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Cervical Cancer Screening
Cervical Cancer Screening
Cervical Cancer Screening
Cervical Cancer Screening
Cervical Cancer Screening
Cervical Cancer Screening
Cervical Cancer Screening
Cervical Cancer Screening
Cervical Cancer Screening
Cervical Cancer Screening
Cervical Cancer Screening
Cervical Cancer Screening
Cervical Cancer Screening
Cervical Cancer Screening
Cervical Cancer Screening
Cervical Cancer Screening
Cervical Cancer Screening
Cervical Cancer Screening
Cervical Cancer Screening
Cervical Cancer Screening
Cervical Cancer Screening
Cervical Cancer Screening
Cervical Cancer Screening
Cervical Cancer Screening
Cervical Cancer Screening
Cervical Cancer Screening
Cervical Cancer Screening
Cervical Cancer Screening
Cervical Cancer Screening
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Cervical Cancer Screening

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A quiz for the 2007/2008 guidelines for Cervical Cancer by ASCCP and the USPSTF.

A quiz for the 2007/2008 guidelines for Cervical Cancer by ASCCP and the USPSTF.

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  • 1. Cervical Cancer Screening Cases by Clinton Pong Using the 2007-8 Guidelines, accessed 1/4/2009.
  • 2. It’s ok to use notes and books <ul><li>I put this together because, as a male, I have no conception of these screens. And its complicated! </li></ul><ul><li>In my opinion, the most important thing is to remember where to look when you can’t remember what you need to do. </li></ul><ul><li>Follow along with the references listed. </li></ul><ul><li>Like USMLE World, read through the other answers for extra information. </li></ul>
  • 3. References <ul><li>Algorithms for abnl cerv CA (ASCCP's October 2007) Click here to download the PDF . </li></ul><ul><li>Algorithms for CIN (October 2007 ASCCP's Journal of Lower Genital Tract Disease. Click here to download the PDF </li></ul><ul><li>USPSTF: Cervical Cancer (Pap Smear): Screening (2003) </li></ul><ul><li>Obstetrics, Gynecology and Infertility: (Red) Handbook for Clinicians 6 th ed. (2007) p 375 </li></ul><ul><li>BETHESDA SYSTEM WEBSITE ATLAS http://nih.techriver.net/ </li></ul>
  • 4. Questions <ul><li>Sexually active woman, screen initiation </li></ul><ul><li>Annual Pap  Q3 yr screen </li></ul><ul><li>D/c of screen </li></ul><ul><li>25 y/o ASCUS </li></ul><ul><li>18 y/o LSIL </li></ul><ul><li>30 y/o ASC-H, CIN I </li></ul><ul><li>30 y/o HSIL, CIN I unsatisfactory colpo </li></ul><ul><li>33 y/o AGC </li></ul><ul><li>33 y/o AIS </li></ul><ul><li>CIN II, III for adult </li></ul><ul><li>CIN II for adolescent </li></ul>
  • 5. Sexually active woman (1 st sexual encounter @ 15 y/o) <ul><li>When should routine screening be initiated? </li></ul><ul><ul><li>15 years old, then annually </li></ul></ul><ul><ul><li>18 years old, then annually </li></ul></ul><ul><ul><li>21 years old, then annually </li></ul></ul><ul><ul><li>30 years old, then annually </li></ul></ul>
  • 6. Sexually active woman (1 st sexual encounter @ 15 y/o) <ul><li>B. 3 years after initiating sexual intercourse or age 21 (which ever comes first) </li></ul><ul><ul><li>15 years old, then annually </li></ul></ul><ul><ul><li>18 years old, then annually (15+3 = 18) </li></ul></ul><ul><ul><li>21 years old, then annually (even in non-sexually active F, it is recommended by many organizations to test annually for 21+ d/t the high prevalence of sexually activity and concerns of inadequate sexual hx taking) ( ref ) </li></ul></ul><ul><ul><li>30 years old, then annually </li></ul></ul>
