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Early Warning Signs & Prevention of Cancers + Screening for Cancer Cervix

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PART 1: CANCER - OVERVIEW AND PREVENTION

Definition

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EARLY WARNING SIGNS OF CANCER

As listed in Park's (verbatim danger signals):

1. A lump or hard area in the breast
2. A change in a wart or mole
3. A persistent change in digestive and bowel habits
4. A persistent cough or hoarseness
5. Excessive loss of blood at monthly period OR blood loss outside usual dates
6. Blood loss from any natural orifice
7. A swelling or sore that does not get better
8. Unexplained loss of weight

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PREVENTION AND CONTROL OF CANCER

A. Primary Prevention

• Environmental factors responsible for 80-90% of all human cancers
• Tobacco is the single largest preventable cause
• HPV vaccine is an "exciting prospect" for primary prevention of cancer cervix
• Treatment of precancerous lesions (cervical tears, intestinal polyposis, warts, chronic cervicitis) is a cornerstone

B. Secondary Prevention

1. Cancer Registration - hospital-based & population-based registries
2. Cancer Screening - early detection of unrecognized malignancy

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PART 2: CANCER SCREENING

Why Screening is Possible - Mnemonic "PLM"

• Pre-malignant lesion precedes malignancy by months to years - its removal prevents cancer
• Localized lesion at early stage = high cure rate
• Most cancers (75%) occur in accessible body sites

Methods of Cancer Screening (Park's)

1. Mass screening - comprehensive cancer detection examination (multiple sites)
2. Single-site screening - uterine cervix, breast, lung
3. Selective screening - high-risk individuals (e.g., parous women >35 yrs for cancer cervix)

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PART 3: SCREENING FOR CANCER CERVIX (Main Topic)

Why Cervix?

• Cervical cancer has a prolonged early phase (cancer in situ) detectable by Pap smear
• One of the most common cancers in women in India
• High cure rate if detected at Stage I or II

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Screening Methods

1. Pap Smear (Cytology) - Traditional Gold Standard

• Parous women at start of sexual activity
• All women - repeat every 3 years
• Prolonged in-situ phase - detectable
• Accepted clinical practice worldwide
• Current policy: Pap test at beginning of sexual activity, then every 3 years
• Organized population-based screening has reduced incidence and mortality in developed countries
• Limitation: Requires labs, equipment, trained personnel - not cost-effective in resource-poor settings

2. Visual Inspection Tests - Alternatives for India

• Apply freshly prepared 5% acetic acid (5 ml glacial acetic acid + 95 ml distilled water)
• Positive test (acetowhite lesion): Well-defined opaque acetowhite lesions close to squamo-columnar junction, well-defined circum-orificial acetowhite lesion, or dense acetowhiting of ulceroproliferative growth on cervix
• Sensitivity of VIA is similar to cytology
• Advantage: Easy to perform, easy to train health workers

• Positive VIA → Same visit → Colposcopy-based treatment at district hospital
• Pap smear + biopsy provide cytological and histopathological back-up

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Summary Table: Pap Smear vs VIA

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Risk Factors for Cancer Cervix (for context)

• H - HPV infection (chief suspect)
• E - Early marriage / early consummation
• M - Multiple pregnancies / multiple sexual partners
• P - Poor genital hygiene / low socioeconomic status

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IEC Activities

• Significance of the disease
• Importance of early detection
• Availability and benefits of screening

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QUICK RECALL - MNEMONICS SUMMARY

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Cancer: Warning Signs, Prevention & Cervix Screening

15 Marks | Park's | NTRUHS MBBS 3rd Year

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1. EARLY WARNING SIGNS OF CANCER

Mnemonic: "CAUTION" (American Cancer Society / Park's)

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2. PREVENTION OF CANCER

Primary Prevention - Mnemonic: "TOPIC"

Also: Dietary modification, personal hygiene, radiation control, air pollution control

