|
By
Dr (Mrs.) Usha Nath, MBBS (Ran.), FRCOG (Lon.), MBSCCP (U.K.)
INTRODUCTION
Despite over 30 years
of effort, very little impact in reducing cervical cancer deaths has been
made in the majority of developing countries, including ours.
We require a new strategy
to reach the masses, screen them and catch the cancer at pre-cancer stage
to treat it effectively to prevent the suffering and avoidable deaths from
this.
Colposcopy is a much
sensitive method compared to cytology, especially in the higher grade lesion
of squamous epithelium and plays an important role in down staging of cervical
cancer.
BACKGROUND
Cervical cancer is the third most common cancer worldwide but sadly most common
cancer in India .
50 Years Of Cancer
Control in India
466,000 new cases
of cervical cancer occur annually, while 231,000 women die out of this disease
every year. Out of 10 cases 8 die in developing country and India take the
brunt by ranking 4th worldwide.
Source: Parkin, 2000
In Western countries,
where well-lubricated screening system is in vogue, the women now have <0.1%
chance of developing cervical cancer while women in developing country have
3%to 5% chance – a big difference.
An important reason for the sharply higher cervical cancer incidence in developing
countries is the lack of effective screening programs aimed at detecting
and treating pre-cancerous conditions.
In the backdrop of high cervical mortality, a poorly available or unavailable
screening program and lack of public awareness, I put the case of widespread
use of Coloposcopy along with mass VIA screening to reach the high risk populations.
BENEFITS OF COLPOSCOPE
-
This can be done
on outpatient basis. The lesion could be visualized instantaneously for
the patient – that is without a worry and/or a wait.
-
It is performed
in OPD with ease by the gynecologist in relaxed understanding environment
for the patient.
-
A directed biopsy
for definitive histological diagnosis could be performed if required, then
and there.
-
If required the
pre-cancer lesion could be treated with cryotherapy immediately.
-
The future management
could be planned without delay
-
A trained gynecologist
can be made “Coloposcopy -literate” with a short training course.
-
Alternative to colposcope
are limited.
-
The benefits make
the procedure extremely worthwhile for the patient and give the opportunity
of “single-visit” management with our social trend.
BASIS OF COLPOSCOPIC
APPEARANCES
-
Colour of the epithelium
-
Surface contour
of the epithelium
-
Arrangements of
the terminal vascular bed
Every colposcopic
picture is the counterpart of a specific tissue patterns under examination.
(Picture on request)
COLPOSCOPIC CLASSIFICATION
(International Federation of Cervical Pathology and Coloposcopy May 1990,
Italy)
-
Normal Colposcopical
findings:
-
Original Squamous
Epithelium.
-
Original Columnar
epithelium
-
Transformation
Zone (Metaplastic epithelium)
-
Abnormal Colposcopic
findings:
Within the transformation
zone
-
Acetowhite Epithelium
-
Leukoplakia (Thin
or Thick)
-
Mosaics (fine
or coarse)
-
Punctation (fine
or coarse)
-
Atypical vessels
| Original Squamous Epithelium |
Original Columnar Epithelium-Grapes |
|
(Picture on request) |
(Picture on request) |
| Normal transformation zone |
Abnormal transformation zone - Early |
|
(Picture on request) |
(Picture on request) |
| White Epithelium with Fine Punctation
|
White Epithelium with Coarse Punctation and
Leukoplakia |
|
(Picture on request) |
(Picture on request) |
| Fine Mosaic |
Coarse Mosaic with dilated vessels & irregular
surface |
|
(Picture on request) |
(Picture on request) |
| A typical vessels Early changes |
Bizarre changes with Coiled dilated and irregular
branching |
|
(Picture on request) |
(Picture on request) |
Outside the transformation zone e.g. Ectocervix, Vagina
-
Acetowhite Epithelium
-
Leukoplakia (Thin
or Thick)
-
Mosaics (fine
or coarse)
-
Punctation (fine
or coarse)
-
Atypical vessels
-
Iodine
negative surface
C. Suspect
invasive carcinoma
(Picture on request)
D.
