Posts tagged: obstetrics and gynecology programs

Hi and welcome everyone to today’s episode of Feature of the Day. Today is 9th of April and in a significant part of India, day is celebrated as either we call it Ugadi or we call it Gudipadva. So in Maharashtra, Gudipadva is the new year for Maharashtrians whereas Ugadi for a few other states indicates that it’s a harbinger of joy, it’s a new era, it’s the beginning of spring.

It is basically just a new beginning and hence I decided to choose a topic that has a significant importance and just a couple of days ago, according to a study, India was said to be the cancer capital of the globe and in just an example, in the current ongoing Indian Premier League, there is one feature called as most valuable player. 

Basically, the player who gives the maximum contribution to the team is given that award of MVP or the most valuable player of the team and similarly, in making India get to that first position to be called as a cancer capital of the globe, cervical cancer was the MVP of our country. It is one of most significant cancers, almost 2 lakh cases according to 2023’s WHO report, almost 2 lakh cases are detected every year and we have around 70,000 deaths.

Yes, we do have other cancers, oral cancers, breast cancer, lung cancers but the sad part about cervical cancer is that it’s a vaccine preventable. It is probably the only preventable cancer that we have currently and yet to have these high numbers is a little disappointing. So, I decided to touch down upon a few topics which included cervical screening and cervical cancer screening as well as immunization and its current status in India in today’s topic.

So, to begin with, these guidelines have been taken from FOCSI’s GPCR. GPCR is the good clinical practice guidelines from FOCSI. FOCSI is the association that controls all the gynecological societies in India.

So, it advises three main modalities for screening, cervical cancer screening. So, the first one is cytology and cytology which is probably the most famous of all of these three is the one that is commonly done in our medical colleges and we do it because it’s a very, it is not really a resource sensitive thing to be done and it can easily be interpreted by a mere microscope. It doesn’t even take much to do the sampling and it is something that can be done at every possible hospital, even a small primary health care center.

The numbers that I’ve written in the packets are the number of years at which frequency of these tests should be scheduled. So, for cytology, it has to be scheduled every three years if the tests are negative. The next test is what we call the HPV DNA test.

In this, from the sample, we check for the DNA of the human papillomavirus, the virus  that causes cervical cancer and we see if it is a high-risk DNA. So, by high-risk, I mean there are around 200 different types of HPVs. Of them, there are few around 15 to 20 of them which are high-risk and by high-risk, I mean they are the ones who are actually causing 90% of the cases of cervical cancer.

The low-risk ones cause genital warts but the high-risk ones are the ones which are dangerous. They directly cause cervical cancer. So, this HPV DNA is used to detect those high-risk DNAs, the significant ones being 16 and 18 and the third one is visual inspection under acetic acid or visual inspection by Lugol’s iodine.

The foxy though recommends this to be done by just acetic acid and not by Lugol’s iodine. In this, there’s the concept that any cancerous cell has a lot of DNA material in it. There’s a lot of chromatin in it.

So, whenever you’re putting any acid on it, in this case, we use acetic acid of almost 0.5% concentration, this chromatin or this DNA material gets coagulated and we can see it as a white spot wherever these cells are present, wherever these malignant cells are present. 

Similarly, by doing it with Lugol’s iodine, therein, the Lugol’s iodine as we have read is the one that stains, it stains glycogen or glucose stores. So, on the contrary to what we had in acetic acid, that it stained the malignant cells, in this, the Lugol’s iodine stains the normal cells and it leaves the patches on places where there are no malignant cells and we call the classic up here the yellowishness, the yellow color that we see with Lugol’s iodine on normal cells, we call it, it’s a mahogany yellow color that we classically see.

In visual inspection with acetic acid, we see classical coagulation, we see white spots. It is also to be done every five years, but it’s a very, it’s very much a thing now that is done only in lower resource settings. We now ideally prefer to do either cytology or HPV DNA or we can combine them both and do something called as a co-test.

It has much higher sensitivity and specificity and it also can be repeated every five years. Now, these were the things that were being done for several years. What are the minor changes that we have gotten? Now, the problem with cytology used to be, we used to collect it with a swab or with an IR spatula, we used to smear it on a slide and then we used to send it to the lab for testing.

Now, there were multiple problems that were arising. The first one was by collection using a swab or an IR spatula. A lot of sample, a lot of cells used to be left behind.

