Cervical cancer screening guidelines 2013 on 7th sept


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  • He first reported that uterine cancer could be diagnosed by means of a vaginal smear in 1928, but the importance of his work was not recognized until the publication, together with Herbert Traut, of  Diagnosis of Uterine Cancer by the Vaginal Smear  in 1943. The book discusses the preparation of vaginal and cervical smears, physiologic cytologic changes during the  menstrual cycle , the effects of various pathological conditions, and the changes seen in the presence of  cancer  of the cervix and of the endometrium of the uterus. He thus became known for his invention of the Papanicolaou test, commonly known as the Pap smear or Pap test, which is used worldwide for the detection and prevention of cervical cancer and other cytologic diseases of the female reproductive system. In 1961 he moved to Miami, Florida, to develop the Papanicolaou Cancer Research Institute at the University of Miami, but died in 1962 prior to its opening. Papanicolaou was the recipient of the Albert Lasker Award for Clinical Medical Research in 1950. [3] Papanikolaou's portrait appeared on the obverse of the Greek 10,000-drachma banknote of 1995-2001, [4]  prior to its replacement by the Euro. In 1978 his work was honored by the U.S. Postal Service with a 13-cent stamp for early cancer detection.
  • Cervical cancer screening guidelines 2013 on 7th sept

    1. 1. Cervical Cancer Screening 2013 Guidelines Dr. Sharda Jain Director :- Founder Chairman PCH OBST/ Gynae Dpt. Sec General : Delhi Gynaecology Forum
    2. 2. Say No to Cervical Cancer
    3. 3. Mentor & Guide Say No to Cervical Cancer
    4. 4. Cervical Cancer Screening •Indian status •Concept of screening •Guidelines 2013 •Methods of screening
    5. 5. Human Suffering Due To Cervical Cancer in India Is depressing•women who die due to Cervical Cancer in the world is an Indian 1 out of 4
    6. 6. Every 7Minutes, 1 Indian woman dies of Cervical Cancer Disease Burden Infact India is a Capital for Cervical Cancer
    7. 7. IF YOU CAN PREVENT IT 100% CANCER You Don’t Need To Cure
    8. 8. Herold Zur Hausen The Nobel Prize Winner, Medicine 2008 HPV is the necessary or the key cause of cervical cancer Cervical cancer does not and will not develop in the absence of the persistent presence of HPV DNA.
    9. 9. HPV 16 HPV 18 HPV 6 HPV 11 Cancer causing Types1,2,4 Non-cancer causing types1,2 >75% of Cervical Cancer5,6 >50% of Vaginal & Vulvar Cancer5 90% of Anogenital warts5 HPV is a necessary cause of cervical cancer – 99.7%4 HPV 1.Schiffman M, Castle PE. Arch Pathol Lab Med. 2003;127:930–934. 2. Wiley DJ, Douglas J, Beutner K, et al. Clin Infect Dis. 2002;35(suppl 2):S210–S224. 3. Muñoz N, Bosch FX, Castellsagué X, et al. Int J Cancer. 2004;111:278–285. Reprinted from J Virol. 1994;68:4503–4505 with permission from the American Society for Microbiology Journals Department. 4. Walboomers JM, Jacobs MV, Manos MM, et al. J Pathol. 1999;189:12–19. 5. X. Castellsagué, S. de Sanjose, T. Aguado, K. S. Louie, L. Bruni, J.Muñoz, M. Diaz, K. Irwin, M. Gacic, O. Beauvais, G. Albero, E. Ferrer, S. Byrne,F. X. Bosch. HPV and Cervical Cancer in the World. 2007 Report. WHO/ICO Information Centre on HPV and Cervical Cancer (HPV Information Centre). Available at: www.who.int/hpvcentre6. Bhatla N et al.Vaccine (2008;26; 2811-17 Human Papillomavirus (HPV)
    10. 10. Ca Cervix Slow Growing Cancer Many opportunities for detection &treatment of Precancerous lesions
    11. 11. • CERVICAL mucosa goes through the SERIES OF CHANGES before developing into full blown carcinoma • SCREENING in such cases becomes a viable option to catch disease young. Normal mucosa Dysplasia Low grade intraepithelial lesion High grade intraepithelial lesion
    12. 12. Natural History of Cervical Cancer HPV infection CIN 1 CIN 2,3 HPV disappearance Invasive CA Avg. 10-13 yrs Avg. 6- 24 mo Avg. 6- 12 mo.
