Reference Manual - IARC Screening Group

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IntroductionWHO generally recommends that women should be offered the samecervical cancer screening options irrespective of their HIV status.RISK FACTORS FOR HPV AND CERVICAL CANCEREpidemiologic studies have identified a number of factors that play asignificant role in the development of CIN (Palank 1998). The riskfactors for HPV acquisition and cervical cancer include the following:• Sexual activity before age 20• Multiple sexual partners• Exposure to sexually transmitted infection (STI)• Mother or sister with cervical cancer• Previous abnormal Papanicolau (Pap) smear• Smoking• Immunosuppression:• HIV/AIDS• Chronic corticosteroid useThe type and pattern of sexual activity, especially in adolescents, aremajor factors in determining whether a person becomes infected withHPV. The number of sexual partners that adolescents have before age 20may be quite large, and each of their partners also may have had multiplepartners. As a result, this pattern of sexual activity increases the risk ofexposure to STIs, especially HPV.Another risk factor is having a blood relative (mother or sister) withcervical cancer. Magnusson, Sparen and Gyllensten (1999) compared theincidence of dysplasia and CIS in relatives of women with disease and inage-matched controls. They found a significant familial clustering amongbiological, but not adoptive, relatives. For biological mothers the relativerisk was 1.8, whereas for adoptive mothers the relative risk was 1.1(relative risk for controls was 1). For biological full sisters the relativerisk was even higher (1.9), whereas it was 1.1 for nonbiological sisters.These data provide strong epidemiological evidence of a genetic link tothe development of cervical cancer and its precursors.Suppression of the immune system (e.g., HIV/AIDS infection) also is animportant risk factor because it makes the cells lining the lower genitaltract (vulva, vagina and cervix) more easily infected by the cancerinducingtypes of HPV (Stentella et al. 1998). There is substantialevidence that HIV-positive women are at increased risk of developingprecancerous lesions (Judson 1992). In two studies, both from high HIV1-4 Cervical Cancer Prevention Guidelines for Low-Resource Settings
Introductionprevalence areas, a statistically significant association between HIV andCIN was reported (Table 1-1). Because the number of adolescents, aswell as adults, with HIV is rising in most countries where cervical canceris largely untreated, cervical cancer rates are expected to continueincreasing.Table 1-1. Odds Ratio* of CIN Among HIV-Positive Women Compared to HIV-Negative WomenAUTHOR COUNTRY DATE ODDS RATIOMiotti et al. Malawi 1996 2.2 (1.10–4.8)Maggwa et al. Kenya 1993 2.69 (1.29–5.49)* Compares likelihood of CIN occurring in HIV-positive group with likelihood in HIVnegativegroup.Other less common conditions that cause immunosuppression includethose requiring chronic corticosteroid treatment, such as asthma or lupus(McDonald 1999). Women also increase their risk for CIN by engagingin other behaviors that are known to suppress the immune system, such asuse of recreational drugs, alcohol and cigarettes. Nicotine and thebyproducts of smoking are thought to increase a woman’s relative risk forcervical cancer by concentrating in the cervical mucus and decreasing theimmune capability of Langerhan’s cells to protect cervical tissue frominvading oncogenic factors, such as HPV infection (Ylitalo et al. 1999).PREVENTING CERVICAL CANCERPrimary PreventionPreventing HPV infection will prevent cervical cancer. This primaryprevention approach, however, presents greater challenges than for mostother STIs. Although condoms significantly reduce the risk of infectionof HIV, there is no conclusive evidence that condoms reduce the risk ofHPV infection. Studies have suggested, however, that condoms mayprovide some protection against HPV-associated diseases, includingcervical neoplasia (NIAID 2001).The most effective way to prevent cervical cancer would be to develop avaccine against HPV. The benefits of such a vaccine would be particularlysignificant in developing countries, where women’s healthcare services areminimal or severely limited. A vaccine, however, would protect a personagainst only some types of HPV. There may be subtypes within these virustypes that would not be prevented by the vaccine. In addition, the types ofHPV associated with cervical disease vary by geographical area. Therefore,a vaccine against HPV would need to contain a mixture of several virustypes (Groopman 1999; Stewart et al. 1996).Cervical Cancer Prevention Guidelines for Low-Resource Settings 1-5
Page 1: Cervical Cancer PreventionGuideline
Page 5: TABLE OF CONTENTSPREFACE AND ACKNOW
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Page 11 and 12: Table C-2Figure C-1Preparing a Dilu
Page 13 and 14: PREFACE AND ACKNOWLEDGMENTSThis ref
Page 15 and 16: ONEINTRODUCTIONMAGNITUDE OF THE PRO
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Page 23 and 24: Introductiontheir performance was t
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Page 27 and 28: IntroductionCompared to other metho
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Page 31 and 32: IntroductionBelinson JL et al. 2001
Page 33 and 34: IntroductionMitchell MF et al. 1998
Page 35 and 36: IntroductionYlitalo N et al. 1999.