Unsatisfactory Colposcopical findings:
-
Squamo - columnar
junction not visible
-
Severe inflammation
or severe atrophy
-
Cervix not visible
E.
Miscellaneous findings
-
Non acetowhite
micropapillary surface
-
Exophytic
condyloma
-
Inflamation
-
Atrophy
-
Ulcer
-
Other
| Inflammation – Trichomonas |
Papilloma with IOCD tail |
|
(Picture on request) |
(Picture on request) |
| Nabothian Cyst |
Vaginal Adenosis |
|
(Picture on request) |
(Picture on request) |
INFERENCE
Cervical cancer is a
preventable disease. Because,
“HPV prevalence falls
but cervical cancer incidence rises with age”
-
We know the risk factors
-
Early Menarche
-
Early age at first
pregnancy
-
Multiparity
-
Early age at first
intercourse
-
Multiple partners
-
Male partner having
multiple partners
-
Sexually Transmitted
Diseases
-
Cigarette smoking
-
Low Socio-economic
group
-
Hygienic practice
-
Immuno-supressed
patients.
-
Failure of screening
either voluntarily or involuntarily.
“Therefore, no
woman should die of this preventable disease” - Lenhart
DISCUSSION
WHO Press Release, 11 October 2001, points out that:
“Low income countries
should consider planned invevestments to improve capacity to diagnose and
treat cervical cancer precursors and early invasive cancers in their health
services before considering even limited screening programmes”.
Extrapolating completely
the industrialized nations program to ours does not help our aim towards striving
to prevent cervical cancer.
We should aim to divert
our resources for screening and treating the high risks group of women. The
effort once or twice in their lifetime will reduce the incidence of cervical
cancer by 50%.
In this scenario the
colposcope uses by most of the specialized gynecologist offers a potent method
of rapid assessment of any dysplasia possibly present.
RECOMMENDATIONS
With our strong cultural background and limited resources we should think
of developing some indigenous innovative method of screening and managing
the cervical pre-cancer to suit our country. That is
-
To introduce the
mass screening involving the grass root workers with a simple method by
VIA (Visual Inspection of the Cervix after diluted Acetic acid wash which
can be taught easily to health workers). It is considered positive when
white area is visible on the cervix.
-
Widespread use of
Coloposcopy for the positive VIA cases to provide single visit management
suited to our society.
-
Use of Cryotherapy
if indicated on OPD basis.
HUMBLE PROPOSALS
TO FOGSI AND STATE HEALTH SERVICES
-
To make a local
wing of FOGSI of the region, all over India, for early detection program
for breast and cervical cancer, two main killers of women in India, under
the sponsorship of state health services.
-
To involve local
grass root health workers and train them in two to three weeks in the use
of VIA and simple breast examination.
-
To train several
motivated and cervical cytology oriented local gynecologists in colposcopy
and cryocautery within two weeks.
-
The positive VIA
patients could be managed in shift by these trained gynecologists (on “sponsored”
voluntary basis) as a single visit approach in one colposcopy center.
The efforts, which we
as Gynecologists in India put into this direction, would translate into reducing
incidence and cervical cancer mortality and saving lives.
A WORTHWHILE REWARD FOR A CLINICIAN.
Papers Presented On 5th December, 04 At All India FOGSI Conference
By
Dr (Mrs.) Usha Nath, MBBS (Ran.), FRCOG (Lon.), MBSCCP (U.K.)
Medical Director
Nath Hospital
Indra Bhawan, Kadru, Ranchi – 834002
Phone: 0651-2240350(Residence), 0651-2341736(Hospital)
Note: To request
a picture specified above, Please contact
Dr. (Mrs.) Usha Nath
|
