MINISTRY of HEALTH

National Directorate of Public Health

National Program for the Prevention and Control of Cervical Cancer and
Mama

Training in VIA and Cryotherapy

Topic: Introduction
Training/Update in Maternal and Neonatal Health
SR/CACUM/PF for Teachers

Mozambique, August 2011

 Magnitude of the Problem
Affects 1.4 million of
Developed Countries
women in the world
83,400 cases annually integer
Each year occurs
460,000 new cases
Each year 231,000
women die from
disease
Developing countries About 80% of new
409,400 cases annually cases occur in the
countries in
Source: J Ferule et al. development
GLOBALCAN 2002 (2004).
Incidence of Cervical Cancer in the World

Source: Globocan 2002

Situation in Mozambique
Cancer registration data of the Section
of the Pathological Anatomy of HCM,
based on diagnosed cases
by histology, cytology, and autopsy,
indicates that 'cervical cancer
it is currently the malignant neoplasm
most common in adult women
that most cases are
diagnosed in advanced stages,
when it is no longer possible to do the
preventive surgical treatment.
Carrilho, 2004
Parkin DM, Ferlay J, Hamdi-Cherif M, Sitas F, Thomas J, Wabinga H, Whelna
SL (eds) Cancer in Africa: epidemiology and Prevention (IARC Scientific
Publications 153), pp. 268-276, Lyon, IARCPress, 2003.
 Context
99.7% of cervical carcinomas are
directly related to a previous infection
human papillomavirus (HPV)
Of the more than 50 types of HPV that infect the organs
genitals, 15 to 20 types are linked to carcinoma of the
cervical (4 of these types are the most
frequently
Frequently, HPV infections do not cause
symptoms
The most common signs are small pink warts.
pink or reddish, itching or burning in the area
5 genital
 Context (cont.)
After a woman becomes infected with the
HPV
The infection can remain locally stable.
It can regress spontaneously,
If the cervix is affected, it can
develop intraepithelial squamous lesions of
low grade (LGSIL), also called
moderate cervical intraepithelial neoplasia (CIN)
I) or initial dysplasia
6
 Context (cont.)
For every 1 million infected women, 10%
(about 100,000) will develop pre-
cancerous in your cervical tissue.
These changes are observed more frequently.
in women aged between 30 to 40 years
About 8% of these women will develop a pre-
carcinoma limited to the superficial layers of the cells
cervical (carcinoma in situ [CIS])
About 1.6% will develop invasive cancer.
less that it is detected and treated
7
 Context (cont.)
The progression to cervical carcinoma
cervical from squamous intra- lesions
high-grade squamous intraepithelial lesions (HGSIL) generally

occurs over a period of 10 to 20 years

Although they are rare, some injuries

precancerous become cancerous within
in one or two years

8
 HIV/AIDS, HPV Infection, and
Cervical Carcinoma
Heterosexual contact is the main channel of
transmission of HIV in new cases.
In women infected with HIV
HPV is detected more frequently and tends to
to be resolved more slowly
The HPV associated with the disease is more difficult to treat.

The pre-carcinoma progression is accelerated.

9
 HIV/AIDS, HPV infection, and
Cervical Carcinoma (cont.)
Cervical cancer screening is
important in this population:
–Onde o HIV é endémico, 15–20% de mulheres são
positive for pre-cancerous lesion
•Squamous cell carcinoma is currently
definition of disease related to AIDS
Antiretroviral medications improve the
quality of life; the effect on the progression towards the
the precancerous lesion is not known
10
 Risk Factors for HPV and
Cervical Cancer
Risk factors associated with development
cervical cancer
. Beginning of sexual activity at a young age (age <20)
. Multiple sexual partners
. History or presence of STIs
. Mother or sister with cervical cancer
. Abnormal pre-test
. Smoker
. Immunodepressive disorder
. HIV/AIDS
. Chronic use of corticosteroids
11
 Prevention of Carcinoma of
Uterine Cavity
The prevention of HPV infection will
prevent cervical carcinoma

