Cervical Cancer Screening

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

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Cervical Cancer Screening

  1. 1. Cervical Cancer Screening Cases by Clinton Pong Using the 2007-8 Guidelines, accessed 1/4/2009.
  2. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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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