  • 7. Annual pap  Q3 year screen <ul><li>In which case would it be acceptable for annual Pap smear screens to transition to Q3 years, according to ACOG? </li></ul><ul><ul><li>25 y/o </li></ul></ul><ul><ul><ul><li>nl until 19 ASCUS , but nl thereafter </li></ul></ul></ul><ul><ul><li>30 y/o </li></ul></ul><ul><ul><ul><li>nl until 25 ASCUS , 25.5 nl, 26 nl, 27-29 nl </li></ul></ul></ul><ul><ul><li>35 y/o </li></ul></ul><ul><ul><ul><li>CIN III @ age 25  LEEP, now found HIV+ </li></ul></ul></ul>
  • 8. Annual pap  Q3 year screen <ul><li>B. > 30 years old after 3 consecutive normal results (ACOG) >age 30, after 3 (-) paps in a row  ok to Δ to Q3! USPSTF: no direct evidence that annual screening is better than Q3 years, but b/c high grade lesions may be missed (single Pap Sn 60-80%) ACS: wait until age 30 ACOG: at least 2 or 3 consecutive nl results before lengthening interval to Q3 years. ( ref ) </li></ul><ul><ul><li>25 y/o (too young) </li></ul></ul><ul><ul><li>3 0+ y/o, 3 (-) paps  Δ to Q 3 ! </li></ul></ul><ul><ul><li>35 y/o (ACOG recommends annual screening in presence of other risk factors like CIN, STDs, high-risk sexual behavior, in-utero DES exposure, HIV+, immunocompromised) </li></ul></ul>
  • 9. Discontinuation of cervical cancer screening <ul><li>Which of the following situations still has an indication for cervical cancer screening? </li></ul><ul><ul><li>Transgender female to male with hormone therapy, status post total hysterectomy </li></ul></ul><ul><ul><li>70 year old immigrant with no history of screening in the past ten years </li></ul></ul><ul><ul><li>40 y/o w/ a total hysterectomy for benign disease </li></ul></ul>
  • 10. Discontinuation of cervical cancer screening <ul><li>B. ACS recs: 70+ F w/ 3+ consecutive nl cervical cytology tests and with no abnl/(+) cytology w/in the last 10 years, can safely stop screening. </li></ul><ul><ul><li>Testosterone  atrophic changes that may mimic dysplasia, pathologist should be notified of pt status. Total hysterectomy indicates removal of cervix </li></ul></ul><ul><ul><li>Optimal age to discontinue screening is not clear by evidence. USPSTF recs: after age 65. ACS recs: at age 70. Screening still recommended for older women who </li></ul></ul><ul><ul><ul><ul><li>have not been previously screened </li></ul></ul></ul></ul><ul><ul><ul><ul><li>when information about previous screening is unavailable </li></ul></ul></ul></ul><ul><ul><ul><ul><li>when screening is unlikely to have occurred in the past (e.g., among women from countries without screening programs) </li></ul></ul></ul></ul><ul><ul><li>USPSTF recommends against routine Pap smear screening in women who have had a total hysterectomy for benign disease. </li></ul></ul>
  • 11. 25 y/o F with ASC-US <ul><li>Which of the following is the most appropriate management? (ASCCP) </li></ul><ul><ul><li>DNA testing for HPV 6, 11, 42, 44 </li></ul></ul><ul><ul><li>Repeat Papanicolaou stain at 6 month intervals x 3 </li></ul></ul><ul><ul><li>Just continue regular screening – annual Pap exam </li></ul></ul><ul><ul><li>Colposcopy w/ 3-5% acetic acid application and directed biopsies of suspicious lesions </li></ul></ul>