    13. 13. HPV Infection Low Grade Lesions High Grade Lesions Invasive Cancer 0–1 Year 0–5 Years 1–20 Years HPV Infection may clear Adapted from Pinto AP et al. Clin Obstet Gynecol. 2000;43:352–362. Facts about HPV Infection Each process takes over a few years Total carcinogenesis takes place over 10-12 years
    14. 14. DISEASE PROGRESSION Invasive cervical cancer Time YearsMonths Normal epithelium HPV infection; koilocytosis CIN I CIN II CIN III CIN I 57% CIN II 43% CIN III 32% Approx. likelihood of regression Borderline Mild Moderate Severe Dyskaryosis
    15. 15. This cancer is 100% Preventable !!
    16. 16. Prevention strategies • Primary prevention – education, vaccination • Secondary prevention – screening, early diagnosis and treatment • Tertiary prevention – stage wise treatment, palliation, rehabilitation
    17. 17. Let’s Recap Screening
    18. 18. Universal Screening- Why? • In many DEVELOPED COUNTRIES, a SUCCESS STORY of decline in the incidence of and mortality caused by cervical cancer as a result of screening by cytology. • Cervical cancer has PRECURSOR, low and high grade intraepithelial lesion, which have EFFECTIVE TREATMENTS available. • Screening also gives an opportunity for educating women who are constantly at high risk.
    19. 19. Type of screening • Conventional cytology • Liquid-based monolayer cytology • Human papillomavirus testing • Testing in resource-poor areas
    20. 20. Widespread introduction of the Pap begins Conventional Pap smear LBC 1949 1996 2000’s HPV testing Vaccine Cervical cancer prevention: Evolution !! Markers
    21. 21. A tribute to Dr.GeorgeA tribute to Dr.George PapanicolaouPapanicolaou
    22. 22. After introduction in 1928 as new cancer diagnosis, After 1943 PAP smear became a routine USA Mortality Due to Cancer Cervix 1940 2000 14/100,000 women 4/100,000 women Screening programmes successful in all developed countries Screens only cervical cancer
    23. 23. Cervical cytology GOLD STANDARD IN CERVICAL CANCER SCREENING. • Eight cross sectional studies from different developing countries show SENSITIVITY ranging from 28.9% to 76.9%. • Recent reviews the mean SENSITIVITY and SPECIFICITY of cytology was 75% and 94% respectively. American Journal of epidemiology,1995 Obstetrics and Gynaecology, 1998 Annals of intrnal Medicine, 2000
    24. 24. HPV Testing
    25. 25. Comparison of HPV DNA to Pap N Eng J Med, 2007: Canadian Cervical Cancer Screening Trial (CCCaST) 94.6% 55.4% 94.1% 96.8% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Sensitivity HPV DNA Sensitivity Pap Specificity HPV DNA Specificity Pap Missed CIN2+ N Eng J Med 2007; 357: 1,579 - 88 95% CI: 84.2-100 95% CI: 33.6–77.2 P=0.01 95% CI: 96.3-97.3 P<0.001 95% CI: 93.4-94.8
    26. 26. Why ca cervix prevention not given importance by Govt. in India? IT IS NOT
    27. 27. Cervical Cancer Screening In India • There are No Organized Screening Programs available in India • Cytology based screening programmes are difficult to organize because: 1. Lack of political will 2. Limited infrastructure 3. Few trained personnel 4. Lack of funds
    28. 28. India Screening – not even tip of iceberg
    29. 29. In India, Universal Vaccination can haveSubstantial effect in reducing the morbidity of cervical cancer in,where an organization screening program may not exist for all women in near future. Villa LL. Vaccine. 2006; 24 (suppl 1) : S2# - 8 GOI – has NO MONEY for universal vaccination
    30. 30. The Recently Launched National Program for Prevention & Control of Cancer, Diabetes, Cardiovascular Diseases & Stroke (NPCDCS, Ministry of Health & FW, Government of India) has among its major objectives cervical cancer control through opportunistic screening of women above 30 years.
