2.

CERVICAL CANCER
Do Screen
Without waiting any complaint
 ORGAN REPRODUKSI PEREMPUAN
Badan Rahim
Saluran telur
Ovarium

Vagina
LEHER RAHIM
Tampilan Leher Rahim Normal

Normal
N Kanker
o
Outline of Cervical Cancer
• Cervical cancer in Indonesia
• Handicap doing Pap test for screening
• Study VIA ~ Pap test, (HPV)
• Prevalence finding
• Accuracy of VIA
• Proactive-VO model
Cervical Cancer Prevention in Developing Country (Indonesian Perspective)
Cervical Cancer Worldwide
Globally, It is the no. 2 female cancer,
and every 2 minutes a woman dies of it

75,000
36,000
266,000
143,000

72,000 79,000
33,000 62,000

Ferlay J et al. Globocan 2002, IARC 2004.

Incidence / year ≈ 500,000 Deaths / year ≈ 270,000

Epidemiology of Cervical Cancer in Indonesia

Indonesia consists of over 13.500 islands;

2005 Population 242 million; Women at risk ± 48 millions
• The most frequent cancer in Indonesia
• Almost 70% in advanced stages ( > stage IIB)
• Very low screening coverage < 5% (ideally ~ 80%)
 Cervical Cancer in Indonesia

 The most frequent of cancer in

Indonesia ~ (34.4% of women
cancer)1
 Almost 70% of advanced stage
( > stage IIB) 2, low survival rate

 15.000 new cases, 8.000 death 3;

40 – 45 new cases,
20 – 25 dies/day,
1 dies/hour

1). Dirjen Pelayanan Medik Departemen Kesehatan RI. Badan Registrasi Kanker IAPI,
Yayasan Kanker Indonesia. Kanker di Indonesia Tahun1998. Data Histopatologik.
2). Mochtarom M. Data registrasi Kanker Ginekologik. Bagian Obstetri dan Ginekologi.RSUPN /FKUI, Jakarta 1992
3). IARC, Globocan 2002 database; Summary table by Cancer 2002. http://www-dep.iarc.fr/top.htm.Accessed Feb 1, 2007
 Kanker Ginekologi
dan Stadium Kanker Leher Rahim
Distribusi dan Stadium Kanker Leher Rahim
RSCM Thn1992
Distribusi Kanker Ginekologi 2.7 (n = 489)

ADVANCED
IV-A 5.5
Trophoblast
5.9% III-B 39.9 71.6%
Vagina 0.6
0.3% II-B 22.9
9.8

EARLY
Vulva
0.7% I-B 18.2 28.4%
0.4
Uterine Ovary
Corpus 14.9%
2.7% 0 % 10 20 30 40 50
Cervical
Cancer
RSCM Thn.1997-8
75.5%
1.7 (n = 469)

ADVANCED
5.3
III-B 37.3 66.5%
National General Hospital
RSCM yr.1994 (n = 597) 0.9
21.3
9.4

EARLY
I-B 18.8 28.6%
0.4
[Missing data : 4.9%]

0 % 10 20 30 40 50
 Cervical Cancer Profile in Indonesia

Community Based - Prevalence of Cervical Cancer in Several Areas

BASED ON CYTOLOGIC / HISTOLOGIC DiAGNOSIS1,2

Jakarta 1 3 cx ca / 3.196 patients ~ 94/ 100.000

(Pademangan)
 Jakarta2 8 cx.ca / 8,011 patients ~ 100 / 100,000
 Bali 2 11 cx.ca / 7,223 patients ~ 152 / 100,000
 Tasikmalaya2 29 cx.ca / 8,051 patients ~ 360 / 100,000
Sidoarjo 3 11 cx.ca / 27,512 patients ~ 49 / 100,000

 NETHERLANDS ~ 9 / 100,000

_________________________________________________________________________________
1)Nuranna L, Cervical cancer model Proactif-VO, Jakarta 2005
2)Female Cancer Programme Report August 2006
3) Tim PKTP Kabupaten Sidoarjo. Materi Loka Karya Nasional Uji Coba Penanggulangan Kanker
Terpadu Paripurna di Kabupaten Sidoardjo Propinsi Jawa Timur, Surabaya February 1995. Buku I.
Stadium kanker serviks
 Perjalanan alamiah penyakit
kanker Leher Rahim

Lesi Pra Kanker Kanker

------------------- 3-17 tahun -----------------------

Displasia Karsinoma Kanker

Displasia Displasia
Ringan Insitu Serviks
Sedang Keras

SKRINING !
 PENYEBAB
HUBUNGAN ANTARA LESI, PERJALANAN
KLINIK DAN TIPE HPV

Tipe HPV Lesi Perjalanan Klinik

6,8 Kondiloma akuminata Jinak

Kondiloma datarJinak
6, 11 Verrucous cancer Destruksi lokal
Kondiloma akuminata Jinak
Kondiloma datarJinak
16, 18 Lesi, putih, datar Neoplastik
31, 33,45 Papulosis bowennoid Kanker dan perkusor
39, 42 Kanker

