Cervical Cancer Screening


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My presentation on Cervical Cancer Screening protocol and recommendations to be given at Mt. Clemens Regional Medical Center on 5/25/09

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Cervical Cancer Screening

  1. 1. Screening for Cervical Cancer Sarah McCormick MSIII Kansas City University of Medicine and Biosciences
  2. 2. Cervical Cancer Risk Factors <ul><li>HPV strains 16 and 18 </li></ul><ul><li>Smoking </li></ul><ul><li>Immuno-suppression </li></ul><ul><li>Early age at first intercourse </li></ul><ul><li>Multiple sex partner </li></ul><ul><li>Obesity </li></ul><ul><li>Multiple pregnancies </li></ul><ul><li>Family history of cervical cancer </li></ul>
  3. 3. Screening <ul><li>Pap Smears </li></ul><ul><ul><li>Every woman who is sexually active or 21 yo </li></ul></ul><ul><ul><li>Annual tests from ages 21 to 30 </li></ul></ul><ul><ul><li>After age 30, pap tests may be given every 2 to 3 years, if the previous 3 tests have been negative, no history of CIN 2 or 3, and no increased risk (no DES exposure, not immuno-compromised) </li></ul></ul><ul><ul><li>>30 HPV testing maybe offered as alternative to cytology, HPV + cytology every 3 years </li></ul></ul><ul><ul><li>Samples the transition zone where the nonkeratinized stratified squamous epithelium (ectocervix) and simple columnar epithelium (endocervix) meet. </li></ul></ul><ul><ul><li>2 Types </li></ul></ul><ul><ul><ul><li>Papanicolaou Smear </li></ul></ul></ul><ul><ul><ul><li>Liquid Preparations </li></ul></ul></ul><ul><ul><ul><ul><li>Thin Prep 1996 (liquid)- most sensitive, viewed twice once by image viewer, then by a lab professional, only test FDA approved for G,C and HPV reflex testing </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Sure Path 2000 </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Mono Prep 2006 </li></ul></ul></ul></ul>
  4. 4. Why Screen? <ul><li>Evidence of screening effectiveness only shown from observational studies </li></ul><ul><ul><li>>50% woman with cervical cancer have never had a pap, were screen only randomly, or did not have a pap in the last 5 years. </li></ul></ul><ul><ul><li>Canadian study found inverse correlation between pap smears performed and a decrease in mortality rate from cervical and uterine cancer. </li></ul></ul><ul><ul><li>Woman without a pap smear in the last 5 years had triple the risk of having invasive cervical cancer </li></ul></ul><ul><ul><li>The IARC found a 90% reduction in cervical cancer incidence from screening adult females </li></ul></ul>
  5. 5. What Happens at the Lab? <ul><li>Smears are fed into automated systems to be read </li></ul><ul><li>Abnormal smears are manually read by a lab technician </li></ul><ul><li>10% negative smears are reread for quality assurance </li></ul>
  6. 6. Normal Pap Squamous and Endocervical Cells
  7. 7. Abnormal Pap <ul><li>Chlamydia infected cells </li></ul>Koilocytes (HPV infected cells) dark wrinkled nuclei surrounded by clear halo Cells demonstrating dysplasia
  8. 8. Bethesda Classification <ul><li>Developed to determine whether a finding was more likely to be cancerous or precancerous versus a finding that was unlikely to progress to cancer. </li></ul><ul><li>Classification </li></ul><ul><ul><li>ASC –Atypical Squamous Cells </li></ul></ul><ul><ul><ul><li>ASC-H (cannot exclude HSIL) </li></ul></ul></ul><ul><ul><ul><li>ASC-US (undetermined significance) </li></ul></ul></ul><ul><ul><li>LSIL (HPV, Mild dyslpasia, CIN 1) </li></ul></ul><ul><ul><li>HSIL (mod-severe dysplasia, CIN2,3, CIS) </li></ul></ul><ul><ul><li>AGC- atypical glandular cell (endometrial, endocervical) </li></ul></ul><ul><ul><li>AIS- endocervical adenocarcinoma in situ </li></ul></ul>
  9. 9. HPV Testing <ul><li>HPV is found in 70-80% cervical cancers, 82% adenocarcinomas, 70% squamous cell carcinomas of the female genital tract </li></ul><ul><li>Persistent HPV infections cause premalignancies </li></ul><ul><li>HPV testing with Pap is more sensitive than Pap alone. (94.6% vs 55.4%) </li></ul><ul><li>Not used as screening test alone due to its poor specificity as compared to the Pap. (94.1% vs 96.8%) </li></ul><ul><li>Better specificity in woman >30yrs old </li></ul><ul><li>According to the Population Based Screening Study Amsterdam HPV + Pap screening led to earlier detection of lesions </li></ul>
  10. 10. HPV Testing Continued <ul><li>Positive HPV refers to the finding of HPV 16 and 18 </li></ul><ul><li>Negative HPV results refer to the finding of no HPV, a finding of HPV strains not related to cancer, or no cells (bad sample) </li></ul><ul><li>HPV testing with Pap approaches 100% sensitivity but 10% false positive rate </li></ul><ul><li>Reflex HPV Test </li></ul><ul><ul><li>tests ASC-US for HPV from same sample as pap </li></ul></ul><ul><ul><li>80% of adolescents may test positive for HPV, so not as effective a test for adolescents </li></ul></ul>
