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Dr Anusha Naidoo, an obstetrician and gynaecologic oncologist at Mediclinic Sandton, has introduced an additional screening procedure for cervical cancer, a colposcopy, which is now offered within her consulting rooms rather than as a theatre procedure.

The importance of accurate and streamlined diagnosis becomes obvious when one considers that cervical cancer presents as the most common cancer in women in sub-Saharan Africa. In South Africa, the incidence rate of cervical cancer is reported between 22.8 and 27 per 100 000 women as compared to the global average of 15.8.

From a global perspective, in 2020, cervical cancer accounted for more than 600 000 new cancer cases and an estimated 300 000 deaths worldwide and was the fourth most common cancer in females. Eighty-four percent of cervical cancer cases were from resource-limited regions. In females in resource-limited countries, cervical cancer was the second most common type of cancer (15.7 per 100 000 females) and the third most common cause of cancer mortality (8.3 per 100 000).

It is clear that global incidence and mortality rates depend upon the presence of screening programmes for cervical pre-cancer and cancer and of human papillomavirus (HPV) vaccination, which are most likely to be available in resource-rich countries.

In the local context, Dr Naidoo explains, “Options for screening for cervical cancer and pre-invasive lesions include assessing cervical cytology and/or testing for oncogenic subtypes of human papillomavirus (HPV).”

“A papsmear is a screening test for abnormal cells on the cervix, but it has a low sensitivity but good specificity, meaning that the false negative rate of tests is higher. An HPV high-risk screening test has a good sensitivity and lower specificity meaning that it is a good test to detect disease and has a lower false negative rate. The HPV test thus serves as an effective complementary screening test to the papsmear or a good primary screening test on its own.”

In patients with abnormal screening results, follow-up with colposcopy and cervical biopsies may result in a diagnosis of cervical intraepithelial neoplasia (CIN) or cervical cancer. Results referred for further evaluation of abnormal cervical cancer screening results would include:

  • HPV-positive with HSIL
  • HPV-positive with atypical squamous cells cannot exclude HSIL (ASC-H)
  • HPV-negative with HSIL
  • HPV positive with atypical squamous cells of undetermined significance
  • HPV positive with low-grade squamous intraepithelial lesion
  • HPV negative with ASC-H
  • HPV 16 and 18 positive with negative cytology.

“A colposcope is a microscope with a magnifying glass that allows a magnified view of the cervix, vagina, vulva, or anus. This allows for identification of pre-cancerous and cancerous lesions so that they may be treated early,” explains Dr Naidoo.

Colposcopy and biopsy are used as a definitive diagnostic test in follow-up abnormal cervical cancer screening tests (such as papsmear test or human papillomavirus testing) or abnormal areas seen on the cervix, vagina, or vulva. The biopsy result then gives a good clinical indication on how to proceed with further management of abnormal screening tests that often include close follow-up or a large loop excision of the transformation zone.

In essence, Dr Naidoo explains that the colposcopy and biopsy provide diagnostic validation of premalignant disease and avoid the missing of higher grade pre-cancer lesions on the cervix. It also avoids over-treatment of young women with a large loop excision of the transformation zone (LLETZ), which can further impact future pregnancies as multiple LETTZ procedures on the cervix can lead to cervical incompetence and possibly early pregnancy losses.

A colposcopy is also valuable for post-treatment surveillance and to ensure that known lesions are completely removed or treated, or to detect any other lesions in surrounding areas

In terms of how this offering benefits the client, Dr Naidoo explains that a colposcopy and biopsy in rooms allows for definitive diagnoses and provides a stepwise approach to abnormal screening tests rather than a colposcopy and LLETZ procedure done under general anaesthetic, which can be overtreatment in some cases.

A LETTZ procedure can also be done in rooms under local anaesthetic. The benefits of this procedure in rooms provide the same effectivity; however, there is less risk of exposure to general anaesthetic, much faster recovery time, less cost of hospital admission and avoidance of having to consult many clinicians due to being forced to move hospitals due to possible admission costs and medical insurance network restrictions.

Dr Naidoo’s commitment to screening remains consistent: regular screening allows for early diagnosis. In a randomised trial of over 130,000 patients in rural India, a single lifetime screen with human papillomavirus (HPV) testing reduced cervical cancer mortality by 50% compared with no screening.

But her call to action is not just screening, with Dr Naidoo being a strong supporter of HPV vaccination. She believes that primary cervical cancer prevention must include vaccination against oncogenic human papillomavirus (HPV) infection. The types of HPV vaccines available include:

  • Human papillomavirus quadrivalent vaccines target HPV types 6, 11, 16, and 18.
  • Human papillomavirus 9-valent vaccine (Gaurdisal 9) targets the same HPV types as the quadrivalent vaccine (6, 11, 16, and 18) as well as types 31, 33, 45, 52, and 58.
  • Human papillomavirus bivalent vaccines target HPV types 16 and 18.

Secondary prevention aims to treat and prevent pre-malignant cervical lesions to avoid their progression to malignant lesions. However, an integral arm remains timeous screening.