    31. 31. Kudos to FOGSI members • ↓ MMR – we are close to realise MDG -5 • Big Challenge of 2013 - ↓ Cancer Cervix Rate in India
    32. 32. •1940-1989: annual “pap smear” for all women -Linkage of “annual pap smear” to “annual health exam” •1987: Walton Commission (British Columbia) -Cytology screening every 3 years •1989: AMA, ACOG, AMWA Consensus Statement -Annually, starting at sexual activity or 18 years old -After 3 negative smears, testing may be done less frequently -Longer intervals based on the absence of risk factors Evolution of Cervical Cancer Screening / Intervals
    33. 33. Cervical Cancer Screening Guidelines for Average-Risk Women 2013
    34. 34. 1. American Cancer Society (ACS) 2.American Society for Colposcopy and Cervical Pathology (ASCCP), 3. American Society for Clinical Pathology (ASCP) 4. U.S. Preventive Services Task Force (USPSTF) 5. American College of Obstetricians and Gynecologists (ACOG) Endorsed by
    35. 35. FOCUS Of Cervical Cancer Screening Guidelines 2013 • When to start screening • Screening method and intervals • When to stop screening • Screening after Hysterectomy • Pelvic exams • Screening among women who have been vaccinated against human papillomavirus (HPV)
    36. 36. Current Recommendation 2013 • Apply to women who have a cervix, regardless of sexual history. • Do not apply to women who have received a diagnosis of a - high – grade precancerous cervical lesion or - Cervical cancer. - Who are immunocompromised (such as those, who are HIV positive)
    37. 37. When to start screening ?
    39. 39. •Most HPV infections are transient •When HPV infection persists, transit to cancer is quite long •Spontaneous regression of low grade lesions is common •Invasive cervical cancer is very rare in 15-19 year olds -14 cervical cancers annually -1-2 cases per 1 million women •In teens, screening does not reduce mortality -Cervical cancer rates have not changed since 1973- 1977, before practice of screening at 18 or first intercourse Why Start Cervical Cytology at 21? ACOG Practice Bulletin No. 109, Dec 2009
    40. 40. Screening method and intervals 21 to 65 Years • Cytology 21-29 years of age EVERY 3 YEARS. (conventional or 30-65 years of age liquid based) Strong recommendation Second Recommendation
    41. 41. Statement about annual screening FOR SCREEN NEGATIVE If Screening Negative Repeat after 3 years Women of any age should not be screened annually by any screening method. (Strong recommendation) However , they should come for annual check-up
    42. 42. HPV + Cytology Co-Testing: Benefits • Compared to cytology alone, improved accuracy and earlier diagnosis of CIN 2+ • High negative predictive value important in women unable or unwilling to have every 3 year screening • While each co-test is more expensive, longer intervals and very high NPV could reduce overall costs
    43. 43. Atypical Squamous Cells of Undetermined Significance (ASC-US) • Most common cytological abnormality • Option 1 : repeat Cytology in 12 months -If Negative-Cytology in 3 years -If ASC or greater-Colposcopy • Option 2 : Preferred: Reflex HPV Testing -If Positive: colposcopy -If Negative: Repeat Co-testing in 3 years
    44. 44. HPV Positive, Cytology Negative Occurs in 11% of women aged 30 to 34 years; 2.6% of women aged 60 to 65 years • Option 1: repeat co-testing in 12 months -If HPV-positive or ASC-US+: colposcopy -If HPV-negative or Cytology negative: rescreen with co- testing in 3 years • Option 2: reflex test for HPV16 or HPV16/18 genotypes -If HPV16 or HPV 16/18 positive: colposcopy -If HPV16 or HPV 16/18 negative: co-test in 12 months • Do not immediately colposcope HPV positive/cyto negatives
    45. 45. HPV co-testing SHOULD NOT BE USED for women aged <30 years. HPV Co -Test (cytology + HPV test administered together) 21-29 years of age
    46. 46. 30 – 65 years of age • If Screen Negative Every 5 years (Strong recommendation) • THIS IS THE PREFERRED METHOD • (Weak recommendation). HPV co-test (cytology + HPV test administered together)
    47. 47. Proposed Algorithm for the Management of Women ≥30 HPV Negative HPV Positive Repeat both tests at 5 years HPV 16 - / 18 – Other HR HPV + HPV 16 + and / or HPV 18 + ColposcopyRepeat both tests at 1 year Cytology Negative + HPV Testing
