Hunan University of Chinese MedicineProfessor Wang Ruoguang, Doctoral Tutor (medical doctor, postdoctoral Biology)Transfer from: China Journ
Hunan University of Chinese Medicine
Professor Wang Ruoguang, Doctoral Tutor (medical doctor, postdoctoral Biology)
Transfer from: China Journal of Obstetrics and gynecology in July 2007 twenty-third. Seventh
The 1WHO publication guidelines for WHO point out that in 2005 there were more than 500 thousand new cases of cervical cancer, and about 90% were from developing countries. It is estimated that more than 1 million of women worldwide suffer from cervical cancer. Most of them have not been diagnosed, or have not been able to cure and prolong life.
In 2005, about 260 thousand women died of cervical cancer, of which nearly 95% in developing countries, cervical cancer has become the most serious threat to women's lives. In many developing countries, the provision of health services is limited, cervical cancer screening or not, or only in a very small number of women who need it. In these countries, cervical cancer is the most common and deadly cancer in women.
In the prevention and treatment of cervical cancer and reduce the incidence and mortality, people have accumulated a lot of experience and evidence. However, until now, the information is still lack of effective guidance. This guide by the WHO and its member publication, aims to provide practical guidance for medical workers at all levels of health care system, including how to carry out the prevention, early detection, treatment and palliative care, especially for primary and secondary health care workers, improve the treatment of cervical cancer knowledge, to better serve the society.
2WHO recommendations on cervical cancer screening
2. 1 health education should be one of the contents of comprehensive prevention and cure of cervical cancer
2. 1 (1) community (1) for the lack of community knowledge and prevention of cervical cancer to guide the negative attitude. (2) develop key information on prevention and use in health education and counseling. (3) talk to community specific people alone. These include young men and women of different ages. (4) provide relevant information, distribute educational and communication materials. (5) consultation of cervical cancer and its prevention, screening and treatment in community.
2. 2. Hospitals (1) use a variety of opportunities to provide information and education, and to promote changes in the behavior of patients in different age groups of. (2) consult with both men and women alone to explain the treatment and early detection of cervical cancer. (3) in the waiting room, the outpatient group to the community to participate in screening the target population. (4) training and help the community health staff and community volunteers, to ensure their consistent use of important information.
2 - 1 - 3 area hospitals (1) for education and consultation on women in the waiting room, consulting room and ward, prevention and early detection of cervical cancer propaganda. (2) the use of various opportunities including the promotion of community screening programmes. (3) to train and guide the staff to support the community and health education to ensure accurate information about cervical cancer prevention.
2. (1. 4) the central hospital to perform all the duties of the regional hospital, but also should be: (1) for patients and their families to develop information on cervical cancer diagnosis, treatment and hospice care and information. (2) to inform and guide policy makers and policy makers about cervical cancer, the impact of cervical cancer on the health of the population and the cost of screening and the cost-effectiveness of prevention and testing.
2 / 2 to carry out the organization and opportunistic cervical cancer screening
2. 2. Tissue screening for tissue screening is the largest number of women with the highest risk of cervical cancer, and is usually performed at the national and regional levels. Special attention should be paid to organized screening: (1) target population. (2) screening interval. (3) coverage. (4) mechanisms to encourage women to participate in screening programmes. (5) examination for screening. (6) measures to ensure that all screening results are positive for women. (7) referral mechanisms for further diagnosis and treatment of positive women. (8) provide treatment recommendations. (9) monitoring and evaluation of screening programmes.
2 - 2 - 2 opportunistic screening for opportunistic screening refers to check when a woman came to the health service for other reasons, independent organization or a population based project abroad. Medical personnel may be recommended for screening or by women themselves. Opportunistic screening focuses on antenatal, in the face of children's health and family planning health care for low-risk young women. Is generally believed that the organization of low cost high efficiency screening than opportunistic screening, more effective use of existing resources and ensure that most women benefit. If there is poor quality control, risk low coverage, excessive screening, low-risk people lost the high rate of organized screening and opportunistic screening are likely to fail.
