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a

 

2 Malaysian Female population in 2000 ʹapprox
10.5m
2 30%-in the reproductive period or older and are
at risk of developing cervical cancer
2 Cancer of the cervix is the second most common
cancer among females in Malaysia after breast
cancer. In 2002, cervical cancer accounted for
12% of all female cancers in Malaysia
2 The incidence of this cancer is 11.6 per 100,000
2 Sarawak incidence rate ʹ 16.2/100,000
u Among its ethnic groups ʹ namely Chinese,
Malays and Indians ʹ the Chinese experienced
the highest incidence rate in 2002, at 28.8 per
100,000 population. This was followed by
Indians at 22.4 and Malays at 10.5 per
100,000 population
Ñhy early detection is VERY important
2 The precursor cancer cells can be easily
detected , provided the women do regular
screening tests called pap smear.
2 There is 30% reduction in the risk of
developing cervical cancer if pap smear is
done every 10 years, 80% every 5years and
90% every 3 years.
2 [ap smear coverage in Malaysia:
2 less than 2% in 1992, 3.5% in 1995 and 6.2% in
1996
2 The reasons for poor screening:-
-poor campaign ʹ unaware of benefits
-social taboo
-wrong time of screening
-target group not widely covered ʹ mostly women
20-30s
2 [ost natal smear
- the epithelium of the cervix is denuded at
delivery of the baby
-inflammation of the cervix post delivery,
masking the cells of interest.
-elderly ʹ atrophy , cervical stenosis

,
 Œ
aŒ

2 åearly all cancer of the cervix arises from a
region called the transformation zone.
2 location differs according -lower in teens and
higher in elderly.
2 Trauma to cervix (e.g SI) induces squamous
metaplasia
2 [ap smear ʹ detect metaplastic (squamous)
cells.
 Œ
aŒ

-sexual intercourse leads to squamous metaplasia
of the transformation zone.
-H[V infection Human [apillomavirus (H[V)-16,18,
31, 33, 35, 39
persistent infection suppresses p53 and the Rb
(Retinoblastoma) genes.
p53 is the guardian of genome ʹrepair DåA
damage inducing cell death(apoptosis) and the
Rb gene regulates the cells
-pregnancy process
 Ma 
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2  a confined to the cervix;
2 Stages IA1 and IA2 should be
based on microscopic
examination of removed tissue,
preferably a cone, which must
include the entire lesion.
2  aŒ: Invasive cancer identified only microscopically.
Invasion is limited to measured stromal invasion with a
maximum depth of 5 mm and no wider than 7 mm.
2  aŒ: Stage IA1: Measured invasion of the stroma no
greater than 3 mm in depth and no wider than 7 mm
diameter.
2  aΠ: Stage IA2: Measured invasion of stroma greater
than 3 mm but no greater than 5 mm in depth and no
wider than 7 mm in diameter.
2  a
: Stage IB: Clinical lesions confined to the cervix or
preclinical lesions greater than Stage IA. All gross lesions
even with superficial invasion are Stage IB cancers.
2  a
: Stage IB1: Clinical lesions no greater than 4 cm in
size.
2  a
: Stage IB2: Clinical lesions greater than 4 cm in
size.
2  aa e-xtends beyond the cervix, but does
not extend into the pelvic wall.
2 involves the vagina, but not as far as the lower
third.

 aaŒ: åo obvious parametrial

involvement. Involvement of up to the upper
two-thirds of the vagina.
2  aŒ
: Obvious parametrial involvement,
but not into the pelvic sidewall.
2  aaa -extension into the pelvic sidewall.
2 On rectal examination, there is no cancer-free
space between the tumour and the pelvic
sidewall.
2 The tumour involves the lower third of the
vagina. All cases with hydronephrosis or a non-
functioning kidney are Stage III cancers.

 aaaŒ: åo extension into the pelvic sidewall

but involvement of the lower third of the vagina.
2  aaa
: Extension into the pelvic sidewall or
hydronephrosis or non-functioning kidney.
2  a -extension beyond the true pelvis or
has clinically involved the mucosa of the
bladder and/or rectum.

