Cervical cancer screening module 3

Cervical Cancer Screening Module III

Techniques of Screening

Screening Guidelines

Special Screening Situations

Cervical Cancer Screening Techniques of Screening

Physical Exam

Visual Inspection with Acetic Acid

Pap Smear

HPV Testing

Cervical Biopsies

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Techniques of Screening Physical Exam

1. Visually examine the vulva and perianal region

2. Insert the speculum into the vagina

3. Visually examine the cervix and the walls of the vagina

4. Palpate the cervix and the walls of the vagina.

5. Palpate the parametria and uterosacral ligaments by rectovaginal exam

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Techniques of Screening Visual Inspection with Acetic Acid

With the speculum in the vagina and the cervix visualized, apply 3% acetic acid using a sponge (ALERT: confirm that the acetic acid has been diluted. 100% acetic acid will cause third degree burns)

Wait 60 seconds and then visually examine .

Dysplastic lesions are nuclear dense. The dehydration of the mucous membrane will temporarily cause dysplastic lesions to look white

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Visual Inspection

Sensitivity – 67-79% Specificity – 49-86%

Technique :Place Speculum

Apply 3-5% Acetic Acid

Wait at least 1 Minute; record Observations

Author, year of publication, country of study

No. of participants Sensitivity, % (95% CI)

Specificity, % (95% CI)

University of Zimbabwe/JHPIEGO [5], 1999, Zimbabwe

2148 77 (70–82) 64 (61–66)

Denny et al. 2000, South Africa

2885 67 (56–77) 84 (82–85)

Belinson et al. [24], 2001, China

1997 71 (60–80) 74 (71–76)

Denny et al. [8], 2002, South Africa

a,c

2754 70 (59–79) 79 (77–81)

Cronjé et al. [9], 2003, South Africa

1093 79 (69–87) 49 (45–52)

Sankaranarayanan et al. [25], 2004 India and Africa

b,c

54,981 79 (77–81) 86 (85–86)

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Techniques of Screening Pap Smear

With a spatula, rotate the spatula 360 degrees around the exocervix

With a cytobrush, place the brush within the endocervix and rotate 360 degrees

Apply both the spatula and cytobrush to a slide and then apply fixative

Or place spatula and cytobrush into liquid based solution and break off the tips

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SCREENING conventional cytologic sampling Thin layer (or liquid-based) cytology ThinPrep (1996) AutocytPrep (1999) SurePath (2000) MonoPrep (2006)

liquid-based : other diagnostic assessments (only Thin Prep is FDA approved )

testing for gonorrhea chlamydia HPV

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Sources of potential error in the Pap smear

The clinician may not sample the area of cervical abnormality.

The abnormal cells may not be plated on the slide or transferred to the liquid medium.

The cells may not be adequately preserved with fixative.

The cytologist may inaccurately report the findings

The cytopathologist may not identify the abnormal cells.

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Techniques of Screening HPV Testing

HPV testing should be confined to testing for high risk (oncogenic) subtypes

HPV testing for low risk (nonocogenic) subtypes has NO role in the evaluation of abnormal pap smears

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HPV TESTING p16 cytology

P16 cytology can be used as a triage test in HPV-positive women.

P16 is a marker of HPV oncogene activity that is independent of carcinogenic HPV tyoe

Carozzi . Lancet Oncol 2012

Of 1170 HPV positive women,493 (42%) overexpressed p16 at baseline

At baseline, 55 of these 493 women had CIN3 (9.7%)

Compared to p16 negative over expression, positive p16 had a longitudinal sensitivity of 82.4%

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Techniques of Screening Colposcopy &Cervical Biopsies

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Cervical Cancer Screening Screening Guidelines

Screening Guidelines can be separated into two sections

General guidelines for when to pap smears and on whom What follow up and intervention is recommended based on pap sear results

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Cervical Cancer Screening Screening Guidelines

Guidelines are only for women at average risk for cervical cancer.

