Current knowledge and state of the art about management of abnormal cervical Cancer screening tests and cancer precursors for health providers in low-income settings is presented.

1. Cervical Screening
State of the Art 2016
Dr Dirk Grothuesmann
http://dg-maternalhealth.de/

2. Expected worldwide Cervical Cancer 2020
2002 2020 2020
(% Increase) (% Burden)
World 493.000* 702.500 100%
(+42%)
Less developed Areas 409.000 639.500 83%
(+56%)
More developed Areas 83.000 92.500 17%
(+11%)
Parkin and Bray, 2006
*530,000 cases in 2008; Arbyn M, et al

3. Cervical Screening

4. Champions of Prevention
Georgios Nikolaou
Papanikolaou *1883 –1962
Hans Hinselmann
*1884 - 1959
Harald zur Hausen
*1936 -

5. Squamoculmnar Junction

6. Squamoculmnar
Junction
Columnar Epithelium
Squamous Epithelium

7. Squamoculmnar Junction
Sellors and Sankaranarayanan, 2003

8. Squamoculmnar Junction

9. Transformation Zone
• The Normal TZ is located between the OSCJ and the colposcopically-
visible, new SCJ
• Dynamic Area
• Carcinogenic factors (HPV, carcinogenic substances e.g. smoking) are
incorporated into vulnerable immature metaplastic epithelia

10. Squamoculmnar Junction/
Transformation zone 1,2,3,
Visibility Line
IFCPC, 2011

11. ASC-US Atypical squamous cells of
undetermined significance
ASC-H Atypical squamous cells –
cannot exclude HSIL
The Bethesda System (TBS), 2001
THE BETHESDA SYSTEM WEBSITE ATLAS, 2003

12. LSIL – Low-grade Squamous Intraepithelial Lesion HSIL – High-grade Squamous Intraepithelial Lesion
The Bethesda System (TBS), 2001

13. AGC-Atypical Glandular Cells
The Bethesda System (TBS), 2001

14. Terminology
Difference between the terms cervical intraepithelial lesion and squamous
intraepithelial lesion
• Squamous intraepithelial lesion (SIL) is used to describe Pap test result
• SIL is not a diagnosis of precancer or cancer
• A cervical biopsy is needed
• Cervical intraepithelial lesion (CIN) used to report cervical biopsy results
• CIN 1 is used for mild (low-grade) changes
• CIN 2 is used for moderate changes
• CIN 3 is used for more severe (high-grade) changes
Moderate and high-grade changes can progress to cancer

15. Different Types of abnormal Pap Test Results
• Atypical squamous cells of undetermined significance (ASC-US)— mostly a
sign of an HPV infection (most common abnormal test result)
• Low-grade squamous intraepithelial lesion (LSIL)—mildly
abnormal.Usually is caused by an HPV infection, goes away on its own.
• High-grade squamous intraepithelial lesion (HSIL)—more serious changes
in the cervix. More likely associated with precancer and cancer.
• Atypical squamous cells, cannot exclude HSIL (ASC-H)—changes that raise
concern for the presence of HSIL.
• Atypical glandular cells (AGC)—Glandular cells also are present inside the
uterus. Changes in glandular cells that raise concern for the presence of
precancer or cancer.

16. Progression of CIN Categories
HIGH-GRADE SQUAMOUS LESION
(HSIL) — HSIL refers to moderate to severe
changes in the cells of the cervix. The risk
that these abnormalities reflect precancerous
changes is as high as 20.8%, and the risk of
cervical cancer is as high as 1.4%
Sellors JW, Sankaranarayanan, R, 2003

17. What Testing is needed after an abnormal cervical
Cancer Screening Test
• Repeat Pap test or Co-Test (Pap test and a test for high-risk types of
HPV)—recommended as a follow-up to some abnormal test result
• HPV Test—presence of the HPV types linked to cervical cancer
• Colposcopy
• Biopsy
• Endocervical sampling

18. Adolescents Needs
• Care for contraception and STI screening/treatment
• NO Pap test
• No speculum examination for asymptomatic women
• STI Testing can be done using urine

19. Rationale for Co-Testing 30 – 64
• Increased detection of prevalent CIN 3
• Decreases CIN 3 in subsequent screening rounds
• Enhances detection of adenocarcinoma (AIS)
• Minimizes numbers of colposcopies

20. Screening for Ages 21 - 29
• Cytology every 3 years
• HPV testing should not be done for screening
• Not as a component of Co testing
• Not as a standard alone screening

