Dr. Shivani Samlall, MBBS, is a specialist in Obstetrics and Gynecology with a sub-specialty in Gynecology Oncology, and with over 10 years of medical practice. Dr Samlall can be contacted at drshivanisamlall26@gmail.com.

CERVICAL CANCER PREVENTION PART 4- SCREENING
JANUARY is dedicated to raising awareness of Cervical Cancer. So, this week’s column explores the topic of screening for Cervical Cancer, which forms the subject of the World Health Organisation’s second pillar. Did you know that Cervical Cancer is one of the few cancers that have screening tests? These screening tests should form an essential part of a woman’s routine health care.

WHY SHOULD WOMEN SCREEN FOR CERVICAL CANCER?
Screening is done to identify pre-cancerous lesions (abnormal changes) in the cervix caused by the Human Papilloma Virus (HPV) so they can be removed in order to prevent Cervical Cancers from developing. It is also done to find Cervical Cancers at an early stage when they can usually be treated successfully.

WHAT SCREENING TESTS ARE USED?
For many years, cytology-based screening, also known as the Pap smear, and VIA (visual inspection using acetic acid) were the only methods for screening. However, with the understanding of the HPV as the main cause of Cervical Cancer, screening now includes HPV testing, which looks for the presence of high-risk HPV types in the cells of the cervix.

HOW IS CERVICAL CANCER SCREENING DONE?
Cervical Cancer screening can be done in a medical office, a clinic, or a community health centre or, in the case of the HPV testing, it can be collected by the woman (self-sampling).

WHEN SHOULD A WOMAN BEGIN CERVICAL CANCER SCREENING, AND HOW OFTEN SHOULD SHE BE SCREENED?
Women should talk with their doctor about when to start screening and how often to be screened. Generally, screening should begin at age 25. Women between ages 25 to 65 should have primary HPV testing every five years. If this is unavailable, screening may be done with a co-test (combines Pap smear and HPV testing) every five years or a Pap test alone every three years. If this is also not available, then VIA can be done.

More frequent screening is recommended for women with certain risk factors such as HIV infection, immunosuppressed (due to organ transplant or long-term steroid use) or women who were exposed to diethylstilbestrol before birth or treated for a precancerous lesion or Cervical Cancer.

Importantly, women who were vaccinated against HPV will still require screening. This is because the vaccines protect against a few and not all the high-risk HPV types.

WHEN CAN A WOMAN STOP SCREENING?
All Cervical Cancer screening should be discontinued in women older than 65 years, with no history of high-grade lesions of the cervix within the past 25 years and with adequate documentation of negative prior screening in the last 10 years.
Women with a total hysterectomy (removal of both the uterus and cervix) where the surgery was done for a benign or non-cancerous condition, can stop screening. However, if the cervix was not removed, the woman will still require screening.
WHAT FOLLOW-UP TESTS ARE DONE IF CERVICAL CANCER SCREENING RESULTS ARE ABNORMAL?

Depending on the test results, it may be recommended to have repeat screening. If verification of the result becomes necessary, a colposcopy (a procedure that involves the use of an instrument called a colposcope) is done to achieve a closer look at the cervix. If any concerning areas are identified, a biopsy or removal of cells or tissues for examination under a microscope is generally indicated.

CONCLUSION
Widespread routine Cervical Cancer screening is important because it has shown to greatly reduce both the number of Cervical Cancer cases and deaths from the disease. In many high-income countries, such as the United States, Cervical Cancer was once a leading cause of death in women; however with widespread screening since the 1950s, it is now the 11th cause of death.
In Guyana, we have access to all these tests. While VIA is available at most public institutions, other tests (Primary HPV testing, Pap smear, and Co-testing) are mostly available at private institutions.
The most important thing to remember is to get screened regularly because the success of Cervical Cancer screening is due, in part, to the repeat testing that women typically undergo over many years. As have mentioned previously, screening is the only way to detect precancerous lesions (abnormal changes in the cervix) or early-stage disease so that treatment can be given to prevent the disease or improve the outcome/survival from the disease.