It’s an exfoliative test. Basically, the cells in the cervical area or in the vagina are the ones that we take for testing and a lot of cells would be left behind. So, probably a patient was getting a falsely negative report which meant that the patient probably could have had cancer but it was not being detected because we weren’t collecting the entire sample.

Plus, after putting it on the slide, it used to get dried by the air. So, by the time the sample reached the laboratory, a lot of sample would either be wasted or the sample just would not be adequate enough on the slide to be good enough for interpretation.

So, the amount of inadequate samples was increasing and we just had a 10 to 20 percent yield of good quality reports of this.

So, what we decided to do is we decided to introduce a liquid media. In this liquid media, we use a brush. We use a brush to take a swab.

So, this brush not only collects the endocervical cells but also the ectocervical cells and we put it in a liquid media. Now, in this liquid media, there is no risk of loss of cells because it is getting all adhered to the brush and we are putting it inside a jar that contains the liquid, what we call as LBC, liquid based cytology. LBC is the way we do it now.

LBCPAP or LBC HPV DNA is what we do now. So, liquid based cytology is what we do now. So, in that liquid, the amount of cells that were being wasted was also reduced and so from that 10 to 20 percent of the yield, now we started getting almost 80 to 90 percent of yield of reports and hence it is practiced or it is used now.

The only problem is that it is a slightly expensive test and is not coded at all the centers. So, these are the modalities that are advised in India for screening. The first is cytology wherein you just take a, where is you just take, you collect the cells that have been shedded by the cervix.

It is exfoliated cytology or you test for the HPV DNA by doing a PCR that is polymerase chain reaction test or you do visual inspection with acetic acid. This is about screening. We will be covering about what are the treatments for each modality of screening and what is to be done next in a separate lecture on our application.

Apart from that, in the vaccination, currently our government, just recently in this budget, the budget that was announced by our finance minister, she announced that our country has now not only started producing its own endogenous vaccine called as Cervavac which is a quadrivalent. The numbers here indicate the valency. By valency, I mean how many different DNAs do these vaccines cover.

So, it can be either a bivalent one which covers 16 and 18 or it can be a quadrivalent one which covers 6, 11, 18 and 16. Or it can cover a non-valent one which covers 9 different subspecies which includes which includes 6, 11, 18, 16, 31, 33, 45, 53, many more of them. So, basically 9 major variants and we call it Gardasil whereas the one that is significant over here is Cervavac.

Now Cervavac is a thing that is produced in India by an Indian company and it has now been put into the national immunization schedule as well for girls. Though it is advised that even boys take it because it reduces the risk of penile cancer and also the transmission of this HPV virus to women but currently in the national immunization schedule, it has been introduced for girls in the age of 9 to 15. The significance of this age is that these are the girls who are still yet to have the onset of sexual activity.

So, when you give this vaccine prior to the onset of sexual activity, it has maximum benefit whereas if you are giving it at a later age after a female has had a sexual activity earlier, the efficacy significantly reduces. Also, in this age group, you just need to give 2 intramuscular doses 6 months apart whereas when the patient is more than 15 years till the age of 27, you have to give 3 doses for them at 0, 1 and 6 months of interval. After 27 years of age, most women have had their sexual activity, the onset of sexual activity and it makes no real sense to be giving them these vaccines because the efficacy is going to be very very poor.

So, that is it for this feature of the day. So, we spoke about not only modalities of screening today which included cytology, HPV DNA and visual inspection with acetic acid. We  also spoke of HPV vaccination in that the significant one is Sarvavac that has been introduced by an Indian company and it is now included for free in the national immunization program as well.

It will be given to girls in the age group of 9 to 15 years of age and it will be given in the form of 2 doses 6 months apart. It will be given intramuscularly and will be given for free by the government. So, thank you for your listening today.

I hope with this lecture, we can bring in a new change in our family. We have several girls in our family. We have women in our family.

So, for those young girls, we can definitely advocate this vaccine. We can be the ones who administer them. We can be the one who encourages them to commit it to their friends, into their school and increase the awareness and for the women, we have our aunts, we have our sisters, we have our mothers.

For them, we can advise them to start doing these modalities of screening regularly from the age of 30 till the age of 65. That is a very significant point. In India, we started from the age of 30 and we can do it till the age of 65 and it depends on which test you are doing to determine the frequency of those tests.

I hope this lecture helps you understand this topic slightly better and I hope you all are the ones who are leading from the front to bring about this change so that 10 years down the line, we can probably shed this tag of being the cancer capital of the world at least on the front of cervical cancer. Thank you.