Cervical Cancer Screening

1
Cervical Cancer Screening

• District I ACOG
• Medical Student Education Module
• Last Updated January 1, 2011

2
Cervical Cancer ScreeningModule Outline

• Brief review of Cervical Cancer
• Brief review of HPV
• What is a Pap Smear? How To Perform?
• Some Pap Terminology
• Who to screen and when
• Abnormal Pap ? What now?

3
Cervical Cancer

• Incidence/Prevalence
• 3rd most common GYN cancer in developed world
• 11,270 new cases in 2009
• 4,070 deaths in 2009
• Most common GYN cancer in developing countries
• 500,000 new cases annually
• 240,000 deaths annually

• Signs Symptoms
• Abnormal Vaginal Bleeding
• Postcoital Bleeding
• Vaginal Discharge (watery, mucoid, purulent,
  malodorous)

4
Cervical Cancer

• Risk Factors
• Early onset of sexual activity
• Multiple sexual partners
• High-risk sexual partner
• History of sexually transmitted diseases
• Smoking (not adenocarcinoma)
• High parity
• Immunosuppression
• Low socioeconomic status
• Prolonged use of oral contraceptives
• Hx of vaginal or vulvar cancer

• Vast majority of cases are caused by persistent
  high risk HPV infection
• Most common Histologies
• Squamous Cell Carcinoma
• Adenocarcinoma
• Adenosquamous

5
Human Papillomavirus

• Lifetime cumulative risk of acquiring HPV in
  sexually active persons 80
• Spectrum of HPV
• Condyloma Acuminata
• Cervical Dysplasia
• Cervical Cancer
• gt 150 different types of the virus
• 15 High Risk Types (16, 18, 31, 33, 35, 39, 45,
  51, 52, 56, 58, 59, 68, 73, 82)
• 16, 18 ? gt 70 all cervical cancers
• 6, 11 ? 90 genital warts
• HPV Vaccine Gardasil
• Active against 16, 18, 6, 11
• FDA approved in US for girls boys ages 9-26

6
What is a Pap Smear?

• Papanicolaou test - 1941
• Dr. Babes Dr. Papanikolaou
• gt 50 decrease in rates of cervical cancer in
  developed countries over last 30 yrs due to
  widespread screening
• A sample cervix cells from transformation zone.
• junction of endocervix and ectocervix
• Use of spatula /- cytobrush, broom stick
• 2 types conventional, liquid-based
• Send for cytologic interpretation

7
How to perform a Pap smear

• Conventional smear
• direct application of cells to a slide
• Liquid Based smear
• 90 of all Pap smears in US
• Transfer cells to a liquid preservative. Liquid
  processed in laboratory and transferred to a slide

8
Bethesda System (2001) Classification

• Specimen Adequacy
• Is the transformation zone present ??
• Negative for intraepithelial lesion or malignancy
  (NILM, NIELM)
• Squamous Cell
• Atypical squamous cells
• Undetermined Significance (ASC-US)
• Not exclude High Grade (ASC-H)
• Low Grade Squamous Intraepithelial lesion (LSIL)
  encompasses CIN I
• High Grade Squamous Intraepithelial lesion (HSIL)
  encompasses CIN II III
• Squamous Cell Carcinoma
• Glandular Cell
• Atypical Glandular cells (AG)
• Atypical Endocervical Cells
• Atypical Endometrial Cells
• Atypical Glandular Cells Not Otherwised Specified
  (AG-NOS)
• Favors Neoplasm
• Adenocarinoma In Situ (AIS)
• Adenocarcinoma

9
Screening Guidelines

• Start at age 21 (regardless of age of first
  intercourse)
• Age 21-29 ? screen every 2 years
• Age 30 ? screen every 3 years if
• Negative cytology x3 previous Paps
• NIELM and negative HR HPV test in 1 year
• No history of high grade lesions
• Annual screening if
• Immunocompromised (ie. HIV, transplant pts)
• History of CIN II, III or cancer
• Exposure to DES in utero
• Stop screening at 65 or 70 yrs if
• 3 prior consecutive normal Paps
• No history of abnormal screening in last 10 yrs
• Stop screening if hysterectomy for benign disease
  with no history of abnormal Pap smears

10
Management of Abnormal Paps

• ASC-US
• Reflex HPV testing if age gt 21
• If positive for high risk HPV (HRHPV) ?
  Colposcopy
• If negative ? Repeat Pap in 1 year
• Adolescents (lt21) ? Repeat Pap in 12 months
• ASC-H
• Refer to colposcopy
• LSIL
• Adolescents (lt21) ? Repeat Pap in 12 months
• Everyone else ? Colposcopy
• HSIL
• Refer to colposcopy

11
Management of Cervical Dysplasia

• Glandular Cells
• Atypical Glandular Cells
• Subtype Atypical Endometrial Cells
• Endometrial biopsy (EMB), endometrial currettage
  (ECC)
• If no endometrial pathology ? Colposcopy
• Rest of Subtypes (AGC-NOS, endocervical, favor
  neoplasm)
• Colposcopy
• EMB ECC
• Adenocarcinoma in situ
• Colposcopy, EMB ECC
• Diagnostic Excisional Procedure / Total
  Hysterectomy