These guideline do not apply to women with:

history of cervical cancer

In Utero exposure to DES

who are immuno-compromised

organ transplantation,

chronic steroid use,

chemotherapy

HIV positive

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Screening Guidelines When to perform pap smear

Do not screen before age 21 years

Screening should start at age 21

Screening guidelines are age dependent

Annual pap smears in women without a history of premalignant or malignant lower genital disease are no longer recommended

Recommended Screening practices should not change on the basis of HPV vaccination status

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PREVALENCE OF CIN 3 OR GREATER BY AGE MOORE 2008

LESS THAN CIN 3 CIN3 OR

GREATER

TOTAL

<50 YEARS 189 (71%) 77 (29%) 266

>50 YEARS 51 (59%) 35 (41%) 86

TOTAL 240 112 352

Patients older than 50 had Signif higher Prevalence CIN3

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Vaccination Against HPV

Recommend routine HPV vaccination for females aged 11 to 12 years

Recommend routine vaccination for females aged 13 to 18 years to “catch-up” those who missed earlier screening

Insufficient data to recommend for or against universal vaccination of females aged 19 to 26 years

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Screening Guidelines When to perform pap smear

Ages 21- 29 years: PAP SMEAR screening every three years

No screening HPV testing

HPV testing only for evaluation of atypical squamous cells of uncertain significance

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Screening Guidelines When to perform pap smear

Ages 30 – 65 years: screening with both PAP SMEAR and HPV testing every five years (preferred)

Or PAP SMEAR testing every three years (accepted)

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Screening Guidelines When to perform PAP SMEAR

Ages greater than 65: No Further Pap Smear Testing who have had > 3 consecutive normal pap tests

or > 2 consecutive negative HPV tests and pap tests in last 10 years with the most recent pap occurring within the last 5 years

or women who have had hysterectomies for benign disease

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Cervical Cancer Screening Screening Guidelines

In 2012 the American Society for Colposcopy and Cervical Pathology (ASCCP) published new guidelines for management of pap smear results

Guidelines should never replace clinical judgment

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ASCCP Guidelines

Guidelines for management of abnormal pap smears are different by the following age categories:

Ages 21- 24

Ages over 30

Guidelines for management of abnormal pap smears are different for the pregnant woman (see screening: special situations)

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ASCCP Guidelines Unsatisfactory Cytology

Repeat pap smear after 2 to 4 months

Refer to colposcopy for persistently unsatisfactory pap smears

http://www.asccp.org/Portals/9/docs/Algorithms%207.30.13.pdf (Page 4)

ASCCP Guidelines Absent Endocervical Cells For ages 21-29: perform routine screening

For ages > 30 : HPV testing

http://www.asccp.org/Portals/9/docs/Algorithms%207.30.13.pdf (Page 5)

ASCCP Guidelines Age > 30: Cytology Negative & HPV positive

For HPV 16 and 18: colposcopy

Repeat co-testing in one year is acceptable

http://www.asccp.org/Portals/9/docs/Algorithms%207.30.13.pdf (Page 6)

Risk of HSIL with + HPV HR

2% (52 of 2562 over 10 years) Khan 2005

3% (88 of 2941 over 10 years) Castle 2002

1.2% (30 or 2562 over 10 years) Miller 2002

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ASCCP Guidelines ASC - US

Repeat pap smear in one year, if ASC-US again: refer to colposcopy

OR

Upfront HPV testing, if HPV positive: refer to colposcopy

http://www.asccp.org/Portals/9/docs/Algorithms%207.30.13.pdf (Page 7)

ASCCP Guidelines Ages 21-24 – ASC-US or LSIL

HPV testing: If HPV negative: return to routine testing

If HPV positive: repeat pap smear in one year

http://www.asccp.org/Portals/9/docs/Algorithms%207.30.13.pdf (Page 8)

ASCCP Guidelines ASC-US ages 21-24 Initial Management

Cytology alone in 12 months is preferred

Reflex HPV testing acceptable

If HPV positive, repeat cytology one year

If HPV negative, return to routine screening with cytology alone in three years

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ASCCP Guidelines LSIL

If LSIl and HPV negative, repeat pap smear in one year

If LSIL and HPV positive: refer to colposcopy

http://www.asccp.org/Portals/9/docs/Algorithms%207.30.13.pdf (Page 9)

ASCCP Guidelines ASC-H

Refer all ASC-H to colposcopy

http://www.asccp.org/Portals/9/docs/Algorithms%207.30.13.pdf (Page 11)

