INTRODUCTION Dr Hiranandani Hospital by mikeholy


									                    FINAL REPORT


                PROJECT NO : 2128/96

Cervical screening for all OPD patients to detect and treat
conservatively at risk patients for pre cancer/early cancer

                 PRINCIPAL WORKER

             SURG. CDR S. CHATTERJEE



            SURG CAPT (MS) P. TARNEJA

                       MD, DGO.



                       ISSUED BY



SR. NO.                TOPIC       PAGE
  1.      CLOSURE REPORT            1
  2.      ABSTRACT                  2
  3.      INTRODUCTION              3
  4.      MATERIALS AND METHODS     10
  5.      RESULTS                   13
  6.      DISCUSSION                24
  7.      CONCLUSION                28
  8.      RECOMMENDATIONS           29
  9.      BIBLIOGRAPHY              30
  10.     PROFORMA                  32

1.     PROJECT NO : 2128/96

2.     TITLE OF PROJECT : Cervical screening of all OPD patients to detect and

       treat conservatively at risk patients for pre cancer/early cancer.


4.     AMOUNT SANCTIONED : Rs.2,50,000/-

5.     AMOUNT SPENT : Rs.2,50,000/-

6.     DATE OF INITIATION : 09.10.06

7.     DATE OF COMPLETION : 09.10.08

8.     AIM & OBJECTS : Cervical screening of all OPD patients to detect and treat

       conservatively at risk patients for pre cancer/early cancer.



I.     Pap smear should be performed on all sexually active women regardless of


II.    Colposcopy is a minimally invasive technique which complements cytology to

       identify “at risk” cervix.

III.   Adequate medical therapy can cure genital infection and thereby check the

       progression to dysplasia. This should be tried first.

IV.    Surgical therapy is more effective than medical therapy and should be resorted

       to when medical therapy fails.

V.     Preventive Oncology should be taught to Gynaecologists and they should be

       attached to Onco centres in rotation.

VI.    Colposcope should be provided to all command hospitals.

VII.   Papers published on this project – Nil.

In the present study the uterine cervix was evaluated using a colposcope. 315 women

who had come to the OPD with some gynaecological complaint were evaluated. 250

were evaluable as they completed the study protocol. Cervical smears were taken and

stained with Papanicolaou stain to ascertain inflammatory lesions, dysplasia or

malignancy. The patients were also examined through a colposcope wherein the

cervix was cleaned with 5% acetic avid and also Schiller’s test was performed. The

patients “at risk” were treated with medical therapy and minimally invasive surgical

techniques which results in a high cure rate.

Cervical cancer is the most common cancer in developing countries and it is the
second most common cancer in women globally, with approximately one-half million
new case each year.

The effectiveness of screening programmes in reducing cervical cancer mortality has
been clearly demonstrated in some countries. However, even though the technique of
cytology has been known for many years, it has not been effectively applied in many
countries, especially those in the developing world, where three-quarters of the cases
of cervical cancer are found. In the long term, primary prevention is likely to be the
most cost effective control for cervical cancer, as it is for many other cancers.

Cervical cancer is the most frequent cancer of women in rural India. While it is
known that mortality from cervical cancer can be reduced by 50 to 60 percent more
by effective and efficient cytological screening, it is unlikely that this approach would
be feasible in India on a nation wide basis for at least a decade (STANLEY 1994).
Currently, cytological facilities are only available in large urban centres. It has been
estimated that even with a 12 fold increase in cytoscreeners, it would only be possible
to screen 25 percent of women at risk by the year 2000. A shift in the age group
screened to the later age groups and a decrease in the frequency of re-screening would
markedly improve the efficiency of screening (STANLEY 1994) However, large
parts of India would still be likely to not have access to cytological services for the
next 20 years (WHO report 1994). The basic choice of these parts of India is either to
do no screening or to do a type of screening other than cytological screening, which
may be less than optimal.

The incidence of invasive cervical cancer is uncommon in the United States, with an
incidence of 15,800 cases and 4800 deaths in 1995 (CANNISTRA 1996) This
relatively low incidence is largely due to the effectiveness of screening programmes
that assess cervical cytology by Pap smear. In our country we do not have facilities of
a mass screening programme. Hence down-stage screening can be effective method
of a “screening programme.”