  11. 11. Follow up <ul><li>Adult Women ASC-US/H </li></ul><ul><ul><li>Reflex HPV </li></ul></ul><ul><ul><ul><li>ASC-US + HPV positive- colposcopy </li></ul></ul></ul><ul><ul><ul><li>ASC-US with negative HPV- repeat Pap 12 mo (most likely inflammation or infection <2% premalignant) </li></ul></ul></ul><ul><ul><ul><li>Repeat Pap is ASC-US- colpo </li></ul></ul></ul><ul><ul><ul><li>ASC-H-colpo </li></ul></ul></ul><ul><li>Adolescents ASC </li></ul><ul><ul><li>-ASC-US (no reflex test due to high positive rate!)- f/u 12 mo repeat pap </li></ul></ul><ul><ul><li>If repeat is HSIL or greater-colpo </li></ul></ul><ul><ul><li>If (ASC, LSIL) repeat pap in 12 mo </li></ul></ul><ul><li>Combined HPV DNA + Pap </li></ul><ul><ul><li>For women >30 yo only, no more than q3yrs </li></ul></ul><ul><ul><li>HPV and cytology positive-colpo </li></ul></ul><ul><ul><li>HPV positive, cytology negative- repeat 12 mo </li></ul></ul><ul><ul><li>Persistently positive HPV-colpo </li></ul></ul>
  12. 12. Follow up LSIL <ul><li>Adult Women </li></ul><ul><ul><li>LSIL-colpo/biopsy (No HPV test needed) </li></ul></ul><ul><li>Adolescent Women </li></ul><ul><ul><li>LSIL-Repeat pap in 12 months if HSIL then colpo, if not repeat pap again in 12 months, if ASC-US or greater—colpo </li></ul></ul><ul><ul><ul><li>Why different? Usually it’s a transient HPV infection that will resolve within 24 months and the cancer rate in age group is zero </li></ul></ul></ul>
  13. 13. Follow Up HSIL <ul><li>Adult and Adolescent Women </li></ul><ul><ul><li>At very high risk of malignancy (>50% have CIN 2 or more) </li></ul></ul><ul><ul><li>Colpo with biopsy </li></ul></ul>
  14. 14. Follow up AGS and AIS <ul><li>AGC (Atypical Glandular Cells) and AIS (Adenocarcinoma In Situ) </li></ul><ul><ul><li>Colpo + biopsy </li></ul></ul><ul><ul><li>if >35 yo endometrial biopsy </li></ul></ul>
  15. 15. Colpo results <ul><li>CIN 1 Adult Women </li></ul><ul><ul><li>Follow up </li></ul></ul><ul><ul><li>LSIL/ASC lesions </li></ul></ul><ul><ul><ul><li>repeat cytology at 6 & 12 mo or HPV DNA test </li></ul></ul></ul><ul><ul><ul><li>If ASC or higher, or HPV positive – re-colpo </li></ul></ul></ul><ul><ul><ul><li>Resume routine screen once negative HPV or 2 negative smears </li></ul></ul></ul><ul><ul><ul><li>If persists >24 months can treat or observe for changes as patient decides (ablation/excision) </li></ul></ul></ul><ul><ul><ul><ul><li>Why? Only 9-16% go onto being malignancies </li></ul></ul></ul></ul><ul><ul><li>HSIL lesions </li></ul></ul><ul><ul><ul><li>Repeat cytology AND colposcopy at 6 and 12 mo </li></ul></ul></ul><ul><ul><ul><li>Resume routine screen once 2 negative colposcopies and cytologies </li></ul></ul></ul><ul><ul><ul><li>ASC or higher detected- excise </li></ul></ul></ul><ul><ul><ul><ul><li>Why? With HSIL preceding the CIN 1, there’s a chance that a CIN 2 or 3 lesion is being missed on colpo. Since CIN 2, 3 is usually related to HSIL, and CIN 1 usually is a LSIL lesion </li></ul></ul></ul></ul>
  16. 16. Colpo Results Continued <ul><li>CIN 1 Adolescent Women (<20 yo) </li></ul><ul><ul><li>Repeat cytology at 12 mo (then follow HSIL/LSIL procedure) </li></ul></ul><ul><ul><li>Only 0.4% progress to CIN 3 </li></ul></ul><ul><li>CIN 2, 3 Adult Women </li></ul><ul><ul><li>Ablation or Excision </li></ul></ul><ul><ul><li>Excise if: </li></ul></ul><ul><ul><ul><li>Suspected microinvasion, Unsatisfactory colposcopy)Lesion, extending into the endocervical canal,Endocervical curettage showing CIN or a glandular abnormality, Lack of correlation between the cytology and colposcopy/biopsies, Suspected adenocarcinoma in situ, Colposcopist unable to rule out invasive disease, Recurrence after an ablative or previous excisional procedure </li></ul></ul></ul><ul><li>CIN 2, 3 Adolescent Women </li></ul><ul><ul><li>Repeat colpo and cytology q6months for 24 months </li></ul></ul><ul><ul><li>2 normal results-return to routine screening </li></ul></ul><ul><ul><li>Persistant CIN2-observation </li></ul></ul><ul><ul><li>Persistant CIN3-Ablation/excision </li></ul></ul>
  17. 17. Discontinuing Screening <ul><li>USPSTF </li></ul><ul><ul><li>65 yo if not at high risk </li></ul></ul><ul><li>ACS </li></ul><ul><ul><li>70 yo with 3 negative test and no positives within last 10 years </li></ul></ul><ul><li>American College of Obstetricians and Gynecologists (ACOG) </li></ul><ul><ul><li>Inconclusive evidence </li></ul></ul>
  18. 18. References <ul><li>www.thinprep.com </li></ul><ul><li>http://www.pathguy.com/lectures/women.htm </li></ul><ul><li>www.uptodate.com </li></ul>