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Cervical Cancer Screening

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sarahmccorm

My presentation on Cervical Cancer Screening protocol and recommendations to be given at Mt. Clemens Regional Medical Center on 5/25/09

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Screening for Cervical Cancer Sarah McCormick MSIII Kansas City University of Medicine and Biosciences
Cervical Cancer Risk Factors HPV strains 16 and 18 Smoking Immuno-suppression Early age at first intercourse Multiple sex partner Obesity Multiple pregnancies Family history of cervical cancer
Screening Pap Smears Every woman who is sexually active or 21 yo Annual tests from ages 21 to 30 After age 30, pap tests may be given every 2 to 3 years, if the previous 3 tests have been negative, no history of CIN 2 or 3, and no increased risk (no DES exposure, not immuno-compromised) >30 HPV testing maybe offered as alternative to cytology, HPV + cytology every 3 years Samples the transition zone where the nonkeratinized stratified squamous epithelium (ectocervix) and simple columnar epithelium (endocervix) meet. 2 Types Papanicolaou Smear Liquid Preparations Thin Prep 1996 (liquid)- most sensitive, viewed twice once by image viewer, then by a lab professional, only test FDA approved for G,C and HPV reflex testing Sure Path 2000 Mono Prep 2006
Why Screen? Evidence of screening effectiveness only shown from observational studies >50% woman with cervical cancer have never had a pap, were screen only randomly, or did not have a pap in the last 5 years. Canadian study found inverse correlation between pap smears performed and a decrease in mortality rate from cervical and uterine cancer. Woman without a pap smear in the last 5 years had triple the risk of having invasive cervical cancer The IARC found a 90% reduction in cervical cancer incidence from screening adult females
What Happens at the Lab? Smears are fed into automated systems to be read Abnormal smears are manually read by a lab technician 10% negative smears are reread for quality assurance
Normal Pap Squamous and Endocervical Cells
Abnormal Pap Chlamydia infected cells Koilocytes (HPV infected cells) dark wrinkled nuclei surrounded by clear halo Cells demonstrating dysplasia
Bethesda Classification Developed to determine whether a finding was more likely to be cancerous or precancerous versus a finding that was unlikely to progress to cancer. Classification ASC –Atypical Squamous Cells ASC-H (cannot exclude HSIL) ASC-US (undetermined significance) LSIL (HPV, Mild dyslpasia, CIN 1) HSIL (mod-severe dysplasia, CIN2,3, CIS) AGC- atypical glandular cell (endometrial, endocervical) AIS- endocervical adenocarcinoma in situ
HPV Testing HPV is found in 70-80% cervical cancers, 82% adenocarcinomas, 70% squamous cell carcinomas of the female genital tract Persistent HPV infections cause premalignancies HPV testing with Pap is more sensitive than Pap alone. (94.6% vs 55.4%) Not used as screening test alone due to its poor specificity as compared to the Pap. (94.1% vs 96.8%) Better specificity in woman >30yrs old According to the Population Based Screening Study Amsterdam HPV + Pap screening led to earlier detection of lesions