Secondary Prevention

• Cancer Registration (hospital-based / population-based)
• Cancer Screening - "search for unrecognized malignancy by rapidly applied tests" (Park's)

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3. CANCER SCREENING - BASIS

Why screening is possible - Mnemonic "PAC"

• Pre-malignant phase precedes cancer by months-years
• Acceptable cure rate if detected early (Stage I/II)
• Cancer occurs in accessible sites (75%)

Methods (Park's)

1. Mass screening - multiple sites
2. Single-site - cervix, breast, lung
3. Selective - high-risk groups only

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4. SCREENING FOR CANCER CERVIX ⭐

Why cervix is screenable:

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METHOD 1: PAP SMEAR

• Start at onset of sexual activity
• Screen every 3 years
• Squamo-columnar junction is sampled

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METHOD 2: VISUAL INSPECTION TESTS ⭐ (India's strategy)

• Apply 5% acetic acid (5 ml glacial acetic acid + 95 ml distilled water)
• Wait → look for acetowhite lesions near squamo-columnar junction
• Positive = well-defined opaque acetowhite area near SCJ

• No lab needed
• Low cost
• Easy to train health workers
• Sensitivity similar to cytology

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Risk Factors for Ca Cervix - Mnemonic "HEMP"

• H - HPV infection
• E - Early marriage/intercourse
• M - Multiple partners/pregnancies
• P - Poor genital hygiene / low SES

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QUICK REVISION BOX

Warning signs    → CAUTION + weight loss
Primary prevention → TOPIC
Why screen?      → PAC
Pap smear        → start at sex activity, every 3 yrs
VIA              → 5% acetic acid, acetowhite = positive
India strategy   → VIA/VIAM/VILI (single visit approach)
Ca cervix RF     → HEMP

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• "Too long" - want it even shorter?
• "Something missing" - want me to add something specific?
• "Not clear" - want simpler language?
• "Write it as an answer" - want it in paragraph/essay format for exam writing?

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National Programme for Cancer Control

From Park's | SPM MBBS 3rd Year | NTRUHS

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NATIONAL CANCER CONTROL PROGRAMME (NCCP)

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OBJECTIVES - Mnemonic: "PST" (3 levels of prevention)

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SCHEMES UNDER NCCP - Mnemonic: "RONDIRE"

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CANCER COMPONENT UNDER NPCDCS

1. Diagnostic services, basic surgery, chemotherapy, palliative care
2. Each district gets Rs. 1.66 crores/year
3. Chemotherapy drugs for 100 patients per district hospital
4. Screening for cervical, breast & oral cancers
5. Education about Breast Self Examination (BSE)
6. Early detection and referral of suspected cancer cases

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NPCDCS - FULL FORM & BACKGROUND

• NCD deaths = 60% of all deaths in India (2016)
• Implemented in all districts of India (12th Five Year Plan)
• Opportunistic screening of persons above 30 years of age
• NCD Clinics at CHC and District level

• Increased healthy food intake
• Increased physical activity
• Avoidance of tobacco and alcohol
• Stress management

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QUICK RECALL BOX

NCCP launched    → 1975-76
Revised          → 1984-85, 2004
Merged into      → NPCDCS (2010)
Objectives       → PST (Primary, Secondary, Tertiary)
Schemes          → RONDIRE
Cancer burden    → 10 lakh new/year, 2.8 million total
Cancer Awareness Day → November 7
Screening targets → Cervix, Breast, Oral
Screening age    → >30 years (NPCDCS)

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Disease Burden of Cancer (Park's)

• Cancer is the 2nd leading cause of death in industrialized countries (after CVD)
• Globally, 19.3 million new cases and 10 million deaths occur per year (2020)
• In India, ~10 lakh (1 million) new cases/year; 2.8 million cases exist at any given time
• >2/3rd of Indian patients present in advanced, incurable stage at diagnosis
• Top cancers in Indian men - lip/oral cavity, lung, stomach; in women - breast, cervix, ovary
• NCDs including cancer account for 60% of all deaths in India (2016)