Telah dikenal hingga 200 tipe HPV

Faktor Risiko Kanker Leher Rahim

• Usia
• Menikah muda (< 20 tahun )
• Mitra seksual multipel
• Terpapar IMS (Inf Menular Seksual )
• Banyak melahirkan
• Merokok
• Defisiensi Vit A./Vit C/Vit E
Faktor Risiko Kanker Leher Rahim
Faktor PROTEKSI Kanker Leher Rahim

• Pernah Skrining:
TES PAP, IVA,
cara lain
• Kontrasepsi
Faktor PROTEKSI Kanker Leher Rahim

• Pernah Skrining:
TES PAP, IVA,
cara lain
• Kontrasepsi :
IUD, Kondom
SIGN and SYMPTOM

• Vaginal bleeding
• Fluor albus
mixed with blood ,odour
• Pelvic pain
• Anuri

Women with vaginal bleeding and fluor albus

not automatically causes of Cervical Cancer
 Cervical Cancer Prevention
Back to Basic Concept
NETWORK Surveillance
PRIMARY SECONDARY TERTIARY • Improved
PREVENTION PREVENTION PREVENTION Screening
Prevent contact Screening Treatment Coverage
with carcinogen early detection & of positive (70-80%)
(HPV) treat precancer or cancer,
early invasive rehabilitation & • HPV Vaccine
lesions palliative care Coverage
•Promotion, • Pap-Smear
Education, • VIA screening Treatment • Reduced
• Treatment advanced
•HPV Vaccine
stage Ca.
Training:
• Health provider
Training Training • Reduced
• PKK (Cadres)
• All women
mortality rate
 Deteksi dini
( Pencegahan sekunder )

Normal Lesi Prakanker Kanker

Tes Pap
IVA
SKRINING KANKER LEHER RAHIM
Metode

• TES PAP = PAP’ S SMEAR

• IVA : Inspeksi Visual dengan Asam asetat
• GINESKOPI

• SERVIKOGRAFI
• KOLPOSKOPI
• PAPNET ( dengan KOMPUTER)
• THIN PREP
• TES HPV
Melakukan Tes Pap / Pap
Smear
PAP’S SMEAR

1. Smear by Eyre spatula on

ectocervix, 2).
Twist on object glass

2. Smear by “Cytobrush” on
endocervix,
Twist on object glass 1).

3. Dip the object glass in

alcohol 96%, minimal 30’
TES PAP
di Indonesia?

SDM :
Dokter Obs – Gin 1385 (data 2004)
Dokter PA < 209 (data 2003)
Skriner < 100
BIDAN ± 84.000 (data 2005)

Apakah dapat dilakukan

untuk seluruh Indonesia ?
CLASSIFICATION PAPANICOLAU SMEAR

PAP GRADE Dysplasia CIS Bethesda

Pap I Negative Negative Normal

Pap II Inconlusive No Term ASCUS
Pap IIIa Mild 1 LGSIL
IIIb Moderate 2 HGSIL
IIIc Severe 3 HGSIL
Pap IV Ca Situ 3 HGSIL
Pap V Carsinoma Carsinoma Carsinoma
PAP’ SMEAR
in INDONESIA ?

Man Power :
Obs – Gin 1385
Pathologist < 300
Screener < 150
MIDWIFES ± 70.000

Can it conducted at all Indonesia ?

SKRINING KANKER SERVIKS
Metode

• Tes Pap = Pap’ s Smear

• IVA : Inspeksi Visual dengan Asam asetat
• GINESKOPI

• SERVIKOGRAFI
• KOLPOSKOPI
• PAPNET ( dengan COMPUTER)
• THIN PREP
• TES HPV
....
 Cervical Cancer Prevention in Developing Country
(Indonesian Perspective)

Screening Alternative ?
VISUAL INSPECTION with
ACETIC ACID (VIA )

 Non –invasive
 Easy - cheap
 PHC (Puskesmas)
 Direct result
 Sensitivity,spesifisity comparable
 Can be done by midwife

APPROPRIATE FOR
DEVELOPING COUNTRY White epithel
 SCREENING by V I A
White epitelium by acetic acid
Simple methode can be done at all Primary health centre

• Light resouce
• Vaginal Speculum
• Gynecologic bed
• Acetic Acid 3-5%
• Cotton bud
• Gloves
Kajian di Indonesia
Sn 92,31%
Sp 98,80%
Akurasi 98,70%
VIA
Provider

• Midwifes
• Nurse with Competency certification
• Medical Doctor
• Obs Gynecologist
Criteria of VIA result
I. Normal
II. (Inflamation – cervicitis)
III. VIA positive : White Epithelium
IV. Cervical Cancer
TAMPILAN I V A
I