ASCCP Guidelines Ages 21-24 -ASC-H

If colposcopy is negative, repeat pap smear and colposcopy every six months for two years

If HSIL is found, acceptable to monitor for one year. If lesion is persistent for one year, treat with excision

http://www.asccp.org/Portals/9/docs/Algorithms%207.30.13.pdf (Page 12)

ASCCP Guidelines HSIL

Immediate LEEP or colposcopy

http://www.asccp.org/Portals/9/docs/Algorithms%207.30.13.pdf (Page 13)

ASCCP Guidelines AGC

All women with AGC need colposcopy

Women > AGC also need an endometrial biopsy

http://www.asccp.org/Portals/9/docs/Algorithms%207.30.13.pdf (Page 14)

ASCCP Subsequent management of AGC after

colposcopy

For CIN 2 but no glandular lesion, manage per ASCCP guideline

For negative biopsies, repeat pap and HPV testing yearly for two years

For preinvasive glandular lesion, treat by excisional biopsy

http://www.asccp.org/Portals/9/docs/Algorithms%207.30.13.pdf (Page 15)

Histologic Outcome after Atypical Glandular Cells Obstet Gynecol 2010; 115:243-248

Age < 50 years Age < 50 years Age > 50 years Age > 50 years

HPV neg (n=656)

HPV pos (n=269)

HPV neg (n=420)

HPV pos (n=497)

CIN 2 10 34 4 9

CIN 3 3 42 1 5

Cervical adenoca in situ

4 29 1 4

Cervical SCC 2 10 1 6

Cervical adenoca

0 7 1 2

Endometrial atypical

10 0 10 0

Endo CA 10 3 44 0

Other cancers 0 0 6 0

ASCCP Guidelines Biopsy: CIN I

No treatment

Repeat pap smear and HPV testing in one year

http://www.asccp.org/Portals/9/docs/Algorithms%207.30.13.pdf (Page 16)

ASCCP Guidelines Biopsy: CIN I after Pap ASC-H or HSIL

Treatment not recommended

Repeat pap smear and HPV testing yearly for two years

http://www.asccp.org/Portals/9/docs/Algorithms%207.30.13.pdf (Page 17)

ASCCP Guidelines

Ages 21-24 – Biopsy CIN I Treatment not recommended

After ASC-US or LSIL pap: Repeat pap smear

After ASC-H or HSIL pap: repeat pap smear and colposcopy every six months for one year

If colposcopy is inadequate: excisional procedure

http://www.asccp.org/Portals/9/docs/Algorithms%207.30.13.pdf (Page 18)

ASCCP Guidelines Biopsy: CIN 2-3

Recommend excisional procedure

http://www.asccp.org/Portals/9/docs/Algorithms%207.30.13.pdf (Page 19)

ASCCP Guidelines Young women, Biopsy: CIN 2-3

Excisional procedure

OR

Pap smear and colposcopy every six months for one year

http://www.asccp.org/Portals/9/docs/Algorithms%207.30.13.pdf (Page 20)

ASCCP Guidelines Biopsy: AIS

Excisional procedure

Hysterectomy is preferred treatment

http://www.asccp.org/Portals/9/docs/Algorithms%207.30.13.pdf (Page 21)

Cervical Cancer Screening Special Screening Situations

Immunosuppression

Pregnancy

After Hysterectomy

After Treatment for Cervical Cancer

After Pelvic Radiation

Challenging Anatomy

History of Sexual Assault

In Utero DES (diethylstilbestrol) exposure

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Special Screening Situations Immunosuppression

Human Immunodeficiency Virus

Organ Transplant

Chronic Steroid Use

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Immunosuppression Human Immunodeficiency Virus

Women with HIV infection are at high risk for preinvasive lower genital tract disease and cervical cancer

They are high risk for persistent HPV infections

They should be screened by PAP SMEAR twice in the first year and then yearly thereafter

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Immunosuppression Organ Transplant

Women who are on high dose immunosuppressants are at high risk for lower genital tract neoplasia

They should be screened by PAP SMEAR twice in the first year and then yearly thereafter

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Immunosuppression Chronic Steroid Use

Chronic steroid use can lead to a reduction in the clearance of HPV infection

They should be screened by PAP SMEAR twice in the first year and then yearly thereafter

