Cervical Cancer Screening

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Cervical CancerScreening

• Dale Akkerman
• Ob/Gyn, Burnsville office

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Remember

• Goal of cervical cancer screening program is to
  detect neoplasia to allow intervention to prevent
  early invasive cervical cancer and to reduce
  mortality
• Goal is not to prevent any or all abnormal
  cytologic reports

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Cervical Cancer Screening

• No screening before age 21 regardless of age of
  onset of sexual activity
• Screening every two years between ages of 21-29
  and every three years after age 30 after three
  consecutive normal Pap tests.
• Stop screening between ages 65-70 if no abnormal
  Pap tests in 10 years.

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Caveat

• Does not apply to women who are immunosuppressed,
  HIV positive, have been exposed to DES in utero,
  or have prior history of CIN 2/3
• Source American Cancer Society and ACOG

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Sources for Abnormal Pap Smear Management

• Definitive reference for abnormal Pap smear
  management is ASCCP (American Society for
  Colposcopy and Cervical Pathology). May download
  guidelines at asccp.org
• Simplification found in Initial Management of
  Abnormal Cervical Cytology. May download at
  icsi.org

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Concept of CIN-2/3

• CIN (cervical intraepithelial neoplasia) is a
  histologic, not cytologic diagnosis
• Various cytologic reports are meant to convey
  more accurately the cytopathologists concern
  that a patients lesion has risk of CIN-2, CIN-3,
  AIS, or cervical cancer

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CIN-2/3 (continued)

• This significant risk is referred to as
• CIN-2/3
• Screening results which suggest a high
  probability of CIN-2/3 should alert the
  clinician the patient needs immediate and
  thorough evaluation to rule out gynecologic
  malignancy

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Concept of Equivalent Risk

• Presence of HPV DNA in an ASC cytology result
  carries an equivalent risk of CIN-2/3 as an LSIL
  cytology result
• Hence, these results should be managed similarly
  (colposcopy and on-going follow-up)

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Special Case Pregnancy

• Only diagnosis which alters clinical management
  of the pregnancy is invasive cancer
• If screening suggests high risk for CIN-2/3,
  patient should undergo colposcopy without
  endocervical sampling
• If low risk for CIN-2/3, either colposcopy as
  above or wait 8-12 weeks postpartum

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Special Case Younger Women

• Spontaneous resolution of CIN-1 and CIN-2 occurs
  at 70 and 50 rates
• Most HPV infections resolve within 24 months
• Risk of invasive cancer approaches zero
• For these reasons, no cervical cancer screening
  is recommended for patients age 20 or younger

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ASCUS (Atypical Squamous Cells)

• Need to known HPV status
• Concern centers on high-risk subtypes (HPV)
• Risk of CIN-2/3 is 5-10

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ASCUS, HPV negative (HPV-)

• This Pap smear is considered normal
• Repeat Pap smear in 12 months
• If persistent for two years, consider referral
  for evaluation of findings source of
  inflammation or rare circumstance of HPV subtype
  not in current testing profile

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ASCUS, HPV positive (HPV)

• Colposcopy
• Endocervical sampling if no lesion visualized or
  if colposcopic exam is unsatisfactory

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ASCUS and HPVColposcopy shows no CIN

• Cytology in 6 and 12 months OR
• Only HPV testing in 12 months
• If cytology ASC or HPV , repeat colposcopy
• If cytology normal or HPV-, return to routine
  screening

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LSIL (Low-grade squamous Lesion)

• Colposcopy
• 15-30 risk CIN-2/3
• 80 HPV
• Endocervical sampling if colposcopic exam
  unsatisfactory except for pregnant patients

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LSIL CIN-2/3

• Per ASCCP guidelines

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LSIL No CIN-2/3

• Cytology at 6 and 12 months OR
• Only HPV testing at 12 months
• If cytology ASC or HPV , repeat colposcopy
• If cytology normal or HPV-, return to routine
  screening

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ASC-H (cannot exclude HSIL)

