Cervical Cancer Screening

1. Cervical CancerScreening Dale Akkerman Ob/Gyn, Burnsville office

2. 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

3. 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.

4. 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

5. 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

6. 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

7. 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

8. 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 on-going follow-up)

9. 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

10. 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

11. ASCUS (Atypical Squamous Cells) • Need to known HPV status • Concern centers on high-risk subtypes (HPV+) • Risk of CIN-2/3+ is 5-10%

12. 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

13. ASCUS, HPV positive (HPV+) • Colposcopy • Endocervical sampling if no lesion visualized or if colposcopic exam is unsatisfactory

14. 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

15. LSIL (Low-grade squamous Lesion) • Colposcopy • 15-30% risk CIN-2/3+ • 80% HPV+ • Endocervical sampling if colposcopic exam unsatisfactory except for pregnant patients

16. LSIL: CIN-2/3+ • Per ASCCP guidelines

17. 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

18. 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

19. 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

20. 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

21. 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)

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. New in HPV Testing • Digene Hybrid Capture 2 (HC2) made by Qiagen detects 13 high-risk HPV subtypes, but does not distinguish individual HPV types [used by PNC] • Cervista HPV 16/18 made by Hologic detects and specifically identifies high-risk HPV types 16 and 18

29. 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

30. 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

31. 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

32. 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

33. 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 that span of time • Source: icsi.org