Download - Cervical Cancer Screening
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