• Colposcopy
• If no CIN-2/3, manage as LSIL no CIN- 2/3
• If CIN-2/3, manage as per ASCCP guidelines

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Pregnant, ASCUS or LSIL

• Preferably immediate colposcopy or defer at least
  6 weeks after delivery (better 8-12 weeks
  postpartum)
• If colposcopy during pregnancy shows no CIN-2/3,
  do follow-up screening postpartum

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HSIL (High-grade squam lesion)

• Up to 95 risk for CIN-2/3
• Either colposcopic exam or immediate LEEP are
  acceptable options
• No LEEP for pregnant women

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HSIL no CIN-2/3

• If unsatisfactory colposcopy, perform diagnostic
  excisional procedure (LEEP)
• If satisfactory, may observe with colposcopy and
  cytology at 6 and 12 months OR perform diagnostic
  excisional procedure (LEEP)
• If negative cytology X 2, routine screening
• If HSIL, needs diagnostic excision (LEEP)

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AGC (Atypical Glandular Cells)

• Several subtypes for this cytologic class
• Also includes AIS (adenoca in situ)
• For any subtype, need colposcopy HPV testing
  endocervical and endometrial sampling
• ICSI guidelines streamline ASCCP recommendations

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Subsequent Managementfor AGC

• Numerous arms and options
• Refer to ASCCP guideline for particular plan of
  action based on initial cytology report AGC
  favor neoplasia, AGC (NOS), AGC favor endometrial
  origin, AGC favor endocervical origin, AIS

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BEC (Benign Endometrial Cells)

• Only reported if patient age 40 or older
• Determine if patient has irregular bleeding, risk
  factors for endometrial cancer, or if patient is
  postmenopausal
• If yes for any of these categories, patient
  needs endometrial sampling
• Otherwise repeat cytology in 12 months

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Risk Factors for Endometrial Ca

• Tamoxifen or other SERM use
• Family or personal history of ovarian, breast,
  colon or endometrial cancer
• Chronic anovulation
• Obesity
• Prior endometrial hyperplasia

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Primary HPV Testing

• Patient 30 years old
• Cytology must be negative and no recent change in
  sexual partner
• If HPV-, routine screening not needed for at
  least 3 years
• If HPV , repeat cytology and HPV testing in 12
  months

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Primary HPV testing, HPV

• If both repeat cytology and HPV-, routine
  screening no sooner than 3 years
• If cytology negative and HPV, needs colposcopy
• If cytology abnormal, follow usual category
  algorithm

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New in HPV Testing

• Digene Hybrid Capture 2 (HC2) made by Qiagen
  detects 13 high-risk HPV subtypes, but does not
  distinguish individual HPV types used by PNC
• Cervista HPV 16/18 made by Hologic detects and
  specifically identifies high-risk HPV types 16
  and 18

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HPV Vaccination

• Minimum age is 9 years old
• There is a quadrivalent vaccine (HPV4) for
  prevention of cervical, vaginal and vulvar cancer
  and genital warts
• There is a bivalent vaccine (HPV2) for prevention
  of cervical cancer
• Best administered before exposure to HPV from
  sexual contact

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HPV Vaccination, continued

• Typically administer first dose to females at age
  11 or 12
• Second dose 1-2 months after first dose and third
  dose 6 months after first dose (minimum of 24
  weeks between first and third dose)
• Can administer to females between ages of 13 and
  18

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HPV Vaccination, continued

• Can do catch-up immunization to age 26
• Relatively older females typically have only one
  strain of HPV and will benefit from the
  vaccination series
• HPV4 can be administered as a three-dose series
  to males aged 9 to 18 to prevent genital warts

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HPV Vaccination, continued

• If pregnancy occurs during series, postpone
  subsequent doses until after pregnancy completed
• No evidence of increased fetal abnormalities or
  fetal wastage from exposure

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HPV Vaccination Reactions

• Alum agent causes 85 to complain of pain and 25
  to have redness at site
• Syncopal episodes not greater than for other
  vaccinations in same age group
• 70 of syncopal episodes occur in first 15
  minutes patient should recline for that span of
  time
• Source icsi.org