fall is believed to be directly related to the cervical screening programme2 which was introduced in 1988. 1. http://cancerscreening.org.uk/cervical/publications/cervical-annual-review-2004.pdf Accessed 12/10/05 2. NHS. Cervical Screening pocket guide. 2004.
  • 10. 10 Cervical Screening in The UK  Computerised call / recall since 1988 reduced deaths from cervical cancer by 60% despite increased incidence CIN 2/3.  Success of UK screening attributed to coverage of >80% of eligible population.  Almost 5000 deaths per year prevented by cervical screening in UK.  England - incidence cervical cancer fallen from 15.4/ 100,000 to 9.6/ 100,000 • Increased fall of mortality from 1-2% to 7% per year. • Now decreased to 5% per year.  England - screening of almost 4 million women per year • Cost £150 million @ £37.5 per woman screened.
  • 12. 12 Cervical cancer incidence rates per 100,000 women, England and Wales, 1971-98
  • 13. 13 Cervical cancer mortality, England and Wales, 1971-2000
  • 15. 15 Screening programmes  1949 first organised regional cervical screening programme. – British Columbia  1960’s further programmes. – Scandinavia, USA, Scotland Variation of current programmes: – USA – screening at onset sexual activity. – Holland – 5 yearly from 30 years.
  • 16. 16 Screening programmes - UK  England and N. Ireland: 3 yearly 25-49  5 yearly 50-65.  Wales: 3 yearly 20-65.  Scotland: 3 yearly 20-60.
  • 17. 17 Screening programmes - UK Outcome of cervical cytology % 90.55 negative 1.74 inadequate 3.95 borderline dyskaryosis 2.37 mild dyskaryosis 0.67 moderate dyskaryosis 0.59 severe dyskaryosis 0.04 ?invasion 0.08 abnormal glandular cells Source - CSP Wales Jan – Jun 2006
  • 18. 18 Screening programmes Developing Countries  4.6 billion people living in developing countries  Only 5% of women offered screening.  900m adults illiterate and >1 billion live on <$1 US/ day.  3rd world screening fails because – Lack of organisation/ monitoring. – Lack of motivation of staff having other disease priorities. – Lack of professional awareness in public health. – Poor coverage. – Poor patient compliance/ understanding. – Poor availability/ affordability/ sustainability.
  • 19. 19 Screening programmes Developing Countries  VIA and VILI are easy to teach but have limited reliability  may be useful in resource poor countries.  VIA: Sensitivity 79%, specificity 83%, PPV 12%, NPV 99% – for detecting CIN 2/3 – >100,000 women from 25 studies.  Performance VILI appears comparable.  VILI could follow VIA for borderline cases.  No magnification.
  • 20. 20 Screening programmes Developing Countries  See and treat patients offered cryotherapy for abnormal results.  VIA/ VILI less useful in postmenopausal women.  Screening result: – 1 visit @ 35 yrs  reduces lifetime risk cancer by 25- 36%. – 2 visits @ 35-40 yrs  reduces risk by further 40%. (Goldie et al, 2005)
  • 22. 22 HPV Infection  HPV DNA is present in virtually all cervical tumours.  It has been proposed as the first ever identified “necessary cause” of a human cancer. 103 HPV genotypes known 35 infect the genital tract 20 carcinogenic 16 & 18 found in75% of cervical cancer cases
  • 23. 23 HPV Infection HPV infection can be: 1- Sub-clinical (flat warts)  Changes similar to CIN 1 that become apparent only with the application of acetic acid.  Satellite lesions may present outside the TZ. 2- Clinical (exophytic warts = condylomas)  Visible on naked eye inspection.  The viral type is usually non-oncogenic ( 6 or 11 in 90% of cases).  Histological confirmation is important since they may mimic invasive lesions.
  • 25. 25 HPV Infection  Reported incidence in developed countries varies between 10-30% in the adolescent age group (16-24 years). The incidence drops to 5% above age of 30 years. An estimated 80% of sexually active women will be exposed to the virus by age 50. 60-80% Clear spontaneously (within 1-2 years) 20-40% CIN (within 2-4 years)
  • 26. 26 HPV Infection Women >30 years with high risk HPV positive and normal smear  the risk of developing CIN 3 is 116 times higher than women with an HPV negative and normal smear. The progression rate of CIN in women with high risk HPV positive is 5% per year.
  • 27. 27 HPV Vaccination  In September 2008 national HPV vaccination programme introduced using Cervarix (GSK), prophylactic vaccine against HPV 16/18.  Vaccination will target 12/13 year old girls.  Catch-up programme over next 3 years: – 18 years old girls vaccinated during 2008/9. – 16/17 years old girls during 2009/10. – 14/15 year old girls during 2010/11.
  • 28. 28 HPV Vaccination  Case for HPV vaccination based on evidence from RCT showing virus like particle (VLP) vaccine effectively prevented HPV 16/18 specific high grade CIN.  Evidence of cross protection against HPV 31/45 in the longer term.  Cervarix does not protect against genital warts.  Cervarix will reduce incidence HPV 16 related VaIN/ VIN.
  • 29. 29 HPV Vaccination  Since >60% CIN2/3 cases are HPV 16/18 related  incidence is expected to ↓ over next 15 years.  However, cervical screening will still be needed for unvaccinated women and to prevent non HPV 16/18 related cancer in vaccinated women.  Further modelling studies/ trials to design changes to screening programme are required. • ? increasing screening intervals
  • 30. 30 HPV Vaccination  The vaccine should be administered as 3 IM injections at months 0, 2 and 6.  Each dose is 0.5ml.  Presented in a pre-filled syringe with safety device.  The vaccination schedule permits flexibility if necessary.  Generally well-tolerated: -The commonly reported adverse events were injection site reactions and mild fever.