Screening Tests for Brest & Cervical Cancer

1. Screening Tests for Brest & Cervical Cancer Dr. Yeşim YASİN Spring-2014

2. Outline • Screening for breast cancer • Mammography • Clinical breast exam • Breast self-exam • Screening for cervical cancer • Pap-smear • HPV DNA testing • Screenings in Turkey

5. Breast cancer warning signs • Lump • Skin changes • Underarm swelling • Veins • Nipple inversion or discharge • Depression of the breast • Change of size of the breast

7. 95% of Breast Cancer begins in the breast ducts

8. Most common screening tests • Mammography • Clinical breast exam • Breast self-exam

9. Mammography-1 • Compression aided radiologic study • Screenings vs Diagnostic which should yield a final assessment and recommendation • Obese women are more likely to have false positives and need additional views

11. Mammography-2 • 7 statistical models Mammography reduces the rate of death from breast cancer by 7%-23% with a median of 15%1. 1. Berry DA, et al. N Eng J Med. 2005:353:1784-1792.

12. Age and interval for mammography Age • Regular screening lowers breast cancer mortality by • 15%-20% in women aged 40-49 • 25%-30% in women aged 50-69 • Limited evidence for effectiveness in women aged 70+ Interval • Optimal interval unknown • Reductions in mortality have occurred at intervals ranging from 12-33 months • Many organizations recommend annual screening for women aged 40-49

13. MRI • Annual MRI screening recommended for women with genetic mutations for breast cancer or with other factors that put them at very high risk • MRI improved staging and treatment planning, enhanced evaluation of augmented breasts and better detection of recurrences • Requires contrast injection • 10 cancers per 1000 women with >15% life time risk • 18-38 per 1000 women suspected of BRCA mutation carriers

15. Breast Ultrasound (US) • Effectiveness not yet demonstrated • High risk women are 2 to 3 times more likely to have a cancer seen only on US • Used primarily to • Evaluate breast abnormalities identified through clinical breast examination or mammography • Guide breast biopsies and Fine Needle Aspiration (FNA)

17. Is US a good stand-alone option? • 3 Studies of women with hereditary risk1: • 2 of 83 cancers detected solely by annual ultrasonography • 2 additional cancers detected through screenings at 6-month intervals 1. Berry DA, et al. N Eng J Med. 2005:353:1784-1792.

18. Clinical Breast Examination • May identify 4.5%-10.7% of breast cancers that mammography misses1 • Clinical proficiency impacts effectiveness • Recommendations vary: • American Cancer Society2 • Every 3 years for average-risk women in 20s and 30s • Annually for women aged 40 and above • U.S Preventive Services Task Force3 • No recommendation/Not enough evidence

19. Breast Self-Exam • Not shown to have an affect on breast cancer mortality rate1. • US Preventive Services Task Force: • Not enough evidence to recommend for or against it2. • ACS and others: Teach women the procedure and give them the option of using it3.

21. Cervical Screening

22. Why cervical screening? • Regular screening reduces the risk of developing cervical cancer • Cervical screening can prevent about 80 – 90% of cervical cancers developing • Due to cervical screening, incidence of cervical cancer dropped drastically in many parts of the world.

23. Cervical carcinogenesis Wright et al. NEJM 2003

24. Epidemiology of cervical cancer • Over 99% of cervical cancers have HPV DNA detected within the tumor • 70% of cervical cancer is caused by one of two types of HPV, 16 or 18 • The quadrivalent HPV vaccine protects against Types 6, 11, 16 and 18

25. What is cervical screening? • It is NOT a test for cancer • It aims to detect possible abnormalities in cells on the cervix which may develop into cancer in years to come if not treated • The test is either HPV (HPV DNA) test or “pap-smear” test

26. Special conditions • Following conditions should be reported: • Bleeding between periods • Offensive vaginal discharge • Pelvic pain

27. Performing Pap-smear A vaginal speculum is used to view the cervix • One method involves brushing the cervix with a spatula and broom, and then smearing what is collected on a slide • The second involves collecting a specimen with the spatula and broom, and then putting it into a container of fluid that can be plated onto a slide.

28. Not routinely needed group: • Women aged under 20 years • Women aged 65 years or over • Women who have had a total hysterectomy • Women who are pregnant • Women who have had radiotherapy to the cervix

29. Test results-1 • Most results are normal this means that no abnormal cells were found at that time • If the sample is not good enough the result is insufficient, and the smear must be repeated • The smear should not be repeated within 6 weeks of the last test • If abnormal cells are found it is very unlikely that it is cancer

30. Test results-2 • Mild abnormalities often go back to normal on their own – the smear needs to be repeated in six months time • More significant changes such as moderate or severe abnormalities will need further investigation (colposcopy) and sometimes treatment • Almost all abnormalities detected should be treated

31. Pap-smear terms • Cervical Dysplasia • Abnormal cell changes • Precancerous cell changes • CIN (Cervical Intraepithelial Neoplasia) • SIL (Squamous Intraepithelial Lesions) • “Warts” on the cervix

32. How accurate is pap-smear? • Cervical screening is not 100% accurate • Having a smear test every three years reduces the risk of developing cervical cancer by 80 - 90% • It is important to report any abnormal symptoms, such as bleeding or discharge

33. Abnormal pap tests • What is usually recommended? • Re-testing • Treat with antibiotics • HPV-DNA testing • Colposcopy • Biopsy

34. Risk factors for cervical cancer: • Being/having been sexually active • Sex at an early age • Multiple sex partners • Partners’ sexual history • Not using condoms • Smoking • Weakened immune system • All Related to the • Human Papilloma Virus • (HPV)

35. HPV DNA classification • Low Risk HPV Types: 6,11,40,42,43,44, 54, 61, 72, 73, 81 • types 6 and 11 responsible for 95% of visible warts • High-Risk HPV Types: 31,33,35,39,45, 51, 52, 56, 58, 59, 68,82 High cancer risk: 16 • Most common-50% of cervical cancer High cancer risk: 18 • 10-12% of cervical cancer • *Risk not well established yet: 26, 53, 66, 73

36. HPV DNA testing • The remaining liquid from the Pap test can be tested for a number of additional things, including HPV.

37. Screenings in Turkey

41. Mammography screening program in Turkey-1 • Aim: To promote diagnosis at an early stage before the onset of clinical manifestations and reduce mortality due to breast cancer. • Method: every 2 years; mammography (bilateral/two poses of each) + clinical breast exam + counseling on self breast exam

42. Mammography screening program in Turkey-2 • Target population: Women at 40-69 ages • Organization by Family Health Centers, Community Health Centers, KETEM • In case of abnormalities: Re-evaluation is needed; detailed examination and biopsy if needed.

43. Cervical screening program in Turkey-1 • Aim: To promote diagnosis at an early, premalignant stage before the onset of clinical manifestations and reduce mortality due to cervical cancer. • Method: every 5 years; HPV Test or Pap smear

44. Cervical screening program in Turkey-2 • Target population: Women at 30-65 ages (not needed in women who had hysterectomy) • Organization by Family Health Centers, Community Health Centers, KETEM • In case of abnormalities: • Pap-smear: Re-evaluation is needed; detailed cervical examination and colposcopy if needed. • HPV: Reflex cytology.

45. THANK YOU!