Down stage (WHO 1994) is the visual inspection of the cervix by paramedical
personnel during routine visits to health centres, in an attempt to find cases in an
earlier stage. Nurse midwives have to be trained to differentiate between a normal
cervix and an abnormal one. The patient then can be referred to a centre wherein a
detailed examination to exclude an abnormality as pre cancer, cancer can be done.
The visual inspection, looking for erosion, could be done during routine visits and
would require only a light, table and a speculum. This approach is considered only
for rural areas and certainly not for areas where trained staff and facilities are

Screening is defined as, “the presumptive identification of unrecognized disease by
the application of diagnostic procedures which can be applied rapidly and safely”.
The screening tests used are designed to sort out apparently well persons from those
who are probably harbouring the disease. However, it is important to recognize that
the screening tests are not intended to be fully diagnostic. Further evaluation of the
case is necessary.

“Mass screening”, is an extension of the screening activity conducted on the whole
population or a major subgroup, for example, all adults. “Selective screening”,
conducted on a segment of population at relatively high risk. High risk groups can be
identified by previous epidemiological studies. Mass screening is expensive and
when resources are limited, selective screening can be resorted to. “Multiphasic
screening”, is when a person can be screened for several conditions are the same
sitting e.g. – breast and genital tract cancers. This reduces the cost of screening.
“Opportunistic screening” is the screening of those attending the hospitals for any
complaint. It has been found to be very useful (SARAIYA – 1998) The case is
strong to implement this in any screening programme, in the initial stages.

Cancer does not arise de-novo. There is a spectrum of changes which occur right
from inflammation to dysplasias and then the carcinoma (MORRIS – 1996). The
natural history of cervical cancer is favourable for effective screening. It has now
been proved beyond doubt that invasive cervical cancer is the end result of a process
of carcinogenesis which starts as its earliest stage with inflammatory change. If the
carcinogen keeps acting on the cells they undergo a series of changes as dysplasias
(mild, moderate and severe) and finally to invasive cancer.

As opposed to many cancers, cervical cancer has a relatively high cure rate. The
overall 5 year survival rate is about 67% (TOTOLERO-LUNA 1996) When
diagnosed at either state I or II the overall survival when treated either by surgery or
radiotherapy or combined is 80% and 60% respectively (STANLEY-1994) A
virtually 100% survival rate can be obtained for cases with displasias or cervical intra
epithelial neoplasias. These can be detected by cytological screening and then
effectively managed. The effectiveness would be reduced would be reduced by about
one-third if instead these cases were diagnosed with stage I and II disease and then
properly treated. Currently it is estimated that approximately 80% of the cases of
carcinoma of the cervix are diagnosed at stage II or IV (TMH Cancer Registry 1996)

Cervical intraepithelial neoplasia (CIN) is defined as, “the spectrum of intraepithelial
changes beginning as with a generally well-differentiated neoplasm, traditionally
classified as mild dysplasia and ending up with invasive carcinoma” (FERENCZY
1994) These changes, confined to the squamous epithelium above the basement
membrane, include nuclear pleomorphism, loss of polarity, abnormal mitosis, loss of
differentiation as cell progress from the basement membrane to the surface

The term CIN was coined by RICHART (1964) and he devised a grading system for
CIN in which lesions are classified from grades 1 to 3 based on the percentage of cells
from the basement membrane to the surface that are undifferentiated. When one third
or less of the distance from the basement membrane to surface is involved, the lesions
are called grade 1 (CIN 1). When more than one third but less than or equal to two
thirds is involved, grade 2 (CIN 2) and when more than two thirds is involved, grade 3
(CIN 3). Full thickness involvement but without involvement of the basement
membrane was called in the pas as carcinoma in situ (CIS) and is now often called
grade 3.
A new classification is now being applied to these lesions. In 1988 the National
Cancer Institute of the United States of America, convened a panel to address the
issue of classification of the Papanicolaou (Pap) Smears (1988). The panel’s goal was
to define a uniform terminology for smear reading, standards for the adequacy of the
smear and guidelines for trying the results of the smear to the clinical management of
the patient. The resulting Bathesda classification has the underlying philosophy that it
is difficult to distinguish between lesions caused by human papilloma virus (HPV)
and CIN 1. The two types of lesions are combined into one category called low grade
squamous intraepithelial lesions (LGSIL) Similarly CIN 2 & 3 are clubber together
into a group called high grade squamous intraepithelial lesions (HGSIL) Lesions that
contain cells with abnormal nuclear characteristics but without changes suggestive of
Koilocytotic atypia or CIN 1 are classified as atypical squamous cells of
undetermined significance (ASCUS). The terms LGSIL and HGSIL, although
designed for use by the cytological community have been adapted for use in the
histopathology community. Many institutes now report the grade of the lesion
concerning depth of involvement and also if the lesion is low or high grade.