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Special Screening Situations Pregnancy

Pap smear is performed at first prenatal visit and at the six week post partum visit

Abnormal Pap smears are evaluated in a similar manner to non-pregnant women

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Special Screening Situations Pregnancy: ASC-US pap

Identical to non-pregnant women

It is acceptable to defer colposcopy until 6 weeks postpartum

Endocervical curettage is unacceptable

For pregnant women with no cytologic, colposcopic , or histologic findings of CIN, postpartum follow-up is recommended

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ASCCP Guidelines Pregnant with LSIL

Colposcopy in pregnancy

Treatment of all preinvasive lesions delayed until after delivery

http://www.asccp.org/Portals/9/docs/Algorithms%207.30.13.pdf (Page 10)

Special Screening Situations After Hysterectomy

Cervical cancer screening is not indicated if removal of cervix or entire uterus in women with no history of cervical cancer or preinvasive disease.

Women who have undergone a subtotal hysterectomy with preservation of the cervix should follow screening recommendations of average risk women

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Special Screening Situations After Treatment for Cervical Cancer

No age cut off for stopping screening

Women should undergo pap smears every 3 to 4 months for the first two years after treatment for cervical cancer.

Pap smear screening is performed every 6 months from years 2 to 5 after treatment

Annual pap smear screening five years after treatment

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Special Screening Situations After Pelvic Radiation

There is a higher risk of radiation induced malignancies after pelvic radiation.

Annual pap smear screening should be performed in women who receive pelvic radiation for all cancer types (lymphoma, cervical cancer, endometrial cancer, rectal and anal cancer)

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Special Screening Situations Challenging Anatomy

Vaginismus

Vaginal Atrophy

Pelvic Floor Prolapse

Vaginal Agglutination

Cervical Stenosis

Obesity

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Challenging Anatomy Vaginismus

Vaginismus is the painful and involuntary contraction of vaginal muscles

Causes: sexual assault, vulvar vestibulitis, inflammatory conditions of the pelvic floor such as diverticulitis

Adequate pelvic examination and pap smear may require an examination under anesthesia

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Challenging Anatomy Vaginal Atrophy

Consideration should be given to a short course of estrogen vaginal cream prior to performing a pap smear

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Challenging Anatomy Pelvic Floor Prolapse

Uterine prolapse can place the cervix at the introitus leading to trauma and cornification of the cervix

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Challenging Anatomy Vaginal Agglutination

Vaginal agglutination can occur after radiation, trauma, surgery, and infection

Evaluation by examination under anesthesia should be considered

Use of vaginal dilators and estrogen vaginal cream should be considered

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Challenging Anatomy Cervical Stenosis

Cervical stenosis is defined as the inability to place a cutip or cytobrush within the endocervix

There is increased risk of a false negative pap smear

Recommendation: Dilation of cervix In a postmenopausal woman, consideration of a transvaginal ultrasound to evaluate the endometrial cavity for fluid

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Challenging Anatomy Obesity

Obesity can in some women lead to difficulty examining the cervix due to discomfort, vaginal wall redundancy, or increased vaginal length.

Sensitive use of larger speculums and retraction of the labia by an assistant can be helpful in optimally postioning the speculum to visualize the cervix

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Special Screening Situations History of Sexual Assault

Women who have survived the trauma of sexual assault should be screened for sexually transmitted disease including HIV testing.

For women who are older than age 30, high risk HPV testing should be offered.

Consideration should be given for a pap smear regardless of the timing of their previous pap smear test within six months of sexual assault for women older than age 21 years.

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Special Screening Situations In Utero DES (diethylstilbestrol) exposure

The cohort of women exposed to In-Utero DES were born before 1980.

They have a twofold increased risk of cervical dysplasia

Based on clinician judgment, they should be screened at least every three years if they have had three consecutive normal pap smears

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CERVICAL CANCER SCREENING

MODULE III CONCLUSIONS

-This module summarizes the screening recommendations for the average risk patient.

-The full algorithms can be reviewed on the asccp website: http://www.asccp.org/Guidelines

-Providers must be cognizant of special screening situations and tailor evaluation to each patient, their particular anatomy, and their particular risk factors.