2. 3 specific screening methods
2. 3. Recommended cytology method for large cervical screening process figure 1, figure 1.
The traditional Pap smear method can be used, if the conditions are available, the liquid based cell method. Report classification selection TBS method. Recommendations for cervical cancer screening age and frequency: (1) the proposed new method began at the age of 30 women aged screening, including less than 30 years of high risk population. Current plans do not include women under 25 years of age. (2) if women are screened only once in their lifetime, the best age is between the ages of 35 and about the age of 45 years old (see article). (3) screening for women at least 1 years of age is appropriate for women over the age of 5 years (50). (4) if resources permit, 25~49 years of age can be screened for 1 times in the age of 3. (5) screening is not necessary at any age. (6) women over the age of 65 will not be screened if the last two smears are negative. (7) the screening for the 1 year and the 1 screening for the same period in the past 3 years are equally effective. If the resources are limited, the screening of for the first time in the year of 5~10 and even the screening for the first time between the ages of 35~45 and 1 will significantly reduce the mortality rate of cervical cancer.
2. 2. Naked eye screening methods include: acetic acid VIA and iodine staining of VILI, which is now recommended for use only in small scale tests and similar surveillance. This method does not apply to postmenopausal women.
2 - 3 - 3HPV DNA HPV detection is not alone as the preferred screening test, and to improve the sensitivity of cytology, or as a screening tool to determine which PAP suspicious results women need colposcopy. The main indications in the Pap smear results for atypical cells of undetermined significance (ASC-US) in women, only high-risk HPV DNA positive need for colposcopy and biopsy, this can reduce the number of patients do colposcopy. Currently, HPV DNA testing as a preferred screening test method is recommended only for a number of pilot projects, or under strict monitoring conditions. Sufficient resources can be combined with cytology or other methods. Below 30 years of age do not recommend doing HPV DNA based screening. Planners should consider the following questions: (1) HPV infection is common in young women, but most are temporary. (2) only a small proportion of HPV infection can cause invasive carcinoma. (3) the development of cervical cancer is very slow, from the early precancerous lesions to invasive cancer usually takes 10~20 years. (4) cervical cancer is rare before the age of 30, screening young women will find a lot of cancer will never develop into the disease, resulting in excessive treatment, the ratio is poor.
In addition, regardless of whether HIV infection, women should have the same chance of cervical cancer screening and treatment; despite the use of oral contraceptives with slightly increased risk of cervical cancer, but do not limit the use of hormonal contraceptives.
2 (4) specific treatment methods (1) colposcopy is recommended as a diagnostic tool, should be trained and skilled medical personnel to operate. (2) whenever, precancerous lesions should be treated in the outpatient department. In the exact diagnostic criteria and equipment conditions, cryotherapy and cervical loop electrosurgical excision procedure (LEEP) are applicable. (3) histological examination and staging of cervical cancer must be made before further examination and treatment. (4) surgery and radiotherapy are the only recommended treatment for cervical cancer. Brachytherapy is an effective measure for the treatment of cervical cancer. Cervical cancer surgery must be completed by specialist training of gynecologic oncologists. Use of existing palliative care or new therapies for women who cannot be cured. Medical staff at all levels should be trained and capable of dealing with common physiological and psychological problems, with particular attention to the control of pain. A comprehensive treatment system for cervical cancer should include the use of opioids, opioids, and adjuvant analgesics, particularly morphine.
3WHO diagnosis and treatment of cervical precancerous lesions
Standard management of cervical precancerous lesions is shown in figure 2.