The efficacy of Pap smear is largely dependent on the quality of the specimen and the
accuracy of the cytological interpretation. (OHLSSON 1996) 11. Pap smears have
been reported to be technically inadequate because of sampling errors in 12.3 percent
cases, and the reported findings may underestimate the intraepithelial findings in 17.5
percent of cases (OHLSSON 1996). Likewise it has been estimated that 15 to 25
percent of patients with intraepithelial results (OHLSSON 1996). Such false negative
results can be minimized by ensuring that proper technique is used to obtain the
cytological specimen. The transformation zone, which is the boundary between
squamous epithelium of the exocervix and columnar epithelium of the endocervix is
the most common site for the development of the intraepithelial lesions that may give
to the invasive disease. False negative results may be due to inadequate sampling of
the transformation zone, which often regresses into the endocervical cancal in post
menopausal women. In addition to the routine cervical scraping performed by using a
spatula, an endocervical sample should also be obtained and this can be done by
obtaining the specimen with a swab stick. Also the Pap smear must not be allowed to
air dry before fixation. Despite the occasional difficulties of sampling and
interpretation the long interval between the appearance of intraepithelial lesion and
invasive disease provides multiple opportunities to detect and interrupt the process of
malignant transformation in majority of the patients.

In an effort to increase greater visibility of the cervix and also the transformation zone
a colposcope was first used in Germany by HINSELMANN in 1925. he designed an
instrument using sharply focused light and binocular magnification. This was the
colposcope. Thus a new field of clinical investigation “colposcopy” was invented. At
first it was thought that cancer of the uterine cervix occurred as a small ulcer or tumor
but this could not be proved by Hinselmann. It gradually became known that there
was an area in the cervix wherein occurred an atypical transformation of cells. Herein
also there were abnormal blood vessels. To visualize this area better with colposcope
acetic acid application was also combined and then in 1928 Lugol’s iodine was
applied to this area (SCHILLER’S TEST) in an effort to identify the normal or
abnormal epithelium on portio-vaginalis of the cervix.
For many years, colposcopy and cytology were considered as competitive methods for
screening cancer cervix, but later it was realized that the combination of the two
improved diagnostic accuracy. Colposcopy provided an optical method for minute
comprehensive examination of the illuminated cervix and the lower genital tract at a
magnification of x 6 to x 40 at a focal length of 20 to 30 cms. It also acts as a uniting
factor between the clinician and Cytopathologist.

This study in an effort to specifically ascertain the incidence of cervical cancer in a
cross section of the families of Armed forces personnel and also to ascertain the high
risk factors and conservative management to treat them.
                        MATERIALS AND METHODS
The present study was carried out at INHS Asvini (Dept. of Obstetrics &
Gynaecology), i.e., the hospital catering to the needs of service personnel and their

The study was conducted on non pregnant women coming with a gynaecological
complaint. A total of 315 patients were examined but only 250 were included in this
study. The criteria for the study was that in those patients wherein abnormal smears
were identified they were given treatment and had to have a follow up after
completion of therapy.