HPV Testing Continued Positive HPV refers to the finding of HPV 16 and 18 Negative HPV results refer to the finding of no HPV, a finding of HPV strains not related to cancer, or no cells (bad sample) HPV testing with Pap approaches 100% sensitivity but 10% false positive rate Reflex HPV Test tests ASC-US for HPV from same sample as pap 80% of adolescents may test positive for HPV, so not as effective a test for adolescents
Follow up Adult Women ASC-US/H Reflex HPV ASC-US + HPV positive- colposcopy ASC-US with negative HPV- repeat Pap 12 mo (most likely inflammation or infection <2% premalignant) Repeat Pap is ASC-US- colpo ASC-H-colpo Adolescents ASC -ASC-US (no reflex test due to high positive rate!)- f/u 12 mo repeat pap If repeat is HSIL or greater-colpo If (ASC, LSIL) repeat pap in 12 mo Combined HPV DNA + Pap For women >30 yo only, no more than q3yrs HPV and cytology positive-colpo HPV positive, cytology negative- repeat 12 mo Persistently positive HPV-colpo
Follow up LSIL Adult Women LSIL-colpo/biopsy (No HPV test needed) Adolescent Women LSIL-Repeat pap in 12 months if HSIL then colpo, if not repeat pap again in 12 months, if ASC-US or greater—colpo Why different? Usually it’s a transient HPV infection that will resolve within 24 months and the cancer rate in age group is zero
Follow Up HSIL Adult and Adolescent Women At very high risk of malignancy (>50% have CIN 2 or more) Colpo with biopsy
Follow up AGS and AIS AGC (Atypical Glandular Cells) and AIS (Adenocarcinoma In Situ) Colpo + biopsy if >35 yo endometrial biopsy
Colpo results CIN 1 Adult Women Follow up LSIL/ASC lesions repeat cytology at 6 & 12 mo or HPV DNA test If ASC or higher, or HPV positive – re-colpo Resume routine screen once negative HPV or 2 negative smears If persists >24 months can treat or observe for changes as patient decides (ablation/excision) Why? Only 9-16% go onto being malignancies HSIL lesions Repeat cytology AND colposcopy at 6 and 12 mo Resume routine screen once 2 negative colposcopies and cytologies ASC or higher detected- excise Why? With HSIL preceding the CIN 1, there’s a chance that a CIN 2 or 3 lesion is being missed on colpo. Since CIN 2, 3 is usually related to HSIL, and CIN 1 usually is a LSIL lesion
Colpo Results Continued CIN 1 Adolescent Women (<20 yo) Repeat cytology at 12 mo (then follow HSIL/LSIL procedure) Only 0.4% progress to CIN 3 CIN 2, 3 Adult Women Ablation or Excision Excise if: Suspected microinvasion, Unsatisfactory colposcopy)Lesion, extending into the endocervical canal,Endocervical curettage showing CIN or a glandular abnormality, Lack of correlation between the cytology and colposcopy/biopsies, Suspected adenocarcinoma in situ, Colposcopist unable to rule out invasive disease, Recurrence after an ablative or previous excisional procedure CIN 2, 3 Adolescent Women Repeat colpo and cytology q6months for 24 months 2 normal results-return to routine screening Persistant CIN2-observation Persistant CIN3-Ablation/excision
Discontinuing Screening USPSTF 65 yo if not at high risk ACS 70 yo with 3 negative test and no positives within last 10 years American College of Obstetricians and Gynecologists (ACOG) Inconclusive evidence
References www.thinprep.com http://www.pathguy.com/lectures/women.htm www.uptodate.com