There is no conclusive evidence that the use

does the condom reduce the risk of infection
for HPV, however, it can offer some
protection against associated diseases
HPV
12
 Primary Prevention: Vaccine
The vaccine is the most effective way to prevent
cervical carcinoma
The vaccine protects the woman only against
some types of HPV
The vaccine needs to contain a mixture of
types of viruses
The vaccine should be used in adolescence,
before HPV infection
13
 Secondary Prevention
Women who are already infected with HPV should be
tracked to identify precancerous lesions
early and easily treatable
-The Pap test (Pap smear) is a well-established method
effective tracking
Other tracking options:
Visual tracking,
The HPV tests
•The automated cytological screening.
The Pap test, with its many steps is
problematic in countries with limited resources
14
 Tracking:
Visual Inspection with Acetic Acid (VIA)
Visual inspection of the cervix using acid
acetic / vinegar (VIA) is as effective as the Test
Papanicolau in the detection of disease

VIA has few technical and logistical constraints.

Study in South Africa, India, and Zimbabwe in 1990
they showed that VIA is a good alternative to the test of
Pap smear
Later studies confirmed that VIA is an option
viable for places with limited resources
15
Visual Inspection using Acid
Acetic
Observation of the cervical collar, to detect
abnormalities, after the application of acid
diluted acetic (vinegar) (3-5%)

Normal CIN III

 Value of VIA in the Locations with
Limited Resources
Can effectively identify most injuries
pre-cancerous
It is non-invasive, easy to execute, and low cost.
It can be carried out by workers of all
levels and in almost all the US
Offers immediate results that can be used
for informed decision making and actions regarding
to the treatment

Requires easily available materials and equipment

17 locally
 Treatment
Testing must be linked to appropriate treatment.
of any detected precancerous lesions
High-grade lesions (CIN II–III) must be treated
because they are more likely to progress to the
carcinoma than low-grade lesions (CIN I)
Most CIN I lesions regress spontaneously and
do not progress to carcinoma
When confirmation or careful follow-up does not
it is advisable to treat all
white acetabular lesions
18
 Factors Affecting the Choice of
Treatment
• Effect on fertility
• Insurance during pregnancy
• Effectiveness of the method
• Safety and potential side effects
• Who is accredited to provide the treatment, and
which training do they need

• The size, extent, severity, and location of the injury

• Equipment and materials needed
• Availability of the method
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• Cost or accessibility of the method
 Management of Pre-Cancerous Disease of the Cervix
Uterine with the Approach in Consultation
Unique

Single Consultation Approach:

-VIA League with treatment using cryotherapy
-Women with positive VIA results and with
indications for cryotherapy are offered
treatment

20
 Advantages and Disadvantages of
Single Consultation Approach
Advantages:
–Reduz o número de mulheres que se perdem no
following
It can be carried out at the lowest level of
health care system
Disadvantages:
VIA has a considerable rate of false positives.
positives (there is a proportion of women who
they are VIA positive and have no pre-existing injuries

21
cancerous
Methods for Deception

Source: Sankaranarayan et al. Int J Obstet Gynaecol, 2005.

 Tratamento de Mulheres com
Unconfirmed Disease
Using the single consultation approach, it will be offered
the immediate treatment for some women with the
VIA test result positive, which does not have a
actual injury

Due to the low morbidity associated with cryotherapy, the

cryotherapy treatment for all women can
be cost-effective by preventing the disease from progressing
for cervical carcinoma

Cryotherapy has the potential to reduce

significantly the probability of developing
23 precancerous lesions or carcinoma
 BREAST CANCER IN MOZAMBIQUE

In general, the diagnosis of breast cancer in

Mozambique, they are already made in stadiums very
advanced.

In the few cases where a woman is subjected

to a clinical examination and if something suspicious is felt they are
referred for breast consultation, in the HC, or for
a surgeon.

In the Pathological Anatomy service of HCM they do

FNA (Fine Needle Aspiration Biopsy) for
diagnose the tumors. After anatomical diagnosis
pathological, the surgeon decides the steps to be taken.
BREAST CANCER IN MOZAMBIQUE

The available treatments

in Mozambique are the
mastectomy is the
chemotherapy. Currently
is not available
radiotherapy.
Methods for tracking
breast cancer
Self-exam
Clinical exam
(Mammography)
 Breast self-exam
Inspection

Breast and axilla palpation

 Connection with other Services of
Saúde Reprodutiva

The connections of the screening services of

cervical and breast cancer with
other reproductive health services is
essential and logical.

The integration of carcinoma prevention

of the cervical colon and screening for cancer of the
mom must be made with the services of
existing reproductive health.
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Thank you!