The patient’s particulars and complaints were noted as per the proforma. All the
patients underwent a thorough general physical and systemic examination. The
procedure for vaginal examination was explained in detail to the patient. The
following procedure was followed for all patients –

1.       A Papanicolau (Pap) smear was taken for all cases initially.

2.       Colposcopy was done in this sitting.

3.       Patients with abnormal smear were given therapy which could have been

4.       Follow up after therapy, wherein a follow up smear was re-taken.

Medical Therapy – Capsule Doxycycline 100 mg OD was exhibited for 3 weeks and
other supportive therapy.

Surgical Therapy – Electrodiathermy ablation and cone biopsy were indicated.

The Colsposcope - The scope in this study was colposcope model – ACP – 930 TG
(OPTICS TAKAGI, JAPAN) with a straight head with 300 mm objective lens, fibro
optic coaxial illumination, 3 step magnification.

     -      A green filter was provided.
     -      Magnification – 4.6 x, 7.7 x, 12.3 x

The steps for colposcopic examination were –

1.       The patient was placed in comfortable dorso-lithotomy position. Naked eye
         examination of the vulva is done to exclude any vulval pathology.

2.       Bivalve, large blade, self retaining Cusco’s speculum is introduced into the
         vagina taking care to avoid any bleeding. The character of vaginal discharge,
         if any, is noted.

3.       Inspection of the unstained cervix with illumination from the light of the
         colposcope. The focal length is adjusted. The cervix and vagina are cleaned
         with moist cotton swab.
4.     A Papanicolaou (Pap) smear was taken from the ectocervix using a cotton
       swab stick which was vigorously rubbed over the cervical surface. This was
       smeared over the entire length of a glass slide which was immediately dipped
       into 95% ethanol solution for fixation.

5.     Inspection of cervix after application of 5% acetic acid. This solution is
       mucolytic and changes the colour of the cervix and also the vascular pattern.
       This change is transient and repeated applications are necessary during the
       procedure. To visulaise the endocervix an endocervical manipulator was used.
       Columnar epithelium is best outlined with this. The white region is known as

6.     Examination through a green filter. This highlights the abnormality of blood
       vessels. The details of blood vessels are enhanced over a green background.

7.     Schiller’s test (application of Lugol’s iodine). The cervix vagina are painted
       with iodine which turns normal squamous epithelium brown. Unstained areas
       indicate areas deficient in glycogen.

8.     Inspection of fornices and vagina.

9.     Biopsy where indicated.

Patients were called back with the initial Pap report and if normal the patients were
asked to have a follow up after 2-3 years. Patients with inflammatory smears were
given medical therapy and recalled for another smear. If normal they too underwent
routine follow up. Abnormal smears were investigated energetically and treated with
surgical therapy as electro coagulation or cone biopsy. Here after the follow up was
done after 12 weeks (BHARGAVA)12. Patients who did not report for a follow up
smear were labeled as lost to follow up.

Colposcopic grading was done as devised by COPPLESON 13. This is given as

Grade I – (Insignificant and not suspicious) – Flat white epithelium, fine calibre and
regular vessels with small inter-capillary distance.

Grade II – (Significant and suspicious) – Flat white epithelium, vessels with dilated
calibre and regular shape, absence of atypical vessels and usually increased inter-
capillary distances.

Grade III – (Highly significant, highly suspicious) markedly white epithelium,
irregularly shaped and dilated vessels with variable inter-capillary distance and
usually irregular surface contour due to microexophytic epithelium.

                                 TABLE 1



CRITERIA – Completion of complete therapy and follow up.

                                 TABLE 2

                        AGE DISTRIBUTION
                                    n = 250

    AGE IN YEARS                NUMBER            PERCENTAGE
       Upto 20 years                40                     16

           20-30                    60                     24

           31-40                    80                     32

           41-50                    40                     16

           >50                      30                     12

           Total                    250                    100

Fifty six percent of patients were in the age group 20-40 years. Out of this the
maximum number were in the age group 31-40 years.
                               TABLE 3

                      PARITY OF PATIENTS
                                  n = 250

   AGE IN YEARS               NUMBER           PERCENTAGE
         Nulipara                  25                  10

            1                      25                  10

            2                     125                  50

        3 or more                  75                  30

          Total                   250                  100

Maximum number of patients in this series were Para 2. However 80 percent of
patients were in the para 2 – 3 group.
                                  TABLE 4