3. Standard methods for the diagnosis of cervical precancerous lesions: colposcopy and biopsy, 1. Colposcopy assisted biopsy is the standard method for the diagnosis of cervical precancerous lesions and early invasive cervical cancer. A satisfactory biopsy should be able to see all the transformed bands in order to estimate the degree of abnormality and determine the biopsy area. If the squamo columnar junction or transformed with some or all hidden in the cervix, cervical speculum examination should be used to facilitate the observation of all the transformation zone, and endocervical curettage (endocervical curettage, ECC) were obtained by histopathology. If the diagnosis of precancerous lesions is established, cryotherapy, LEEP, or cold knife conization should be performed.
3. Two methods of gross observation: acetic acid test (VIA) and iodine test (VILI) (). Because of the lack of experimental equipment, acetic acid and iodine tests are promising to replace cytology in areas where there is a shortage of funds. In developing countries, large, representative, randomized controlled trials are being conducted. Before the results of the experiment were not available, WHO recommends that the acetate test and the iodine test be used only in pilot projects because of its impact on the incidence and mortality of cervical cancer. In the study, the sensitivity of VIA to cervical cancer and precancerous lesions was 77% (~94%), with an average of 86% (~94%). Compared with the naked eye, low magnification can not improve the effect of VIA. A study has shown that VILI can detect 92% of precancerous lesions, which is higher than VIA and cytology. The ability to detect the disease was similar to that of VIA (85%), lower than that of Pap smear. Another study showed that VILI was more reproducible than VIA. VILI and VIA can be carried out in clinics and other outpatient conditions, they are useful when the short, no pain, can be judged immediately, without the need for specimens, etc..
3. Another way to diagnose and treat 3
3. 3. (1) the method of treatment is based on the results of screening, and there is no previous diagnostic test results. The majority of women with positive screening results were screened for primary care while receiving cryotherapy. This is conducive to reducing the loss of access to the control of cervical cancer has a role. However, histological examination could not be performed. If there are no conditions for colposcopy and histological diagnosis, treatment can be performed on the basis of the results of the screening alone, especially in areas where resources are scarce. Screening for immediate treatment includes visual examination, HPV or cytology. Screening with immediate results, such as VILI (after acetic acid staining) (VIA) and iodine staining, the screening and treatment can be performed simultaneously in a hospital visit. However, patients with the following conditions need to see the patient again: (1) patients with menstrual bleeding, pregnancy or need to treat pelvic inflammatory disease (PID). (2) the existing conditions can not provide appropriate treatment. (3) the same medical institutions can not provide adequate treatment, patients need to go to other medical institutions. (4) patients need to consult with their partners before treatment. (5) patients need further evaluation.
The research and the forefront of the research on the treatment of the disease are mainly focused on the application of screening and the treatment of cryotherapy. Due to the convenience of a single visit, this approach can be dispersed into primary care units. The flow chart of this method is shown in figure 3. However, it is not clear that the treatment of cervical cancer incidence and mortality. Therefore, the country should be closely monitored and evaluated to carry out this kind of treatment. The advantages and disadvantages of the screen that is: (1) infrastructure and equipment is simple, cheap, low requirements for the surgeon. (2) a single visit reduces the rate of follow-up and treatment failure, and reduces the burden of follow-up and lost contact. (3) reduce the number of visits, reduce the burden on women. (4) patients and medical staff are easy to accept. Limitations: (1) it is not clear that the incidence and mortality of cervical cancer. (2) ethical and resource utilization considerations, including overtreatment and inadequate treatment. (3) the evaluation of the specimen can not be obtained unless a biopsy is taken before treatment.
3 - 3 - 2 colposcopy on the basis of "that is, that is," this is a compromise approach to avoid the previous approach led to excessive treatment. The results of the screening positive (cervical smear, acetic acid test naked eye observation of VIA, HPV test, the naked eye observation of VILI, or test) patients will undergo colposcopy, if found before the treatment of precancerous lesions. If cryotherapy is selected, biopsy should be performed before the treatment, so that the diagnosis can be confirmed after treatment. If LEEP is selected, the pathological changes can be obtained after operation. This approach requires only equipment and trained and experienced personnel to carry out.