 aŒ: Spread of the tumour into adjacent

pelvic organs.
2  a
: Spread to distant organs.
 ÑHEå TO START SCREEåIå

2 In Malaysia, all women who are, or who have

been sexually active, between the ages of 20
and 65 years, are recommended to undergo
[ap smear testing.
2 If the first two consecutive [ap results are
negative, screening every three years is
recommended.
 Ñhy screen every 3 years
2 Cx ca usually takes a decade to develop in to
cancer, so every 3 years can help with an early
detection
2 3 out of 4 women who develop cancer early
have either never had a pap smear or have
not been screened for last 5 years.
TY[ES OF SCREEåIå
 Types of pap smear
COåVEåTIOåAL CYTOLO Y LIQUID BASED
2 ÑITH S[ATULA MOåOLAYER CYTOLO Y
2 ÑITH CYTOBRUSH
Studies of the accuracy of Studies of the accuracy of
conventional cytology liquid based monolayer
report: cytology report:
2 sensitivity 72% sensitivity 61% to 66%
2 specificity 94% specificity 82% to 91%
[A[ SMEAR [ROCEDURES
Insert Speculum
2 Spread labia
2 Keep labia apart
2 Ñarm water to
lubricates speculum
2 remain closed until fully
inserted
Squamo-Columnar Junction
2 Junction of pink cervical skin
and red endocervical canal
2 Inherently unstable
2 Key portion of the cervix to
sample
2 Most likely site of dysplasia
Sample Cervix
2 Use concave end
2 Rotate 360 degrees
2 Don͛t use too much force
(bleeding, pain)
2 Don͛t use too little force
(inadequate sample)
Cytobrush
2 Insert ~ 2 cm (until brush
is fully inside canal)
2 Rotate only 180 degrees
(otherwise will cause
bleeding)
A broom used in liquid based
monolayer cytology
Œ

 
-ASCUS or A US (atypical cells of
uncertain significance):
may be due to infection with H[V but may also mean
there are precancerous changes present.

-LSIL (low-grade dysplasia) or HSIL (high-

grade dysplasia):
This means precancerous changes are likely to be
present;
|

 |a 
abnormal changes are likely to progress to cancer.

Π
 Π|

Π
 Œ|

åormal cervical epithelium
 a
mmild dysplasia
mconfined to the basal 1/3 of the epithelium.
mcorresponds to infection with H[V,
mtypically will be cleared by immune response .
 a
m involve to the basal 2/3 or more of the
epithelium (Moderate dysplasia to severe
dysplasia.)
 [
 
   
status action
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 Indications for colposcopy:

2 Suspicious looking cervix.

2 Unexplained post-coital bleeding. .[ersistent unsatisfactory smear on 3 occasions,
3 monthly. .[ersistent inflammatory smear on 3 occasions, 3 monthly (despite
treatment). .[ersistent Atypical Squamous Cells of Undetermined Significance
(ASC-US) on 2 occasions.
2 Atypical Squamous Cells of Undetermined Significance (ASC-US), positive for high
risk H[V.
2 Atypical Squamous Cells -cannot exclude high grade lesion (ASC-H) [ersistent Low
rade Squamous Intraepithelial Lesion (LSIL)on 2 occasions, 6 monthly.
2 [ersistent Low rade Squamous Intraepithelial Lesion (LSIL) with high risk factors.
2 High rage Squamous Intraepithelial Lesion (HSIL).
2 Squamous Cell Carcinoma (SCC).
2 Atypical landular Cells (A US)
2 Adenocarcinoma.
2 [ositive for high risk H[V DåA.
2 Young women who are infected with HIV
and/or are immunocompromised should
follow the US [ublic Health System uide-
lines, i.e., obtain a [ap test twice in the first
year after diagnosis of HIV infection and, if the
results are normal, annually thereafter.
 RISK FACTORS
2 First sexual Intercourse at an early Age
2 A åumber of sex patners or sex partner who
has had a number of sex partners
2 Cigarette Smoking
2 History of H[V, [ID or Ñart Virus .
Œ|Œ   Œ aŒ |a
a |a

 Œ

Œ

CLASS I åE åORMAL åORMAL åORMAL

CLASS II åO TERM ATY[IA ATY[IA ASCUS

REACTIVE OR
åEO[LASTIC
CLASS II åO TERM H[V H[V LOÑ RADE SIL

CLASS II åO TERM ATY[IA ÑITH ATY[IA LOÑ RADE SIL

H[V ͞condylomatous
atypia͟ and
͞koilocytic
atypia͟
CLASS III MODERATE MODERATE CIå 1 LOÑ RADE SIL
DYS[LASIA DYS[LASIA
CLASS III SEVERE SEVERE CIå 11 HI H RADE SIL
DYS[LASIA DYS[LASIA
CLASS IV CIS CIS CIS HI H RADE SIL

CLASS V IåVASIVE CA IåVASIVE CA IåVASIVE CA IåVASIVE CA

 references
2 å
 



  


 uidance on the use of
liquid-based cytology for cervical screening
2 uidebook for pap smear screening (management of abnormal pap
smear bethesda classification 2001)
2 Management uidelines for Abnormal [ap Smear and [reinvasive
Disease of the
2 Cervix - Cervical Screen Singapore.
2 United States [reventive Services Task Force (US[STF) recommends
waiting three years.[1] American Congress of Obstetricians and
ynecologists (ACO )
2 Family health development division MOH 1998
2 Cervical Ca-from bleak to bright future ʹ school of medical sciences
, USM
2 åational Cancer Society of Malaysia