NORMAL

II

OVULA NABOTI

EKTOPI SERVIKS
VIA
III.
PRACANCER Lesion

Low Grade
Squamo Intraepithelial Lesion
~ CIN I (NIS I)
VIA
IV.
INVASIVE
CERVICAL CANCER
 Proposed Solution Model
Proactive-VO

•Surveillance
•Sustainable
• Improved
Screening
Coverage
• Organization (70-80%)
Structure
• HPV Vaccine
Coverage
• Registration/
Monitoring, • Reduced
evaluation advanced
stage Ca.
• Budget • Reduced
Mortality rate
SKRINING KANKER SERVIKS
Metode

• Tes PAP = PAP’s SMEAR

• IVA : Inspeksi Visual dengan Asam asetat
• GINESKOPI

• SERVIKOGRAFI
• KOLPOSKOPI
• PAPNET ( dengan COMPUTER)
• THIN PREP
• TES HPV
....
Cervicography
Camera product cervix
panoramic with high
resolution.

Adjunctive Test to improve

sensitivity and spesivicity
from Pap’s test .
COLPOSCOPY
EARLY DETECTION METHODE
CERVICAL CANCER

• PAP’ S SMEAR
• VISUAL INSPECTION = VIA
• GYNESCOPI

• SERVICOGRAPHY
• COLPOSCOPY
• PAPNET (by COMPUTER)
• Thin Prep
• HPV Testing
....
Papnet
• Solve the screening errors

Thinprep
• Solve the failure of sample taker
error, inadequate fixation, random
distribution of cell distribution,
vary smear taker.
EARLY DETECTION METHODE
CERVICAL CANCER

• Pap Smear
•VISUAL INSPECTION = VIA
• GYNESCOPI

• SERVICOGRAPHY
• COLPOSCOPY
• PAPNET (by COMPUTER)
• Thin Prep
• HPV Testing
....
HPV Test

HPV difficult to culture

For early detection and HPV
typing
3 TEST
Hybrid Capture 2 ( HC2)
Polymerase Chain Reaction (PCR)
In Situ Hybridization (ISH)
 Kanker Leher Rahim
TIPE HPV ~ Risiko
HPV DNA Test uses two RNA Probe cocktails,
to differentiate between carcinogenic and low
risk HPV types

• Low risk
– 6, 11, 42, 43, 44
• High risk
– 16, 18, 31, 33, 35, 39, 45,
51, 52, 56, 58, 59, 68
Early Detection for Cervical Cancer, Breast Cancer,
and Sonography on Reproduction Organ

Sonography on
Reproductive Organ
Early Detection for Cervical Cancer, Breast Cancer,
and Sonography on Reproduction Organ
Early Detection for Cervical Cancer, Breast Cancer,
and Sonography on Reproduction Organ
Early Detection for Cervical Cancer, Breast Cancer,
and Sonography on Reproduction Organ
Early Detection for Cervical Cancer, Breast Cancer,
and Sonography on Reproduction Organ
Early Detection for Cervical Cancer, Breast Cancer,
and Sonography on Reproduction Organ
Early Detection for Cervical Cancer, Breast Cancer,
and Sonography on Reproduction Organ
Early Detection for Cervical Cancer, Breast Cancer,
and Sonography on Reproduction Organ
Early Detection for Cervical Cancer, Breast Cancer,
and Sonography on Reproduction Organ
Early Detection for Cervical Cancer, Breast Cancer,
and Sonography on Reproduction Organ
Early Detection for Cervical Cancer, Breast Cancer,
and Sonography on Reproduction Organ
Early Detection for Cervical Cancer, Breast Cancer,
and Sonography on Reproduction Organ
 Cancer of Reproductive Organ

Jenis Payudara Leher rahim Indung telur Badan Peny. Trofo.

kanker rahim Ganas

Keluhan Benjolan Perdarahan, Perut Perdaraha Perdarahan

Keputihan, membesar n Setelah hamil
Nyeri panggul anggur

Kelomp. Perempuan, Sudah usia muda - >> usia Usia subur,

Perempua (laki-laki) menikah usia tua menopaus Sdh kawin
n e
Diturunka (+) (-) (+) (+) (-)
n

Det. Dini Mamografi, Tes PAP, Prks. Dalam USG B-hCG darah
USG, IVA USG
SADARI
Kanker pada Perempuan

Take Home Messages (1):

• Kanker pada perempuan tersering
Kanker leher rahim,
Kanker payudara
Kanker ovarium
Kanker badan rahim
• Kanker payudara, skrining: mamografi, USG, SADARI
• Kanker leher rahim, skrining: Tes Pap atau IVA
• Tes Pap tidak dapat untuk skrining kanker indung telur
atau kanker badan rahim
The Ideal Examination
for Cancer Screening in a Women

• mammogram Clinical
breast exam, Breast USG
• Breast self exam instruction
• Pap smear
• Pelvic exam
• Trans Vaginal Sonography
……..salah satu kunci penanggulangan
kanker pada perempuan adalah
SKRINING /DETEKSI DINI