                                     n = 250

LESION                          NUMBER             PERCENTAGE
Labial Cyst                           5                     2

Labial Abscess                        3                    1.2

Fibroma                               2                    0.8

Leukopalkia                           2                    0.8

Vulval warts                          1                    0.4

Total                                13                    3.4

In 13 cases (5.2%) incidental vulval lesions were found which underscores the fact
that a vulval examination is necessary.
                                  TABLE 5

                                      n = 250

       LESION              AGE (Yrs.)           NUMBER        PERCENTAGE
INTRAEPITHELIAL                  45               1                   0.4

A ingle case of vaginal intraepithelial neoplasia was detected and conservatively
                                   TABLE 6

                     CYTOLOGICAL ANALYSIS
                                      n = 250

CYTOLOGY                         NUMBER             PERCENTAGE
Normal                                130                   52.0

Inflammatory                          88                    35.2

Dysplastic                            30                    12.0

Malignant                              2                     0.8

Despite the abnormal cytology, 20% of patients may have a healthy cervix.
                               TABLE 7

                                  n = 120

TYPE OF LESION                NUMBER           PERCENTAGE
Healthy cervix                     24                  20

Erosion cervix                     36                  30

Hypertrophied cervix               6                    5

Cervix bleeds to touch             12                  10

Endocervicitis                     30                  25

Suspicious of Carcinoma            12                  10

In 47.2% of cases the cytology was abnormal, but only in 12.8% was there any
evidence of dysplasia/malignancy.
                                TABLE 8

                      DYSPLASTIC LESIONS
                                 n = 30 (12%)

DYSPLASIA                      NUMBER            PERCENTAGE
Mild                                18                   60

Moderate                            9                    30

Severe                              3                    10

The mild dysplasias were CIN 1, moderate was CIN 2 and severe was amounting to
CIN 3 or a suspected in situ lesion.
                                   TABLE 9

                     COLPOSCOPIC GRADING
                                      n = 250

GRADING                          NUMBER             PERCENTAGE
              I                       212                   84.8

             II                       28                    11.2

             III                      10                     4.0

The colposcopic grades correlated well with the abnormal cytology. Though the
majority were normal but wherein there were atypical vessels seen at colposcopy with
increased inter-capillary distance it indicated an abnormality.
                                 TABLE 10

                                 n = 118 47.2%

CYTOLOGY                        NUMBER             PERCENTAGE
Normal                               71                    60.2

Inflammatory                         40                    34.1

Dysplastic                            7                    5.7

71 cases (60.2%) had normal Pap smears after medical therapy. The remainder of the
cases were treated surgically.
                                TABLE 11

                       SURGICAL THERAPY
                                    n = 47

SURGERY                          NUMBER             PERCENTAGE
                                      42                   89.9
CONE BIOPSY                            5                   10.7

The above mentioned surgical procedures can be performed as OPC procedures. For
cone biopsy all cases had general anaesthesia and were in hospital for 48 hours.
                                  TABLE 12

                                       n = 46

CYTOLOGY                          NUMBER             PERCENTAGE
Normal                                 43                    93.5

Inflammatory                           3                      6.5

Dysplastic                              -                      -

Malignant                               -                      -

In this series there was 1 case lost to follow up. The response was very good after 3
months as 93.5% were normal. No patient revealed any abnormal cells.

Cervical cancer is a potentially preventable disease. It is uncommon in developed
countries. With the turn of the century it should also take a downward trend in the
third world countries. It is important to be aware of the risk factors, screening
techniques, available diagnostic options and with special attention to the management
of pre invasive disease. In the Armed Forces today we are a small society. Quality
medical facilities are readily available. Follow up of cases is also easy as the
community is receptive towards health care and prevention of disease. This study was
undertaken in an effort to screen premalignant lesions and treat them conservatively
and effectively.

To be suitable for screening, a disease must pass through preclinical phase during
which it is undiagnosed but detectable. It is believed that most squamous cell
carcinomas begin as dysplastic lesions and progress to CIS and then to invasive
disease over a variable period of time.

