Cervical cancer screening module 3


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Cervical Cancer Screening Module 3 - from Massachusetts Medical Society. Copyright © 2013. Massachusetts Medical Society, 860 Winter Street, Waltham Woods Corporate Center, Waltham, MA 02451-1411

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Cervical cancer screening module 3

  1. 1. Cervical Cancer Screening Module III Techniques of Screening Screening Guidelines Special Screening Situations
  2. 2. Cervical Cancer Screening Techniques of Screening Physical Exam Visual Inspection with Acetic Acid Pap Smear HPV Testing Cervical Biopsies Module III
  3. 3. Techniques of Screening Physical Exam 1. Visually examine the vulva and perianal region 2. Insert the speculum into the vagina 3. Visually examine the cervix and the walls of the vagina 4. Palpate the cervix and the walls of the vagina. 5. Palpate the parametria and uterosacral ligaments by rectovaginal exam Module III
  4. 4. Techniques of Screening Visual Inspection with Acetic Acid With the speculum in the vagina and the cervix visualized, apply 3% acetic acid using a sponge (ALERT: confirm that the acetic acid has been diluted. 100% acetic acid will cause third degree burns) Wait 60 seconds and then visually examine . Dysplastic lesions are nuclear dense. The dehydration of the mucous membrane will temporarily cause dysplastic lesions to look white Module III
  5. 5. Visual Inspection Author, year of publication, country of study No. of participants Sensitivity, % (95% CI) Specificity, % (95% CI) University of Zimbabwe/JHPIEGO [5], 1999, Zimbabwe 2148 77 (70–82) 64 (61–66) Denny et al. 2000, South Africa 2885 67 (56–77) 84 (82–85) Belinson et al. [24], 2001, China 1997 71 (60–80) 74 (71–76) Denny et al. [8], 2002, a,c South Africa 2754 70 (59–79) 79 (77–81) Cronjé et al. [9], 2003, South Africa 1093 79 (69–87) 49 (45–52) 54,981 79 (77–81) 86 (85–86) Sankaranarayanan et al. [25], 2004 India and b,c Africa Sensitivity – 67-79% Specificity – 49-86% Technique :Place Speculum Apply 3-5% Acetic Acid Wait at least 1 Minute; record Observations Module III
  6. 6. Techniques of Screening Pap Smear With a spatula, rotate the spatula 360 degrees around the exocervix With a cytobrush, place the brush within the endocervix and rotate 360 degrees Apply both the spatula and cytobrush to a slide and then apply fixative Or place spatula and cytobrush into liquid based solution and break off the tips Module III
  7. 7. SCREENING  conventional cytologic sampling  Thin layer (or liquid-based) cytology     ThinPrep (1996) AutocytPrep (1999) SurePath (2000) MonoPrep (2006)  liquid-based : other diagnostic assessments (only Thin Prep is FDA approved )    testing for gonorrhea chlamydia HPV Module III
  8. 8. Sources of potential error in the Pap smear The clinician may not sample the area of cervical abnormality. The abnormal cells may not be plated on the slide or transferred to the liquid medium. The cells may not be adequately preserved with fixative. The cytologist may inaccurately report the findings The cytopathologist may not identify the abnormal cells. Module III
  9. 9. Techniques of Screening HPV Testing HPV testing should be confined to testing for high risk (oncogenic) subtypes HPV testing for low risk (nonocogenic) subtypes has NO role in the evaluation of abnormal pap smears Module III
  10. 10. HPV TESTING p16 cytology P16 cytology can be used as a triage test in HPV-positive women. P16 is a marker of HPV oncogene activity that is independent of carcinogenic HPV tyoe Carozzi . Lancet Oncol 2012 Of 1170 HPV positive women,493 (42%) overexpressed p16 at baseline At baseline, 55 of these 493 women had CIN3 (9.7%) Compared to p16 negative over expression, positive p16 had a longitudinal sensitivity of 82.4% Module III
  11. 11. Techniques of Screening Colposcopy &Cervical Biopsies Module III
  12. 12. Cervical Cancer Screening Screening Guidelines Screening Guidelines can be separated into two sections General guidelines for when to pap smears and on whom What follow up and intervention is recommended based on pap sear results Module III
