1. THE MANAGEMENT OF
WOMEN WITH MINOR
SMEAR ABNORMALITIES
Dr Grainne Flannelly
Colposcopy Course on line
BSCCP
2. Objectives
• If you have a low grade smear what are the chances of
having High grade CIN?
• What are we trying to achieve in managing these women?
• Management strategies – example of policies in evolution
• How should these women be managed at Colposcopy?
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3. Aim of cervical screening –public health
perspective
Reduce the
incidence and
mortality of cervical
cancer
Detection and
treatment of high
grade precancerous
lesions
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4. Aim of Cervical screening - woman's
perspective
To achieve a normal
smear result!!!
In the presence of any
uncertainty to get
further information
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5. Low grade cytological abnormalities in the
NHSCSP
In England in
2009, 239,907
women got a smear
result with minor
abnormality
Most of these
women do not have
high grade CIN
Category Number
Inadequate 105,258
Negative 3,215,943
Borderline 153,471
Mild dyskaryosis 86,436
Moderate Dyskaryosis
21,839
Severe Dyskaryosis
24,186
?Invasive cancer 929
Glandular 1,882
Total 3,609,944
(NHS statistics 2009/2010)
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6. In England in 2009, 51% of referrals to colposcopy were for
low grade abnormalities
Inadequate
2%
BNA
19%
Mild
32%
Moderate
13%
Severe
15%
Glandular
0%
Clinical
urgent
1% Clinical non
urgent
14%
Other
4%
Referrals to colposcopy
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7. Management Of Low Grade Smears; In Search Of
Balance
Risk of
Cancer
Risk of
Harm
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8. Management options; the tools
Repeat
smears in the
community
Colposcopy
and biopsy
Triage with
HPV tests?
Traditional management
• Cytological surveillance with
colposcopy for repeated low
grade.
Recent guidelines
• Immediate colposcopy is
ideal for mild dyskaryosis”
News: April 2011
• Introduction of HPV Triage
for low grade abnormalities
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10. Advantages of early colposcopy strategy
Recognition of covert CIN II-III
Treatment/Eradication of abnormal cells
Return to normal cytology
Reassurance for woman
Reassurance for doctor
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11. Low grade abnormalities and the
natural history of HPV infection
•Transmission by
sex
•Lifetime risk 80% -
most within 18
months
Exposure
•Transient
•Most resolve
within 18 months
Infection
•Less than 20%
persist
•No antibodies
detectable
Persistence
•Virus integrates
into host DNA
Malignant
Transformation •Loss of tumour
supressor gene
E2
•Uncontrolled cells
division
CIN
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12. Natural history;ASCUS /Borderline smears are
associated with an increased risk of high grade
CIN
• Risk of High grade CIN 10.1%,
• Risk of invasive cancer 0.62%,
• Relative risk of 15-30 for high grade
CIN/Cancer
ASCUS:
• Relative risk of 3.5 for high grade
CIN/Cancer
ASCUS index
smear followed by
a normal smear
Nygard,J.F., Acta Cytol, 2003.
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13. Natural history: Mild dyskaryosis - risk of
subsequent high grade disease?
Risk of Subsequent
High Grade
• Nassiel (n=555) 26%
• Fletcher (n=666) 14%
• Robertson (n=1347) 19%
Risk of cancer on
surveillance
• 0.5% (Robertson)
• 1% (Kirby)
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14. Woman's attitudes to mildly abnormal smear
result
47% of women
in immediate
colposcopy
group thought
they had cancer
33% of women
in the
surveillance
group thought
they had cancer
Following an
educational
interview
• Most women
with LSil chose
Colposcopy
Following an
educational
interview
• Most women with
ASCUS chose
virus testing
(ALTS Study)
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15. What about including patient choice?
476 women randomised to either
surveillance or choice between
immediate colposcopy or
surveillance
Both groups of
women showed
high levels of
anxiety initially.
No difference
between the two
groups
Fewer women
defaulted in the
choice arm
(Kitchener, 2004)
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16. Cytological Surveillance is less efficient
than immediate colposcopy - Tombola
Detection of high grade
disease
• Immediate colposcopy
Cumulative detection -
79/1000 person years
• Cytological surveillance
Cumulative detection
58/1000 person years.
Anxiety
• Both strategies were
associated with anxiety
• No difference between two
arms
(BMJ, 2009)
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17. Time for a radical change in approach?
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18. HPVAs Triage For Women WithASCUS;AMeta-
analysis
• Sensitivity 94.8%
• Specificity 67.3%
HPV testing
(HC 2)
• Sensitivity 81.8%
• Specificity 57.6%
Cytology
The addition of HPV testing to cytology increased sensitivity
Arbyn et al, J Natl Cancer Inst. 2004 Feb 18;96(4):280-93.
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19. HPV testing increases the numbers referred
for colposcopy
3488 women with
ASCUS/LSIL
HPV Testing
• 95.9% sensitivity for high
grade CIN
Would have resulted in
56% of women being
referred for colposcopy
(ALTS study, Solomons, 2001)
Size of impact depends on preexisting policy regarding women with
mild dyskaryosis
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20. NHS Triage Pilot in Three laboratories BMJ 2006
• Repeat smears reduced significantly (70-87%)
• Referrals to colposcopy doubled
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21. Risks of Triage; Psychosocial
HPV triage has the
potential to
increase anxiety in
women
• It could result in
an explicit
diagnosis of a
sexually
transmitted
infection
• Increased rate of
Solutions
• High quality
information
• Adequate
colposcopy
capacity to
maintain low
waiting times
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22. Psychological Impact; Australia
• HPV positive result
was associated
with initial distress
as was repeat pap
testing
• Levels of distress
decreased with
time
Mc Caffrey K, BMJ 2010
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23. Women with low grade abnormalities; management
at colposcopy- Tombola
Comparison of immediate
LLETZ versus biopsy and
deferred treatment
• 60% of LLETZ showed
no CIN
• No difference in
cumulative detection of
CIN 2/3
Targeted punch
biopsies with
• Subsequent
treatment for
CIN2/3
• Cytological
surveillance for
grade I or less
Immediate
treatment with
LLETZ should be
avoided
BMJ 2009;339:b2548
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24. Management at Colposcopy
NewAlgorithm - NHSCSP Triage
Borderline/Mild dyskaryosis
HPV +
Colposcopy+-
Biopsy
Abnormal
CIN2/3
Treatment
CIN1
Repeat smear
in 12 months
Normal
HPV -
Routine
Recall
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25. Evidence for early discharge if colposcopy
normal
965 women in NHS Pilot sites with low grade cytology and HPV
+ with negative colposcopy with or without biopsy at recruitment
• 94.6% of cases of CIN2/3 were detected at the first visit to colposcopy
• 42 cases of CIN 2/3 were identified within 3 years
Kelly et al, BJOG May 2011)
Good quality colposcopy will be essential if these results are to be
reproducible in routine practice !
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26. Conclusions
The road ahead Key questions
• Role of colposcopy –
especially negative
colposcopy
• Compliance
• New tests – biomarkers?
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