21. Rational of avoiding HPV test among Women Ages
21 - 29
• Prevalence of carcinogenic HPV approaches 20% in teens and early
20s
• Most carcinogenic HPV resolve without intervention
• Identifying carcinogenic HPV that will resolve spontaneously will lead
to repeated call-back, anxiety and interventions without benefit

22. Screening for Women Ages 30 - 64
• Cytology plus HPV (Co-testing) every 5 years is
preferred
• Cytology every 3 years is acceptable

23. Rationale for Co-testing Ages 30 -64
• Increased detection of CIN 3
• Decreased CIN 3 in subsequent screening rounds
• Enhances detection of adenocarcinoma in situ (AIS)
• Minimizes the increased numbers of colposcopies

24. Why not Co-testing all Women Ages 30 – 64
Lack of access to co-testing
• Financial
• Logistical
Cytology remains effective but:
• Requires more frequent visits
• Requires more colposcopies for equivocal results

25. Managing ASC-US/HPV negative tests
“Women with ASC-US cytology and negative HPV test result
should continue screening with age-specific guidelines “
• CIN 3 od ASC-US/HPV neg < 2% is below threshold for colposcopy

26. Managing HPV+/Cytology- Cotests
Women contesting HPV+/Cytology- :
• Repeat Cotesting in 12 month
• Immediate HPV genotype specific testing for HPV 16/18
Direct referral to colposcopy not indicated

27. Repeat Cotest in 12 Month
• If either test is positive, refer to colposcopy
• If both tests are negative return to routine screening

28. Immediate HPV Genotyping
• If HPV 16 or HPV 16/18 are positive refer to Colposcopy
• If HPV 16 or HPV 16/18 are negative repeat cotest in 12
month
• If ether repeat test is positive: Colposcopy
• If both test are negative return to routine screening

29. When to stop Screening
Stop screening at 65 with adequate negative
screening (no CIN in last 20 years)
This means:
• 3 consecutive Pap screenings
• 2 consecutive neg. HPV tests

30. Stop Screening at 65
Screening “should not resume even it woman
reports having a new sexual partner”
When not to stop:
• If history of CIN2, CIN3, AIS (in these cases at least 20 years screening)
ASCCP Guidelines, 2012

31. Cervical Cancer Screening and Follow Up
The American College of Obstetricians and Gynecologists, 2016

32. Cervical Cancer Screening and Follow Up

33. Cervical Cancer Screening and Follow Up

34. Literature
Arbine et al, 2011, Worldwide burden of cervical cancer in 2008. Ann Oncol, 22(12), 2675 - 86
ASCCP Guidelines, 2012, from http://www.asccp.org/guidelines
Sellors JW, Sankaranarayanan, R, 2003, Colposcopy and Treatment of Cervical Intraepithelial Neoplasia: A Beginners’ Manual, from
http://screening.iarc.fr/doc/Colposcopymanual.pdf
Parkin DM and Bray, 2006, Chapter 2: The burden of HPV-related cancers, Vaccine, 31;24 Suppl 3:S3/11-25
IFCPC, IFCPC Nomenclature 2011, from http://www.ifcpc.org/en/healthcare-professionals/resource-material/2011-ifcpc-nomenclature
THE 2001 BETHESDA SYSTEM, from http://nih.techriver.net/bethesdaTable.php
2011 Colposcopic Terminology of the International Federation for Cervical Pathology and Colposcopy, Bornstein, j et al., OBSTETRICS & GYNECOLOGY, 120, (1), 166- 172
from http://jgcs21.umin.jp/colposcopy_02.pdf
2012 Updated Consensus Guidelines for the Management of Abnormal Cervical Cancer Screening Tests and Cancer Precursors, Steward ML et al., 2013, Journal of
Lower Genital Tract Disease, Volume 17, Number 5, 2013, S1YS27
The American College of Obstetricians and Gynecologists, 2016, Abnormal Cervical Cancer Screening Test Results, FAQ187, from
http://www.acog.org/Patients/FAQs/Abnormal-Cervical-Cancer-Screening-Test-Results
THE BETHESDA SYSTEM WEBSITE ATLAS, 2003, from http://nih.techriver.net/

35. Aim of my Project
Dr. Dirk Grothuesmann Consultancy
Improving Maternal Health and Gynecology Services by Training Health Care
Providers: Relaying on standardized training modules I teach evidence-based
obstetrical procedures, gynecology surgery and related evaluation tools to local
personnel in developed and developing countries. Completing the programs
offered, skills gained enable to serve women in need in any requested setting.
http://dg-maternalhealth.de/index2.html

37. http://dg-maternalhealth.de/
Dr Dirk Grothuesmann
Consultancy