  13. 13. Cervical Cancer Screening Screening Guidelines Guidelines are only for women at average risk for cervical cancer. These guideline do not apply to women with: history of cervical cancer In Utero exposure to DES who are immuno-compromised organ transplantation, chronic steroid use, chemotherapy HIV positive Module III
  14. 14. Screening Guidelines When to perform pap smear Do not screen before age 21 years Screening should start at age 21 Screening guidelines are age dependent Annual pap smears in women without a history of premalignant or malignant lower genital disease are no longer recommended Recommended Screening practices should not change on the basis of HPV vaccination status Module III
  15. 15. PREVALENCE OF CIN 3 OR GREATER BY AGE MOORE 2008 CIN3 OR GREATER LESS THAN CIN 3 TOTAL <50 YEARS 189 (71%) 77 (29%) 266 >50 YEARS 51 (59%) 35 (41%) 86 TOTAL 240 112 352 Patients older than 50 had Signif higher Prevalence CIN3 Module III
  16. 16. Vaccination Against HPV Recommend routine HPV vaccination for females aged 11 to 12 years Recommend routine vaccination for females aged 13 to 18 years to “catch-up” those who missed earlier screening Insufficient data to recommend for or against universal vaccination of females aged 19 to 26 years Module III
  17. 17. Screening Guidelines When to perform pap smear Ages 21- 29 years: PAP SMEAR screening every three years No screening HPV testing HPV testing only for evaluation of atypical squamous cells of uncertain significance Module III
  18. 18. Screening Guidelines When to perform pap smear Ages 30 – 65 years: screening with both PAP SMEAR and HPV testing every five years (preferred) Or PAP SMEAR testing every three years (accepted) Module III
  19. 19. Screening Guidelines When to perform PAP SMEAR Ages greater than 65: No Further Pap Smear Testing who have had > 3 consecutive normal pap tests or > 2 consecutive negative HPV tests and pap tests in last 10 years with the most recent pap occurring within the last 5 years or women who have had hysterectomies for benign disease Module III
  20. 20. Cervical Cancer Screening Screening Guidelines In 2012 the American Society for Colposcopy and Cervical Pathology (ASCCP) published new guidelines for management of pap smear results Guidelines should never replace clinical judgment Module III
  21. 21. ASCCP Guidelines Guidelines for management of abnormal pap smears are different by the following age categories: Ages 21- 24 Ages over 30 Guidelines for management of abnormal pap smears are different for the pregnant woman (see screening: special situations) Module III
  22. 22. ASCCP Guidelines Unsatisfactory Cytology Repeat pap smear after 2 to 4 months Refer to colposcopy for persistently unsatisfactory pap smears http://www.asccp.org/Portals/9/docs/Algorithms%207.30.1 3.pdf (Page 4)
  23. 23. ASCCP Guidelines Absent Endocervical Cells For ages 21-29: perform routine screening For ages > 30 : HPV testing http://www.asccp.org/Portals/9/docs/Algorithms%207.30 .13.pdf (Page 5)
  24. 24. ASCCP Guidelines Age > 30: Cytology Negative & HPV positive For HPV 16 and 18: colposcopy Repeat co-testing in one year is acceptable http://www.asccp.org/Portals/9/docs/Algorithms%207.30 .13.pdf (Page 6)
  25. 25. Risk of HSIL with + HPV HR 2% (52 of 2562 over 10 years) Khan 2005 3% (88 of 2941 over 10 years) Castle 2002 1.2% (30 or 2562 over 10 years) Miller 2002 Module III
  26. 26. ASCCP Guidelines ASC - US Repeat pap smear in one year, if ASC-US again: refer to colposcopy OR Upfront HPV testing, if HPV positive: refer to colposcopy http://www.asccp.org/Portals/9/docs/Algorithms%207.30 .13.pdf (Page 7)
  27. 27. ASCCP Guidelines Ages 21-24 – ASC-US or LSIL HPV testing: If HPV negative: return to routine testing If HPV positive: repeat pap smear in one year http://www.asccp.org/Portals/9/docs/Algorithms%207.30. 13.pdf (Page 8)
  28. 28. ASCCP Guidelines ASC-US ages 21-24 Initial Management Cytology alone in 12 months is preferred Reflex HPV testing acceptable If HPV positive, repeat cytology one year If HPV negative, return to routine screening with cytology alone in three years Module III
  29. 29. ASCCP Guidelines LSIL If LSIl and HPV negative, repeat pap smear in one year If LSIL and HPV positive: refer to colposcopy http://www.asccp.org/Portals/9/docs/Algorithms%207.30.13.p df (Page 9)
  30. 30. ASCCP Guidelines ASC-H Refer all ASC-H to colposcopy http://www.asccp.org/Portals/9/docs/Algorithms%207.30.13.p df (Page 11)
