cervical cancer screening module 3
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Cervical Cancer Screening Module 3 - from Massachusetts Medical Society. Copyright © 2013. Massachusetts Medical Society, 860 Winter Street, Waltham Woods Corporate Center, Waltham, MA 02451-1411TRANSCRIPT
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.