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Cervical Cancer Screening

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Screening for Cervical Cancer. District I ... Dr. Babes & Dr. Papanikolaou. Medical screening method. Detect premalignant and malignant processes of cervix. ... – PowerPoint PPT presentation

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Title: Cervical Cancer Screening


1
Cervical Cancer Screening
  • District I ACOG
  • Medical Student Education Module
  • Last Updated January 1, 2011

2
Cervical Cancer ScreeningModule Outline
  • Brief review of Cervical Cancer
  • Brief review of HPV
  • What is a Pap Smear? How To Perform?
  • Some Pap Terminology
  • Who to screen and when
  • Abnormal Pap ? What now?

3
Cervical Cancer
  • Incidence/Prevalence
  • 3rd most common GYN cancer in developed world
  • 11,270 new cases in 2009
  • 4,070 deaths in 2009
  • Most common GYN cancer in developing countries
  • 500,000 new cases annually
  • 240,000 deaths annually
  • Signs Symptoms
  • Abnormal Vaginal Bleeding
  • Postcoital Bleeding
  • Vaginal Discharge (watery, mucoid, purulent,
    malodorous)

4
Cervical Cancer
  • Risk Factors
  • Early onset of sexual activity
  • Multiple sexual partners
  • High-risk sexual partner
  • History of sexually transmitted diseases
  • Smoking (not adenocarcinoma)
  • High parity
  • Immunosuppression
  • Low socioeconomic status
  • Prolonged use of oral contraceptives
  • Hx of vaginal or vulvar cancer
  • Vast majority of cases are caused by persistent
    high risk HPV infection
  • Most common Histologies
  • Squamous Cell Carcinoma
  • Adenocarcinoma
  • Adenosquamous

5
Human Papillomavirus
  • Lifetime cumulative risk of acquiring HPV in
    sexually active persons 80
  • Spectrum of HPV
  • Condyloma Acuminata
  • Cervical Dysplasia
  • Cervical Cancer
  • gt 150 different types of the virus
  • 15 High Risk Types (16, 18, 31, 33, 35, 39, 45,
    51, 52, 56, 58, 59, 68, 73, 82)
  • 16, 18 ? gt 70 all cervical cancers
  • 6, 11 ? 90 genital warts
  • HPV Vaccine Gardasil
  • Active against 16, 18, 6, 11
  • FDA approved in US for girls boys ages 9-26

6
What is a Pap Smear?
  • Papanicolaou test - 1941
  • Dr. Babes Dr. Papanikolaou
  • gt 50 decrease in rates of cervical cancer in
    developed countries over last 30 yrs due to
    widespread screening
  • A sample cervix cells from transformation zone.
  • junction of endocervix and ectocervix
  • Use of spatula /- cytobrush, broom stick
  • 2 types conventional, liquid-based
  • Send for cytologic interpretation

7
How to perform a Pap smear
  • Conventional smear
  • direct application of cells to a slide
  • Liquid Based smear
  • 90 of all Pap smears in US
  • Transfer cells to a liquid preservative. Liquid
    processed in laboratory and transferred to a slide

8
Bethesda System (2001) Classification
  • Specimen Adequacy
  • Is the transformation zone present ??
  • Negative for intraepithelial lesion or malignancy
    (NILM, NIELM)
  • Squamous Cell
  • Atypical squamous cells
  • Undetermined Significance (ASC-US)
  • Not exclude High Grade (ASC-H)
  • Low Grade Squamous Intraepithelial lesion (LSIL)
    encompasses CIN I
  • High Grade Squamous Intraepithelial lesion (HSIL)
    encompasses CIN II III
  • Squamous Cell Carcinoma
  • Glandular Cell
  • Atypical Glandular cells (AG)
  • Atypical Endocervical Cells
  • Atypical Endometrial Cells
  • Atypical Glandular Cells Not Otherwised Specified
    (AG-NOS)
  • Favors Neoplasm
  • Adenocarinoma In Situ (AIS)
  • Adenocarcinoma

9
Screening Guidelines
  • Start at age 21 (regardless of age of first
    intercourse)
  • Age 21-29 ? screen every 2 years
  • Age 30 ? screen every 3 years if
  • Negative cytology x3 previous Paps
  • NIELM and negative HR HPV test in 1 year
  • No history of high grade lesions
  • Annual screening if
  • Immunocompromised (ie. HIV, transplant pts)
  • History of CIN II, III or cancer
  • Exposure to DES in utero
  • Stop screening at 65 or 70 yrs if
  • 3 prior consecutive normal Paps
  • No history of abnormal screening in last 10 yrs
  • Stop screening if hysterectomy for benign disease
    with no history of abnormal Pap smears

10
Management of Abnormal Paps
  • ASC-US
  • Reflex HPV testing if age gt 21
  • If positive for high risk HPV (HRHPV) ?
    Colposcopy
  • If negative ? Repeat Pap in 1 year
  • Adolescents (lt21) ? Repeat Pap in 12 months
  • ASC-H
  • Refer to colposcopy
  • LSIL
  • Adolescents (lt21) ? Repeat Pap in 12 months
  • Everyone else ? Colposcopy
  • HSIL
  • Refer to colposcopy

11
Management of Cervical Dysplasia
  • Glandular Cells
  • Atypical Glandular Cells
  • Subtype Atypical Endometrial Cells
  • Endometrial biopsy (EMB), endometrial currettage
    (ECC)
  • If no endometrial pathology ? Colposcopy
  • Rest of Subtypes (AGC-NOS, endocervical, favor
    neoplasm)
  • Colposcopy
  • EMB ECC
  • Adenocarcinoma in situ
  • Colposcopy, EMB ECC
  • Diagnostic Excisional Procedure / Total
    Hysterectomy
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