In this study though a total of 315 patients were enrolled, only 250 (79.4%) were
found evaluable. The criteria for evaluation being follow up (one) after completion of
therapy. The study has revealed that the maximum number of patients with
gynaecological complaints are in the age group of 20-40 years (56%). This is
consistent with the world wide phenomenon of increasing trend of cervical neoplasia
among young women (MORRIS)5. This trend is poorly understood and should be
interpreted with caution. In our country this may be due to the fact that women do
have early marriages. Sexual intercourse at an early age with subsequent infection
may indicate the likelihood of exposure for a longer period of time of the cervix to
carcinogens. Several independent studies have shown an independent effect of early
age at first sexual intercourse and the subsequent development of cervical neoplasia

It was observed that eight percent of the study group were in the Para 2 and above
group. The association between parity, or number of births, and also the risk of
cervical neoplasia has been reported in recent case controlled studies (ELUF –
NETO)15. Women with 2 or more pregnancies were found to have an 80% higher
risk of CIS compared with nulliparous women after adjustment for age, sexual
behaviour. It has been reported by BOSCH14 that there is a strong association
between invasive cervical cancer and early age at first birth. This association
appeared to be independent of early age at first intercourse. There is a four fold
increased risk in patients who have had the first child before age 22. women who had
one or more vaginal deliveries had a 70% higher risk for CIN than women without a
history of vaginal delivery. There is no clear biologic mechanism to support this
association although repeated trauma to the cervix during child birth has been
suggested (MORRIS)5.

Table 4 reveals that 13 cases (5.2%) were found to have incidental vulval lesion. This
underscores the fact that a thorough vulval examination is necessary prior to cervical
examination. Also cervical disease is known to have a multicentric origin. These
lesions can be treated by conservative surgery. Table 5 reveals one case of VAIN
which was diagnosed colposcopically and treated conservatively with wide excision.

Cytological evaluation reveals that 52% of smears were normal, 47.2% had revealed
abnormality i.e. evidence of inflammation and only 12.0% had dysplasia. A small
number i.e. 0.8% was overtly malignant. This compared well with MISHRA who has
reported 13.5% dysplastic smears in patients who had contacted genital infection.
Frank cancer was seen in 0.1% of cases.

A correlation was drawn between abnormal cytology and the cervical morphology. In
20% of symptomatic cases the cervix was normal. This did not compare with the
work of MISRA16 where only 1.63% symptomatic cases had a normal cervix. The
increase in normal appearing cervix in our community may be due to the fact that the
population reports to the hospital faster and disease is picked up much before it is
overt. In 80% of the patients a lesion on the cervix was detected which varied from
erosion to lesions which were suspicious for carcinoma. The lesions suspicious for
carcinoma turned out to have disease or severe dysplasia (Table 7).

Table 8 shows the number of dysplastic smears. The total number of smears which
revealed dysplasia were 30, this was 12% of the total study group. This compared
well with the work of MISRA et al1 6. In this study dysplasia was found in 13.5% of
the cases. Moderate and severe dysplasis comprised 40% of cases and mild dysplasia
was found in 60% cases.

Colposcopic grading correlated very well with the cytology. Patients with Grade I
colposcopy were 84.8% where as 87.2% of patient were without dysplasias. Thus the
negative predictive value (how often women without disease listed negative) of
colposcopy was high. This too was the finding of MORRIS et al in whose series this
value was 74%. The positive predictive value (how often women with abnormality
tested positive) was 84.2%. In the work of MORRIS et at it was 83%. This
investigation is quite reliable and its sensitivity increases when it is compared along
with cytology.

One hundred and eighteen patients were treated with combination antibiotics. 71
patients were found to be normal (60.2%). This indicates that a course of antibiotics
can help in a large number of cases. The greatest effect was noticed in the case earlier
reported having dysplasia were reduced from 30 to 7 indicating that genital infection
can ultimately led to cervical neoplasia JONES17.

47 cases were subjected to surgery the surgical procedures were electrocautory and
cold knife cone biopsy wherein a cone of cervical tissue is removed with a scalpet.
Both procedures are minor with patient’s hospital stay being minimum. The surgical
form of therapy was found to be very effective and in the follow up 93.5% patients
were found to be normal. This was also the experience of MITCHELL18 who
achieved a 95% cure rate. No patient showed any evidence of dysplastic cells post
surgical therapy. The 3 cases who had inflammatory smears on follow up were
subsequently put on surveillance. They have been asymptomatic.

