Monday, April 26, 2010

Cervical Cancer Prevention Week..

As part of the effort to create an awareness and making the cervical cancer vaccine more accessible to all walks of life, Klinik Wan dan Keluarga, along with GSK will organized a Cervical Cancer Prevention Week starting from 18th May to the 25nd May.

We provide free counselling in regards to Cervical cancer, the vaccine, prevention method, and screening methods.
On that particular week, we offer Thin Prep Pap Smear with only half the actual price.
The cost of vaccination will be the same, much lower than the current market price,  and would further enjoy more discounts if the price of three doses are paid in full.

Already lower than current market price...

or enjoy further discounts is three jabs are paid in full.
And we accept payment by credit card, with no extra charges.

In addition to this, Thin Prep Pap Smear which usually cost RM90, will be reduced to RM45.

RM 45 (from 18 May to 25 May)

Please note
1.You need not do Pap Smear prior to vaccination.
2.You do not need to be followed up by the doctor in charge of Klinik Wan & Keluarga      after vaccination.  
3. Insist on Thin Prep Pap Smear by your respective doctor.
4. Price of vaccination will remain the same after the Cervical Cancer Prevention Week.
5. Klinik Wan & Keluarga provides free counselling all year long. 
6.  The Vaccine that is available in Klinik Wan & Keluarga is Cervarix.
7. You need not set an appointment for the vaccination.

If you have difficulties finding the clinic, click here for map and directions.

We will be organizing a talk on "Measures to prevent Cervical Cancer" on the 22.5.2010.
So, bring along your friends and family members.
Remember, Cervical cancer is now preventable BY CHOICE.Grow up and grow old healthily and gracefully, instead of becoming a "number in statistics" for others to study upon.
Please call us at 03-62722678 to inquire on price that is guaranteed the lowest in the country

Wednesday, April 21, 2010

Now that I am vaccinated, then what?...

The expressed opinion in this post are made entirely based upon the author's own impression and knowledge. They are not influenced in any way, nor the author being given remunerations in any form by any party.
In the effort to reduce the incidence of Cervical Cancer, multiple awareness campaigns held by pharmaceutical company isn't suffice. It may serve the purpose to remind the public the presence of this disease, and that the vaccine against it is available. But I doubt the public knows the degree of seriousness this disease and it's impact upon the lives of patients and caretakers.
Personally, as a medical practitioner, I felt the need to be more proactive and reach out to the public since the community is unaware of the impact cervical cancer has.
Public perception is the single most important factor in the effort to lower the prevalence of cancer.
No doubt, cervical cancer vaccine receives its share of bad reputation from media. Those 12,000 reported adverse effects are mainly against Gardasil, not Cervarix.
Naturally, first and foremost important task to achieve is to educate the public and to make available the true facts to dispel the negative impression the public had perceived.
Through campaigns, seminars, talks, public forums, internet, etc.. any form of mass media that enable to reach out the facts on this vaccine. However, the facts shouldn't be biased, and to reveal possible side effects, right from the trivial to the serious side effects.

My preference for GSK's Cervarix is based upon it's quality which I determine by :-
1. The spectrum of protection it provides
2. The duration of immunity the vaccine provides.
As the law states, any products which is of pharmaceutical grade is required to list it's possible side effect, even if its remote and rare.
GSK does just that in their brochure which is handed to the public.

Possible side effects are divided into very common,common, and rare

These brochures are distributed by the nurses to the patients, or displayed in strategic areas in clinics for patients to to read while awaiting their turn to consult the doctor.

For patient's convenience, these brochures come with a follow up card with columns to write the dates for vaccination.

This goes to show that GSK goes all the way not only to encourage, promote, but to remind patients of their date of the subsequent doses.

Does completion of vaccination prevents cervical cancer altogether? Absolutely not. Individuals who have had intercourse prior to vaccination are required to continue with their annual Pap smear.Cervical Cancer Vaccination DOES NOT replace annual Pap Smear for screening for pre malignant changes.

Pap Smear was discovered during World War II. Since then, it has reduced the mortality due to Cervical Cancer drastically by early detection of pre-malignant changes. If Cervical Cancer is diagnosed upon the first symptom, often the malignancy would have been in the advance stage.

It's a easy clinical procedure to collect sample from the cervix. Procedure is done with patient lying on their back.

A wooden spatula is used to collect sample from the surface of the cervix.

When the spatula is in contact with the cervix, it is then rotated 360 degrees to obtain the lining epithelium of the cervix.

The sample is then smeared on a glass slide, which is then chemically fixed with a cytofix.

As shown in the picture above, the sample is fixed onto the slide with the cytospray. It is then examined by histologist/cytologist to detect changes of the cellular make up. 
Despite the drastic reduction of mortality rate in cervical cancer , the incidence of "false negative" reports in Pap Smear is relatively high. (False negative is failure to detect early pre malignant changes,hence the sample is reported as normal) this gives the patient a false sense of security.
Pap smear is an effective way of screening for cancer, however, it's not diagnostic. Even when considered effective, there is still possibility of a false negative report. The percentage of false negatives ranges between 5%-50%, out of which 80% are true false negative, and the rest are due to mistakes done in the laboratory.
To date, there is yet to exist a "perfect" test to detect and diagnose cancer in terms of cost effectiveness and accuracy.