  • 12. 25 y/o F with ASC-US <ul><li>D. Colposcopy. </li></ul><ul><ul><li>DNA testing for ( HPV 6, 11, 42, 44) is low risk.  </li></ul></ul><ul><ul><ul><li>Test for HIGH RISK forms of HPV 16, 18, 31, 33, 45 </li></ul></ul></ul><ul><ul><li>Pap at 6 month ( intervals x 3 is too long.)  </li></ul></ul><ul><ul><ul><li>Only need x 2 negative results (@ 6, 12 mo) </li></ul></ul></ul><ul><ul><li>Repeat pap stain at ( 12 month intervals) </li></ul></ul><ul><ul><ul><li> 6 month x 2, then resume routine screening </li></ul></ul></ul><ul><ul><li>Definition of colposcopy: </li></ul></ul><ul><ul><ul><li>examination of the cervix,the vagina, and, in some instances the vulva with the colposcope after the application of a 3-5% acetic acid solution coupled with obtaining colposcopically directed biopsies of all lesions suspected of representing neoplasia. </li></ul></ul></ul>
  • 13. 18 y/o F with LSIL <ul><li>Which of the following is the most appropriate management? (ASCCP) </li></ul><ul><ul><li>DNA testing for HPV 16, 18, 31, 33 </li></ul></ul><ul><ul><li>Repeat Papanicolaou stain at 6 mo x 2 </li></ul></ul><ul><ul><li>Just continue regular screening -- annual pap exam </li></ul></ul><ul><ul><li>Colposcopy w/ 3-5% acetic acid application and directed biopsies of suspicious lesions </li></ul></ul>
  • 14. 18 y/o F with LSIL <ul><li>C. Adolescent w/ ASCUS or LSIL receive the same management: repeat cytology after 1 year </li></ul><ul><ul><li>Rates of HPV DNA (+) are much higher in younger women with ASC-US despite a low risk cancer. </li></ul></ul><ul><ul><ul><li>HPV DNA testing unnecessarily refers adolescent women to colposcopy. </li></ul></ul></ul><ul><ul><li>Repeat Papanicolaou stain at 6, 12 mo </li></ul></ul><ul><ul><ul><li>Indicated for Regular adult population, 20+ y/o. </li></ul></ul></ul><ul><ul><li>Annual exam only b/c most dysplasia clears spontaneously after 2 years in young pts </li></ul></ul><ul><ul><ul><li>Repeat Papanicolaou stain at 12 mo </li></ul></ul></ul><ul><ul><ul><ul><li>then, only HSIL  colposcopy. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>CIN I is still treated with repeat cytology after 1 year </li></ul></ul></ul></ul><ul><ul><li>Colposcopy (only if repeat pap after 1 yr = HSIL) </li></ul></ul>
  • 15. 30 y/o F with ASC-H (cannot exclude High-grade SIL): Colpo shows CIN I <ul><li>Which of the following is the most appropriate management? (ASCCP) </li></ul><ul><ul><li>DNA testing for HPV 16, 18, 31, 33 at current visit. </li></ul></ul><ul><ul><li>Repeat Papanicolaou stain at 6 mo x 2 </li></ul></ul><ul><ul><li>Repeat Papanicolaou stain at 12 mo (continue regular screening) </li></ul></ul><ul><ul><li>Colposcopy w/ 3-5% acetic acid application and directed biopsies of suspicious lesions </li></ul></ul>
  • 16. <ul><li>B. Either Cytology @6,12 mo OR HPV DNA testing @ 12 mo. </li></ul><ul><ul><li>DNA testing for HPV 16, 18, 31, 33 </li></ul></ul><ul><ul><ul><li>Wait 12 months and then perform HPV testing </li></ul></ul></ul><ul><ul><li>Repeat Papanicolaou stain at 6 mo x 2 </li></ul></ul><ul><ul><li>Repeat Papanicolaou stain at 12 mo (continue regular screening) </li></ul></ul><ul><ul><li>Colposcopy, ablative treatment if persistent > 2 yr </li></ul></ul>30 y/o F with ASC-H (cannot exclude High-grade SIL): Colpo shows CIN I If the Cytology (-)@6,12 mo OR HPV (-) @ 12 mo, then If the Cytology (+) @6,12 mo OR HPV (+) @ 12 mo, then