Page 37 and 38: TWOHUMAN PAPILLOMAVIRUS AND CERVICA
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Page 51 and 52: Pathophysiology of Cervical Cancerp
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Page 59 and 60: FOURTALKING WITH WOMEN ABOUTCERVICA
Page 61 and 62: Talking with Women About Cervical C
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FIVEPREVENTING INFECTIONS INHEALTHC
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Preventing Infections in Healthcare
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SIXCLIENT ASSESSMENT AND VIA TESTIN
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Client Assessment and VIA TestingFi
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Client Assessment and VIA TestingIN
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Client Assessment and VIA Testingsp
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Client Assessment and VIA Testingth
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SEVENTREATMENT AND FOLLOWUPBACKGROU
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Treatment and Followupregardless of
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Treatment and FollowupFigure 7-1. L
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Treatment and FollowupTable 7-6. Co
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Treatment and FollowupFigure 7-2 is
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Treatment and Followup• Regulator
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Treatment and FollowupCRYOTHERAPY P
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Treatment and FollowupStep 6 Point
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Treatment and FollowupNote: When CO
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Treatment and FollowupStep 5Advise
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Treatment and FollowupBerget A, B A
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APPENDIX ATESTS FOR CERVICAL CANCER
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Tests for Cervical Cancer Screening
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APPENDIX BSCREENING TEST QUALITIES
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Screening Test Qualities and Their
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APPENDIX CINFECTION PREVENTION PROC
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Infection Prevention Processesfor m
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Infection Prevention Processeswith
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Infection Prevention ProcessesFigur
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Table C-4. Preparing and Using Chem
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Infection Prevention ProcessesStora
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Infection Prevention Processes• h
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APPENDIX DTECHNICAL OVERVIEW OF THE
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Technical Overview of the Cryothera
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Figure D-5. Removing Protector Tube
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Technical Overview of the Cryothera
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Figure D-11. Gas Cylinder Secured t
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APPENDIX ETROUBLESHOOTING WITH THEC
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Table E-1. Following-Up on Commonly
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APPENDIX FPROCESSING SURGICAL GLOVE
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Processing Surgical GlovesTable F-1
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Processing Surgical GlovesSTEP 10:
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APPENDIX GPERFORMING BREAST AND PEL
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Performing Breast and Pelvic Examin
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Figure G-2. Breast Puckering or Dim
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Figure G-5. Checking for Nipple Dis
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Figure G-18. Speculum in Place with
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APPENDIX HPERCEIVED BARRIERS TO PRO
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AVAILABILITY OF BASIC SUPPLIES AND
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GLOSSARYAcetic AcidAcetowhite Chang
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PatulousSquamocolumnarJunction (SCJ
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ADDITIONAL READINGAlliance for Cerv
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Reference Manual - IARC Screening Group

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