  31. 31. ASCCP Guidelines Ages 21-24 -ASC-H If colposcopy is negative, repeat pap smear and colposcopy every six months for two years If HSIL is found, acceptable to monitor for one year. If lesion is persistent for one year, treat with excision http://www.asccp.org/Portals/9/docs/Algorithms%207.30.13.p df (Page 12)
  32. 32. ASCCP Guidelines HSIL Immediate LEEP or colposcopy http://www.asccp.org/Portals/9/docs/Algorithms%207.30.13.p df (Page 13)
  33. 33. ASCCP Guidelines AGC All women with AGC need colposcopy Women > AGC also need an endometrial biopsy http://www.asccp.org/Portals/9/docs/Algorithms%207.30.13.p df (Page 14)
  34. 34. ASCCP Subsequent management of AGC after colposcopy For CIN 2 but no glandular lesion, manage per ASCCP guideline For negative biopsies, repeat pap and HPV testing yearly for two years For preinvasive glandular lesion, treat by excisional biopsy http://www.asccp.org/Portals/9/docs/Algorithms%207.30.13.p df (Page 15)
  35. 35. Histologic Outcome after Atypical Glandular Cells Obstet Gynecol 2010; 115:243-248 Age < 50 years Age < 50 years Age > 50 years Age > 50 years HPV neg (n=656) HPV pos (n=269) HPV neg (n=420) HPV pos (n=497) CIN 2 10 34 4 9 CIN 3 3 42 1 5 Cervical 4 adenoca in situ 29 1 4 Cervical SCC 2 10 1 6 Cervical adenoca 0 7 1 2 Endometrial atypical 10 0 10 0 Endo CA 10 3 44 0 Other cancers 0 0 6 0
  36. 36. ASCCP Guidelines Biopsy: CIN I No treatment Repeat pap smear and HPV testing in one year http://www.asccp.org/Portals/9/docs/Algorithms%207.30.13.p df (Page 16)
  37. 37. ASCCP Guidelines Biopsy: CIN I after Pap ASC-H or HSIL Treatment not recommended Repeat pap smear and HPV testing yearly for two years http://www.asccp.org/Portals/9/docs/Algorithms%207.30.13.p df (Page 17)
  38. 38. ASCCP Guidelines Ages 21-24 – Biopsy CIN I Treatment not recommended After ASC-US or LSIL pap: Repeat pap smear After ASC-H or HSIL pap: repeat pap smear and colposcopy every six months for one year If colposcopy is inadequate: excisional procedure http://www.asccp.org/Portals/9/docs/Algorithms%207.30.13.p df (Page 18)
  39. 39. ASCCP Guidelines Biopsy: CIN 2-3 Recommend excisional procedure http://www.asccp.org/Portals/9/docs/Algorithms%207.30.13.p df (Page 19)
  40. 40. ASCCP Guidelines Young women, Biopsy: CIN 2-3 Excisional procedure OR Pap smear and colposcopy every six months for one year http://www.asccp.org/Portals/9/docs/Algorithms%207.30.13.p df (Page 20)
  41. 41. ASCCP Guidelines Biopsy: AIS Excisional procedure Hysterectomy is preferred treatment http://www.asccp.org/Portals/9/docs/Algorithms%207.30.13.p df (Page 21)
  42. 42. Cervical Cancer Screening Special Screening Situations Immunosuppression Pregnancy After Hysterectomy After Treatment for Cervical Cancer After Pelvic Radiation Challenging Anatomy History of Sexual Assault In Utero DES (diethylstilbestrol) exposure Module III
  43. 43. Special Screening Situations Immunosuppression Human Immunodeficiency Virus Organ Transplant Chronic Steroid Use Module III
  44. 44. Immunosuppression Human Immunodeficiency Virus Women with HIV infection are at high risk for preinvasive lower genital tract disease and cervical cancer They are high risk for persistent HPV infections They should be screened by PAP SMEAR twice in the first year and then yearly thereafter Module III
  45. 45. Immunosuppression Organ Transplant Women who are on high dose immunosuppressants are at high risk for lower genital tract neoplasia They should be screened by PAP SMEAR twice in the first year and then yearly thereafter Module III
  46. 46. Immunosuppression Chronic Steroid Use Chronic steroid use can lead to a reduction in the clearance of HPV infection They should be screened by PAP SMEAR twice in the first year and then yearly thereafter Module III
  47. 47. Special Screening Situations Pregnancy Pap smear is performed at first prenatal visit and at the six week post partum visit Abnormal Pap smears are evaluated in a similar manner to non-pregnant women Module III
  48. 48. Special Screening Situations Pregnancy: ASC-US pap Identical to non-pregnant women It is acceptable to defer colposcopy until 6 weeks postpartum Endocervical curettage is unacceptable For pregnant women with no cytologic, colposcopic , or histologic findings of CIN, postpartum follow-up is recommended Module III
