Cervical CancerScreening

Dale AkkermanOb/Gyn, Burnsville office

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

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.

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

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

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 cytopathologist’s concern that a patient’s lesion has risk of CIN-2, CIN-3, AIS, or cervical cancer

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

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 ongoing follow-up for adult women)

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

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

ASCUS (Atypical Squamous Cells)

• Need to known HPV status• Concern centers on high-risk subtypes

(HPV+)• Risk of CIN-2/3+ is 5-10%

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

ASCUS, HPV positive (HPV+)

• Colposcopy• Endocervical sampling if no lesion

visualized or if colposcopic exam is unsatisfactory

ASCUS and HPV+:Colposcopy 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

LSIL (Low-grade squamous Lesion)

• Colposcopy• 15-30% risk CIN-2/3+• 80% HPV+• Endocervical sampling if colposcopic

exam unsatisfactory except for pregnant patients

LSIL: CIN-2/3+

• Per ASCCP guidelines

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

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

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

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

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)

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

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

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

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

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

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

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

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

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

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

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 than span of time

• Source: icsi.org