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Cervical Cancer Screening

  • 1. Screening for Cervical Cancer Sarah McCormick MSIII Kansas City University of Medicine and Biosciences
  • 2. Cervical Cancer Risk Factors HPV strains 16 and 18 Smoking Immuno-suppression Early age at first intercourse Multiple sex partner Obesity Multiple pregnancies Family history of cervical cancer
  • 3. Screening Pap Smears Every woman who is sexually active or 21 yo Annual tests from ages 21 to 30 After age 30, pap tests may be given every 2 to 3 years, if the previous 3 tests have been negative, no history of CIN 2 or 3, and no increased risk (no DES exposure, not immuno-compromised) >30 HPV testing maybe offered as alternative to cytology, HPV + cytology every 3 years Samples the transition zone where the nonkeratinized stratified squamous epithelium (ectocervix) and simple columnar epithelium (endocervix) meet. 2 Types Papanicolaou Smear Liquid Preparations Thin Prep 1996 (liquid)- most sensitive, viewed twice once by image viewer, then by a lab professional, only test FDA approved for G,C and HPV reflex testing Sure Path 2000 Mono Prep 2006
  • 4. Why Screen? Evidence of screening effectiveness only shown from observational studies >50% woman with cervical cancer have never had a pap, were screen only randomly, or did not have a pap in the last 5 years. Canadian study found inverse correlation between pap smears performed and a decrease in mortality rate from cervical and uterine cancer. Woman without a pap smear in the last 5 years had triple the risk of having invasive cervical cancer The IARC found a 90% reduction in cervical cancer incidence from screening adult females
  • 5. What Happens at the Lab? Smears are fed into automated systems to be read Abnormal smears are manually read by a lab technician 10% negative smears are reread for quality assurance
  • 6. Normal Pap Squamous and Endocervical Cells
  • 7. Abnormal Pap Chlamydia infected cells Koilocytes (HPV infected cells) dark wrinkled nuclei surrounded by clear halo Cells demonstrating dysplasia
  • 8. Bethesda Classification Developed to determine whether a finding was more likely to be cancerous or precancerous versus a finding that was unlikely to progress to cancer. Classification ASC –Atypical Squamous Cells ASC-H (cannot exclude HSIL) ASC-US (undetermined significance) LSIL (HPV, Mild dyslpasia, CIN 1) HSIL (mod-severe dysplasia, CIN2,3, CIS) AGC- atypical glandular cell (endometrial, endocervical) AIS- endocervical adenocarcinoma in situ
  • 9. HPV Testing HPV is found in 70-80% cervical cancers, 82% adenocarcinomas, 70% squamous cell carcinomas of the female genital tract Persistent HPV infections cause premalignancies HPV testing with Pap is more sensitive than Pap alone. (94.6% vs 55.4%) Not used as screening test alone due to its poor specificity as compared to the Pap. (94.1% vs 96.8%) Better specificity in woman >30yrs old According to the Population Based Screening Study Amsterdam HPV + Pap screening led to earlier detection of lesions
  • 10. HPV Testing Continued Positive HPV refers to the finding of HPV 16 and 18 Negative HPV results refer to the finding of no HPV, a finding of HPV strains not related to cancer, or no cells (bad sample) HPV testing with Pap approaches 100% sensitivity but 10% false positive rate Reflex HPV Test tests ASC-US for HPV from same sample as pap 80% of adolescents may test positive for HPV, so not as effective a test for adolescents
  • 11. Follow up Adult Women ASC-US/H Reflex HPV ASC-US + HPV positive- colposcopy ASC-US with negative HPV- repeat Pap 12 mo (most likely inflammation or infection <2% premalignant) Repeat Pap is ASC-US- colpo ASC-H-colpo Adolescents ASC -ASC-US (no reflex test due to high positive rate!)- f/u 12 mo repeat pap If repeat is HSIL or greater-colpo If (ASC, LSIL) repeat pap in 12 mo Combined HPV DNA + Pap For women >30 yo only, no more than q3yrs HPV and cytology positive-colpo HPV positive, cytology negative- repeat 12 mo Persistently positive HPV-colpo
  • 12. Follow up LSIL Adult Women LSIL-colpo/biopsy (No HPV test needed) Adolescent Women LSIL-Repeat pap in 12 months if HSIL then colpo, if not repeat pap again in 12 months, if ASC-US or greater—colpo Why different? Usually it’s a transient HPV infection that will resolve within 24 months and the cancer rate in age group is zero
  • 13. Follow Up HSIL Adult and Adolescent Women At very high risk of malignancy (>50% have CIN 2 or more) Colpo with biopsy
  • 14. Follow up AGS and AIS AGC (Atypical Glandular Cells) and AIS (Adenocarcinoma In Situ) Colpo + biopsy if >35 yo endometrial biopsy
  • 15. Colpo results CIN 1 Adult Women Follow up LSIL/ASC lesions repeat cytology at 6 & 12 mo or HPV DNA test If ASC or higher, or HPV positive – re-colpo Resume routine screen once negative HPV or 2 negative smears If persists >24 months can treat or observe for changes as patient decides (ablation/excision) Why? Only 9-16% go onto being malignancies HSIL lesions Repeat cytology AND colposcopy at 6 and 12 mo Resume routine screen once 2 negative colposcopies and cytologies ASC or higher detected- excise Why? With HSIL preceding the CIN 1, there’s a chance that a CIN 2 or 3 lesion is being missed on colpo. Since CIN 2, 3 is usually related to HSIL, and CIN 1 usually is a LSIL lesion
  • 16. Colpo Results Continued CIN 1 Adolescent Women (<20 yo) Repeat cytology at 12 mo (then follow HSIL/LSIL procedure) Only 0.4% progress to CIN 3 CIN 2, 3 Adult Women Ablation or Excision Excise if: Suspected microinvasion, Unsatisfactory colposcopy)Lesion, extending into the endocervical canal,Endocervical curettage showing CIN or a glandular abnormality, Lack of correlation between the cytology and colposcopy/biopsies, Suspected adenocarcinoma in situ, Colposcopist unable to rule out invasive disease, Recurrence after an ablative or previous excisional procedure CIN 2, 3 Adolescent Women Repeat colpo and cytology q6months for 24 months 2 normal results-return to routine screening Persistant CIN2-observation Persistant CIN3-Ablation/excision
  • 17. Discontinuing Screening USPSTF 65 yo if not at high risk ACS 70 yo with 3 negative test and no positives within last 10 years American College of Obstetricians and Gynecologists (ACOG) Inconclusive evidence