3 ~ 4 cervical precancerous lesions in the treatment of precancerous lesions CIN II, CIN III must be treated. Most of CIN I can naturally subside, but patients with CIN I can not be followed up or in some special cases need treatment.
3. 4. Frozen therapy indications: (1) positive screening results of cervical precancerous lesions (1). (2) the range of lesions is small, and it can be covered by frozen probe. The lesion edge is less than 2mm. (3) the border of the lesions was clear, and there was no involvement of the cervix and vagina. Contraindications: (1) there is evidence to prove or suspected invasive cervical cancer or abnormal glands. (2) the range of lesions exceeded the edge of frozen probe 2mm. (3) pregnancy. (4) PID (unless treated). (5) when the menstrual volume is more.
3. 4. Cervical loop electrosurgical excision procedure (LEEP) indication: (1) diagnosis of cervical precancerous lesions (). (2) the cervical canal involvement was less than 1cm. Contraindications: (1) suspected invasive carcinoma or atypical hyperplasia of glandular epithelium. (2) lesions involving the cervical canal range of more than 1cm, or can not see the lesion edge or upper limit (such lesions should choose cold knife conization). (3) cervical infection or PID (unless treated or cured). (4) within 12 weeks of pregnancy or postpartum.
3. 4. Cold knife conization: (1) screening or diagnosis of suspected small invasive cancer in. (2) cervical intraepithelial lesions, cervical canal curettage abnormal. (3) positive screening results need to be removed, but LEEP and other outpatient surgery cannot be performed. Contraindications: (1) untreated cervicitis or PID. (2) within 12 weeks of pregnancy or postpartum. (3) invasive carcinoma.
Cryotherapy, LEEP and cold knife conization compared advantages of cryotherapy: small lesions and higher cure rate (86% ~95%); has the advantages of simple equipment, low price; trained specialist and non specialist to implement. The training is only a few days; it can be carried out in the primary clinic; the operation time is short (double freezing method is about 15min); no anesthesia is needed; no electricity is needed; the complications and side effects are less. Disadvantages: a larger range of lesions, the effective rate was slightly lower (1 year cure rate of less than 80%); no histological examination of the specimen; the need for continuous CO2 and N2O supply; water secretion is more, long duration. LEEP has the advantages of high cure rate (91% ~98%); can obtain histological samples to exclude invasive cancer; less complications; two hospital outpatient department to carry out; short operation time (5 ~ 10min), the operation is simple; soon see and treat in the diagnosis and treatment can be done at the same time. Disadvantages: the need for intensive training; postoperative bleeding rate of nearly 2%; need certain equipment; need to use electricity; need local anesthesia. The advantage of cold knife conization is that the cure rate is higher (90% ~94%); the simple surgical specimen, the edge is not burned, it is helpful to evaluate whether the edge of the lesion is completely removed. Disadvantages: the need for hospitalization and operation room; need spinal anesthesia or general anesthesia; need highly skilled surgery; complications may occur, including bleeding, infection, cervical stenosis, cervical incompetence, reduce fertility.
3 - 4 - 4 after treatment follow-up in patients with recurrent hospital referral should be 2~6 weeks after treatment. The referral contents include: (1) to determine the healing of cervical gynecological examination. (2) explain and stress the need for regular follow-up. (3) to discuss histopathological findings (patients with LEEP or conization).
If the lesions were resected, the patient should be in 6 months after treatment and 12 months. If LEEP or cold knife conization, specimen edge positive (precancerous lesions), it should be recommended for patients with close follow-up and even need further treatment.
Follow up at 6 and 12 months after surgery included the following: (1) a screening test, if possible, colposcopy and biopsy of the persistent lesions. (2) patients with CIN I or CIN II can return to routine screening if the first two follow-up visits are not abnormal. Patients with CIN III should be screened 1 times a year for a period of up to 5 years and then return to the routine screening (see Figure 2). (3) if the disease progresses or persists, it needs to be treated again.