From this study it is concluded that –

1.     315 patients were selected for study but only 250 completed the protocol and
       were included in the study group.

2.     Pap smear should be performed on all sexually active women regardless of age
       coming to gynaecological OPD.

3.     Examination of the external genitalia is important prior to taking a pap smear
       to exclude incidental vulval lesion and to exclude multicentric origin of

4.     Normal morphology of the cervix does not always indicate a healthy cervix.

5.     Colposcopy is a minimally invasive procedure which complements cervical
       cytology in identifying potentially “at risk” cervix.

6.     Abnormal vascular architecture on the cervical surface is indicative of
       pathology and patient should be on follow up.

7.     Genital infection can contribute to dysplasia and medical therapy can eradicate

8.     Surgical treatment is most effective where medical therapy has failed.

9.     In the Armed Forces cervical cancer can be prevented.

1.   Pap smear should be performed on all sexually active women regardless of

2.   Medical therapy should be adequately exhibited to cure genital infection
     which will reduce incidence of dysplasia.

3.   Colposcope complements cytology in identifying “at risk” cervix.

4.   Preventive Oncology should be introduced in the training curriculum and
     Gynaecologist should be attached to Onco centres to learn the same.

5.   A colposcope should be provided to all Command Hospitals.

1.    Stanley K : Cancer Unit Bulletin WHO Geneva Switzerland, 1992

2.    Stanley K : Cancer Unit Bulletin WHO Geneva Switzerland, 1994

3.    Cannistra S.A. Niloff J.M., The New England Journal of Medicine

4.    Saraiya V.B. The Journal of Obstetrics and Gynecology of India 48:189:1998

5.    Morris, Vicki v. Baker, Anais Maltrica Obstetrics and Gynaecology Clinics of
      North America 23:2:347:1996

6.    Tortolero – Luna, Obstetrics and Gynaecology Clinics of North America

7.    Tata Memorial Hospital, Cancer Registry Publication 1996

8.    Ferenczy A, Wright TC, Blaustein’s Pathology of the Female Genital tract

9.    Richart R.H., Observations on the biology of cervical dysplasia.        Sloane
      Bulletin 75:64:1964

10.   Richart R.H., Cancer 18:950:1965

11.   Ohisson A, Farine       D,   The   New    England    Journal    of   Medicine

12.   Bhargava V.L. Singh V, Colposcopy, 58:1994

13.   Coppleson M, Colposcopy of the cervix Gynaecologic                   Oncology,
      Fundamental Principles and Clinical Practise 14:1:1992

14.   Brinton LA, Epidemiology of cervical cancer, IARC, Sci Publ, 119:3:1992

15.   Eluf – Neto J, Brooth M. British Journal of Cancer 69:114:194

16.   Misra J.S., Das H., The Journal of Obstetrics & Gynaecology of India

17.   Jones CJ, Brinton LA, Cancer, 50:3657:1993

18.   Mitcheli MF, Operative Gynaecology : 231:1993

19.   Bosch FX, Munoz N, International Journal of Cancer 52:750:1992

20.   National Cancer Institute Workshop publication Jama, 262:932:1989

(AFMRC PROJECT NO : 2128/96)

Patient’s Name                               Cytology No.

Address                                      No:-

                                             Unit :
Husband’s Name :

Rank:                                        Age                     Date

Caste                   Age at Marriage/Intercourse                Years of Married life

MH-     Present                                LMP


OH-     Deliveries                             Age of 1st Child

        Abortions                              Age of last Child

        M.T.P.                        Personal History : Genital Hygeine


Clinical Exam : Gen. Phys.                   Systemic

Contraception : Hormone/Ci-T/Barrier/Other

P.S. – Discharge – Pres/Abs.                 P.V.

        Character – Mucoid / Bloody / Purulent / Mucopurulent / Other

Specimen          Vg.          Ecto Cx.      Endo Cx.       Endoment       Wet Smear
                                                            (if indicated)





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