  • 17. 30 y/o F w/ HSIL Colpo shows CIN I but colposcopy is unsatisfactory <ul><li>Which of the following is the most appropriate management? (ASCCP) </li></ul><ul><ul><li>DNA testing for HPV 16, 18, 31, 33 </li></ul></ul><ul><ul><li>Repeat Papanicolaou stain AND colposcopy at 6 mo x 2 </li></ul></ul><ul><ul><li>Repeat Papanicolaou stain at 12 mo (continue regular screening) </li></ul></ul><ul><ul><li>Diagnostic excisional procedure </li></ul></ul><ul><ul><li>Review of all findings </li></ul></ul>
  • 18. 30 y/o F w/ HSIL Colpo shows CIN I but colposcopy is unsatisfactory <ul><li>D. DEP. </li></ul><ul><ul><li>DNA testing for HPV 16, 18, 31, 33 </li></ul></ul><ul><ul><li>Repeat Papanicolaou stain AND colposcopy at 6 mo x 2 </li></ul></ul><ul><ul><ul><li>An option if colposcopy was satisfactory </li></ul></ul></ul><ul><ul><li>Repeat Papanicolaou stain at 12 mo (continue regular screening) </li></ul></ul><ul><ul><li>Diagnostic excisional procedure </li></ul></ul><ul><ul><ul><li>An option if colposcopy was satisfactory also </li></ul></ul></ul><ul><ul><li>Review material – includes referral cytology, colposcopic findings, and all biopsies </li></ul></ul><ul><ul><ul><li>An option if colposcopy was satisfactory </li></ul></ul></ul>
  • 19. 33 y/o w/ AGC <ul><li>What is the initial workup for atypical glandular cells? </li></ul><ul><ul><li>Colposcopy </li></ul></ul><ul><ul><li>Colposcopy + endocervical curetting </li></ul></ul><ul><ul><li>Colposcopy + ECC + HPV DNA testing </li></ul></ul><ul><ul><li>Colposcopy + ECC+ HPV DNA testing + Endometrial sampling </li></ul></ul>
  • 20. 33 y/o w/ AGC <ul><li>C. include EMB only if > 35 y/o, <35 y/o w/ AUB, obesity or oligomenorrhea </li></ul><ul><ul><li>Colposcopy </li></ul></ul><ul><ul><li>Colposcopy w/ endocervical curetting </li></ul></ul><ul><ul><li>Colposcopy + ECC + HPV DNA testing </li></ul></ul><ul><ul><ul><li>Protocol for ALL women with AGC, unless they are > 35 y/o or at risk for endometrial neoplasia </li></ul></ul></ul><ul><ul><li>Colposcopy + ECC + HPV DNA testing + Endometrial biopsies (EMB) </li></ul></ul>
  • 21. 33 y/o w/ AGC after ECC found to have AIS <ul><li>What is the preferred management for Adenocarcinoma in situ (AIS) diagnosed from a DEP, if future fertility is not desired? (ASCCP) </li></ul><ul><ul><li>Re-pap/ECC Q6mo </li></ul></ul><ul><ul><li>Hysterectomy </li></ul></ul><ul><ul><li>LEEP </li></ul></ul><ul><ul><li>CKC (cold knife cone) </li></ul></ul>
  • 22. 33 y/o w/ AGC after ECC found to have AIS <ul><li>B. Hysterectomy preferred, especially if future fertility is not desired. </li></ul><ul><li>If fertility is desired, acceptable conservative managements may include: </li></ul><ul><li>(B) LEEP or (C) CKC </li></ul><ul><ul><li>If margins are (-), long term f/u </li></ul></ul><ul><ul><ul><li>(A) Re-pap/ECC Q6mo and GYN/ONC consult recommended </li></ul></ul></ul><ul><ul><li>If margins are (+) </li></ul></ul><ul><ul><ul><li>Re-excision recommended </li></ul></ul></ul><ul><ul><ul><li>OR re-evaluation @ 6 months (also acceptable) </li></ul></ul></ul>
  • 23. CIN II or III for adults <ul><li>What is the management for CIN II, III? (ASCCP) </li></ul><ul><ul><li>Re-pap OR Pap/HPV Q6mo until (-)x2 </li></ul></ul><ul><ul><li>Immediate LEEP </li></ul></ul><ul><ul><li>Colpo/Pap Q12 wk </li></ul></ul><ul><ul><li>Hysterectomy </li></ul></ul>