Even though our government provide free Pap Smear screening program at government hospital, sadly percentage of woman who actually did the test remains low. To my opinion, this is due to the attitudes toward cervical cancer and participation in early detection and screening services are well known to be profoundly affected by cultural beliefs and norms.
 Pap smear coverage in the country was a dismal figure of less than 2% in 1992, 3.5% in 1995 and 6.2% in 1996.Most woman have a wrong perception of Pap Smear.Many believe it to be  diagnostic rather than screening, hence do not see the necessity to get it done, until the presence of symptoms that prompts them to do so.

Other main reasons for not doing the screening included lack of awareness of Pap smear indications and benefits, perceived low susceptibility to cervical cancer, and embarrassment. Other reasons for not being screened were related to fear of pain, misconceptions about cervical cancer, fatalistic attitude, and undervaluation of own health needs versus those of the family.
These are some of the many reason behind the drawbacks of Pap smear. As I had mentioned earlier, public perception and an awareness of the nature of disease is of utmost importance in the effort to decrease of its occurrence. 
Say ,somehow we managed to change the mindset of society towards annual screening, the next question would be the accuracy of Pap Smear. 
It's rather unfortunately that I've encountered quite a number of patient who's family member who previously goes for their annual Pap Smear religiously, was reported to  be normal, but 5-6 months later, succumbed... due to Cervical cancer. With total disbelieve, those family members would never have a closure to what has happened.
The inaccuracy of Pap Smear could be due to sampling where inadequate samples are collected. Based on head of histology and cytology department, Gribbles Laboratory(Malaysia), upon smearing the sample onto the surface of the glass slide, only 20% of the samples are deposited, while the other 80% are discarded along with the wooden spatula. 

.....which is of course naturally discarded into the waste bin.

....... Such a small and trivial avoidable mistake that cost someone's life....

All it takes for  a more thorough screen is all still on the surface of this spatula...
While Conventional Pap Smear is a good method to detect squamous cell carcinoma(85% of cervical cancer that arises from the ectocervix)......

...Ectocervix is part of the cervix that faces the vagina, while 15% of cervical malignancy is due to adenocarcinoma which often arise from the endocevix...

...Endocervix is the part of cervi that faces the uterus. Hence conventional Pap Smear is unable to detect adenocarcinoma.

...advance stage of Cervical cancer....
Though conventional Pap Smear reduced the number of mortality significantly, nevertheless, for those unlucky undetectable "adenocarcinoma" type, 15%,30%, or 50% doesn't mean anything to them. It simply doesn't make any difference.
Since 1996, an improvised version to counter the problem in sampling by Conventional Pap Smear was found.
Thin Prep Pap Smear.

This process differs and possesses several advantages over conventional Pap Smear.

Most importantly, the brush which is used to collect the sample is designed  in such a way to enable a thorough sampling from both ecto and endo cervix.

As you can see, the design of the brush is such a way that the centre bristles are longer than the surrounding ones. The longer bristles is able to reach deep into the endocervix, and collection of sample is done by rotating the the brush once it's inserted on the right place.

The sample taken from the brush has both endo and ecto cervix.

The brush is then rinsed by pushing the brush into the bottom of the sampling vial several times, forcing the bristles apart. Lastly, the brush is then swirled vigorously to further release the sample.

The name and the ID number of the patient is written of the surface of the container, and send to the lab for investigation.

The second advantage being that the sample are screen twice compared to only once in conventional Pap Smear, which then depends on the experience of the pathologist who writes the report.
While in Thin Prep, the first stage is screen by a computerized imaging device that screens and detects abnormal cellular picture, which then proceeds to the second stage where the abnormality is confirmed by the pathologist.
If at all there are presence of abnormal findings in the Thin Prep, the same sample can be sent for HPV DNA testing to determined the subtype of HPV, in addition to STDs, while in conventional Pap Smear would require a second sample to be taken.
Today, 90% of cervical cancer screening in the US is done via Thin Prep Pap Smear. The high sensitivity and specificity of this test is significantly more accurate than conventional Pap Smear.

It's rather alarming to know that not many general practitioners are aware of the availability of such test. Out of all the Pap Smear samples received by Gribbles Lab( Malaysia) only 30% are Thin Prep Pap Smear, and out of that, only 20% are sent by general practitioners.
Considering the awareness, or rather ignorance among doctor on the availability of such investigation, the public aren't the one to be blamed. How would the public know if it's not being brought up by the doctor?

It's in the book. Just in case if my fellow doctor aren't aware on where to look for it, it's here...

Yes.. It's on page 13.

I would encourage my fellow doctors to constantly update ourselves through the internet or medical journal in regards to latest advancement, new regime of treatment, latest method of investigations..etc.. because decisions made by us determines the outcome of lives of others.
So, fellow, readers, after reading this particular post, the thing to remember is:-
1. Get vaccinated NOW!

You would be deluded to even consider contracting cervical cancer is being far fetched.
2.DO NOT DEFAULT in your vaccination.

3. Upon completion of vaccination, it doesn't mean you need not do your annual Pap Smear.

4.Request for Thin Prep Pap Smear instead of conventional Pap Smear.

5.Spread the news around. Discuss with your doctor today about Cervical Cancer. Inform your friends and ask them to come along if you feel hesitant on seeing the doctor by yourself.

Cervical cancer is the second cancer which is preventable by choice. So chose not to have cervical cancer. Get vaccinated at the clinic near you today!