    48. 48. Annual cervical cancer screening should NOT be performed. (Level A evidence) Patients should be counseled that annual well-woman visits are recommended even if cervical cancer screening is not performed at each visit. HPV Co- Test Screen Negative inwomen aged 30–65 years
    49. 49. Primary HPV testing (alone) For Screening screening by HPV testing alone is not recommended in most clinical settings. (Weak recommendation)
    50. 50. When to Stop Screening • Stop at age 65 for women with adequate negative prior screening, no CIN2+ within the last 20y. Definition of adequate negative screening: • 3 consecutive negative Paps or • 2 consecutive negative HPV tests
    51. 51. Rationale for stopping at 65 years • CIN2+ is rare after age 65 – Most abnormal screens, even HPV+, are false + and do not reflect precancer • HPV risk remains 5-10% • Incident HPV infection unlikely to lead to cancer within remaining lifetime Chen HC et al. JNCI 2011;103:1387-96; Rodrigues AC et al. JNCI 2009;101:721-8
    52. 52. When NOT to stop at age 65 years If history of CIN2, CIN3, or AIS – Continue “routine screening” for at least 20 years, “even if this extends screening past age 65.”
    53. 53. When to stop screening - 2 • Stop after HYSTERECTOMY with removal of cervix and no history of CIN2+ • “Evidence of adequate negative prior screening is not required”
    54. 54. Rationale for stopping after Hysterectomy • Vag cancer rate is 7/million/year • 663 vag cuff Paps needed to find one VAIN • 2,066 women followed after hyst. for average 89 months – 3% had VAIN, 0 had cancer • Risk of Pap abnormality after hyst = 1%. Pearce KF et al. NEJM 1996;335:1559-62; Piscitelli JT et al. AJOG 1995;173:424-30
    55. 55. Women who have had a SUPRA-CERVICAL HYSTERECTOMY (cervix intact) should continue screening according to Age guidelines. (Strong recommendation) SCREENING IN POST – HYSTERECTOMY CASE
    56. 56. Women at any age with a history of HPV Vaccination should be screened according to the age specific recommendations for the general population. Screening among those immunized against HPV 16/18 5th Recommendation
    57. 57. SCREENING A VACCINATED COHORT • Vaccination against HPV 16/18 – Reduces CIN3+ by 17-33% – Reduces colposcopy by 10% – Reduces treatment by 25% • “ Recommended screening practices should not change on the basis of HPV vaccination.” Paavonen J et al. Lancet 2009;374:301-14
    58. 58. The need for a BIMANUAL PELVIC EXAM in subsequent yearly check-ups <21 – No need 21 - shared decision
    59. 59. Let’s Recap 2013 Guidelines
    60. 60. AGE SCREENING < 21 No Screening 21-29 Cytology alone every 3 years 30-65 Acceptable: Cytology alone every 3 years* Preferred ??: Cytology + HPV every 5 years* OR > 65 No screening, following 3 consequetive neg prior screens in last decade After total hysterectomy No screening, if no history of CIN2+ in the past 20 years of cervical cancer ever HIV-positive -Immunosuppressed (e.g., Annually 2013 Guidelines : ACS, ASCCP, American Society for Clinical Pathology CA Cancer J CLIN March 2012 • 1st time that all 3 organizations involved with cervical cancer prevention and the USPSTF have endorsed equivalent guidelines
    61. 61. How to prepare for your pap test - Not to schedule during periods. - If you are going to have a pap testing in the next two days • You should not douche (rinse the vagina with water or another fluid). • You should not use a tampon • You should not use a birth control foam, cream or jelly • You should not use a medicine or cream in your vagina
    62. 62. Summary 1. 27% of the world burden of Cervical Cancer is seen in India. 2. Screening is recommended in women of >21yrs 2013 3. No screening required before 21 yrs 4. Screening should stop at 65 yrs and after hysterectomy “The biggest gain in reducing cervical cancer incidence and mortality would be achieved by increasing screening rates among women rarely or never screened. . . Clinicians, hospitals, health planners, and public health officials should seek to identify and screen these women.” ACS, 20002
    63. 63. Thank You Say No to Cervical Cancer