  • 24. CIN II, III for adults <ul><li>B. Immediate ablative/excisional treatment </li></ul><ul><ul><li>Re-pap OR Pap/HPV Q6mo until (-)x2 </li></ul></ul><ul><ul><ul><li>Management s/p LEEP </li></ul></ul></ul><ul><ul><li>Immediate LEEP </li></ul></ul><ul><ul><ul><li>CIN II = 40% regression rate </li></ul></ul></ul><ul><ul><ul><li>CIN III = rare </li></ul></ul></ul><ul><ul><li>For pregnant women: </li></ul></ul><ul><ul><ul><li>Colpo/Pap Q12 wk, and 6-8 wk post-partum </li></ul></ul></ul><ul><ul><ul><li>OR delay and just colpo/pap post-partum </li></ul></ul></ul><ul><ul><li>Hysterectomy not recommended, may be considered for persistent or recurrent CIN 2-3 </li></ul></ul>
  • 25. CIN II or III For adolescents <ul><li>What is the management for CIN II, III? (ASCCP) </li></ul><ul><ul><li>Pap/HPV Q6mo until (-)x2 </li></ul></ul><ul><ul><li>Pap/colpo Q6mo until (-)x2 </li></ul></ul><ul><ul><li>Immediate LEEP </li></ul></ul><ul><ul><li>Colpo/Pap Q12 wk </li></ul></ul>
  • 26. CIN II For adolescents <ul><li>B. Observation preferred for adolescents w/ CIN II. CIN III/unsatisfactory colposcopy -> tx </li></ul><ul><ul><li>Pap/HPV Q6mo until (-)x2 </li></ul></ul><ul><ul><ul><li>HPV is not specific to Cervical CA in adolescents </li></ul></ul></ul><ul><ul><li>Pap/colpo Q6mo until (-)x2 </li></ul></ul><ul><ul><ul><li>Q6mo for up to two years </li></ul></ul></ul><ul><ul><ul><li>if appearance worsens or HSIL (+) then biopsy </li></ul></ul></ul><ul><ul><li>LEEP </li></ul></ul><ul><ul><ul><li>Treat if CIN III arises </li></ul></ul></ul><ul><ul><ul><li>OR if CIN 2,3 persists for 2 yr since initial dx </li></ul></ul></ul><ul><ul><li>For pregnant women: </li></ul></ul><ul><ul><ul><li>Colpo/Pap Q12 wk, and 6-8 wk post-partum </li></ul></ul></ul><ul><ul><ul><li>OR delay and just colpo/pap post-partum </li></ul></ul></ul>
  • 27. Summary <ul><li>Important ages to remember: </li></ul><ul><ul><li><20 y/o = adolescent, has different management </li></ul></ul><ul><ul><li>21 y/o OR 3 y/a 1 st time: begin screening </li></ul></ul><ul><ul><li>>30 y/o: may lengthen screening to Q3yr if (-)x3 </li></ul></ul><ul><ul><li>>35 y/o w/ AGC: req EMB to r/o adenocarcinoma </li></ul></ul><ul><ul><li>70+ w/ 3(-), no (+)for 10 yr: d/c screens </li></ul></ul><ul><li>HPV is not a primary screen (only adjuvant to Pap) and it is less useful for adolescents </li></ul>
  • 28. Review of answers <ul><li>Sexually active woman, screen initiation 3yr p or 21 </li></ul><ul><li>Annual Pap  Q3 yr screen @ 30 after 3(-)s. </li></ul><ul><li>D/c screen @ 70 after 3(-)s, and no (+) for 10 yr </li></ul><ul><li>25 y/o ASCUS: colposcopy </li></ul><ul><li>18 y/o LSIL: resume normal screen (repeat pap @12) </li></ul><ul><li>30 y/o ASC-H, CIN I: repeat pap @ 6, 12 or HPV @12 </li></ul><ul><li>30 y/o HSIL, CIN I unsatisfactory colpo: DEP </li></ul><ul><li>33 y/o AGC: colpo + ECC + HPV - EMB (+EMB > 35) </li></ul><ul><li>33 y/o AIS: hysterectomy </li></ul><ul><li>CIN II, III for adult: LEEP </li></ul><ul><li>CIN II for adolescent: observation Pap/colpo Q6mo until (-)x2 </li></ul>
  • 29. References <ul><li>Algorithms for abnl cerv CA (ASCCP's October 2007) Click here to download the PDF . </li></ul><ul><li>Algorithms for CIN (October 2007 ASCCP's Journal of Lower Genital Tract Disease. Click here to download the PDF </li></ul><ul><li>USPSTF: Cervical Cancer (Pap Smear): Screening (2003) </li></ul><ul><li>Obstetrics, Gynecology and Infertility: (Red) Handbook for Clinicians 6 th ed. (2007) p 375 </li></ul><ul><li>BETHESDA SYSTEM WEBSITE ATLAS http://nih.techriver.net/ </li></ul>

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