  49. 49. ASCCP Guidelines Pregnant with LSIL Colposcopy in pregnancy Treatment of all preinvasive lesions delayed until after delivery http://www.asccp.org/Portals/9/docs/Algorithms%207.30.13.p df (Page 10)
  50. 50. Special Screening Situations After Hysterectomy Cervical cancer screening is not indicated if removal of cervix or entire uterus in women with no history of cervical cancer or preinvasive disease. Women who have undergone a subtotal hysterectomy with preservation of the cervix should follow screening recommendations of average risk women Module III
  51. 51. Special Screening Situations After Treatment for Cervical Cancer No age cut off for stopping screening Women should undergo pap smears every 3 to 4 months for the first two years after treatment for cervical cancer. Pap smear screening is performed every 6 months from years 2 to 5 after treatment Annual pap smear screening five years after treatment Module III
  52. 52. Special Screening Situations After Pelvic Radiation There is a higher risk of radiation induced malignancies after pelvic radiation. Annual pap smear screening should be performed in women who receive pelvic radiation for all cancer types (lymphoma, cervical cancer, endometrial cancer, rectal and anal cancer) Module III
  53. 53. Special Screening Situations Challenging Anatomy Vaginismus Vaginal Atrophy Pelvic Floor Prolapse Vaginal Agglutination Cervical Stenosis Obesity Module III
  54. 54. Challenging Anatomy Vaginismus Vaginismus is the painful and involuntary contraction of vaginal muscles Causes: sexual assault, vulvar vestibulitis, inflammatory conditions of the pelvic floor such as diverticulitis Adequate pelvic examination and pap smear may require an examination under anesthesia Module III
  55. 55. Challenging Anatomy Vaginal Atrophy Consideration should be given to a short course of estrogen vaginal cream prior to performing a pap smear Module III
  56. 56. Challenging Anatomy Pelvic Floor Prolapse Uterine prolapse can place the cervix at the introitus leading to trauma and cornification of the cervix Module III
  57. 57. Challenging Anatomy Vaginal Agglutination Vaginal agglutination can occur after radiation, trauma, surgery, and infection Evaluation by examination under anesthesia should be considered Use of vaginal dilators and estrogen vaginal cream should be considered Module III
  58. 58. Challenging Anatomy Cervical Stenosis Cervical stenosis is defined as the inability to place a cutip or cytobrush within the endocervix There is increased risk of a false negative pap smear Recommendation: Dilation of cervix In a postmenopausal woman, consideration of a transvaginal ultrasound to evaluate the endometrial cavity for fluid Module III
  59. 59. Challenging Anatomy Obesity Obesity can in some women lead to difficulty examining the cervix due to discomfort, vaginal wall redundancy, or increased vaginal length. Sensitive use of larger speculums and retraction of the labia by an assistant can be helpful in optimally postioning the speculum to visualize the cervix Module III
  60. 60. Special Screening Situations History of Sexual Assault Women who have survived the trauma of sexual assault should be screened for sexually transmitted disease including HIV testing. For women who are older than age 30, high risk HPV testing should be offered. Consideration should be given for a pap smear regardless of the timing of their previous pap smear test within six months of sexual assault for women older than age 21 years. Module III
  61. 61. Special Screening Situations In Utero DES (diethylstilbestrol) exposure The cohort of women exposed to Utero DES were born before 1980. In- They have a twofold increased risk of cervical dysplasia Based on clinician judgment, they should be screened at least every three years if they have had three consecutive normal pap smears Module III
  62. 62. CERVICAL CANCER SCREENING MODULE III CONCLUSIONS -This module summarizes the screening recommendations for the average risk patient. -The full algorithms can be reviewed on the asccp website: http://www.asccp.org/Guidelines -Providers must be cognizant of special screening situations and tailor evaluation to each patient, their particular anatomy, and their particular risk factors.