#168 Cervical Cancer Screening and Prevention Flashcards
What is the incidence of cervical cancer in the US?
6.7 per 100,000 women.
What is the mortality from cervical cancer in the US per 100,000 women?
2.3 per 100,000 women (not per cases)
About how many new cases of cervical cancer are diagnosed in the US per year. And how many deaths per year from cervical cancer in the US?
12,900 new cases per year. 4,100 deaths per year.
What percent of women diagnosed with cervical cancer never had cervical cytology?
50%
What percentage of women diagnosed with cervical cancer never had cervical cytology or had not been screened within the 5 years prior to diagnosis?
60%
Does HPV infection typically transient or persistent?
Transient
Persistent HPV infections after what amount of time strongly predicts subsequent risk of CIN3 or cancer regardless of age?
1 year and 2 years
HPV 16 accounts for what % of cervical cancer worldwide?
55-60%
HPV 18 accounts for what % of cervical cancer worldwide?
10-15%
How many genotypes of HPV are associated with cervical cancer?
15-18, (13-14 most common) genotypes
What cofactors increase the likelihood of persistent HPV infection?
Cigarette smoking, a compromised immune system, HIV infection
In women younger than 21, how long does it take on average to clear HPV infection?
8 months
Is newly acquired HPV infection more likely to persist when acquired at age 35 vs 22?
No, appears to have same low change of persistence regardless of age
Why do we cotest for HPV infection at >30yrs when newly aquired HPV infection has same low chance of persistence regardless of age?
HPV infection detected in women older than 30yrs is more likely to reflect persistent infection (correlates with increasing rates of HSIL)
With untreated CIN3, what is the risk of invasive cancer after 30years
30.1%
What materials can interfere with pap smear specimen interpreteration
Blood, discharge, and some lubricants (including personal lubricants used by patients)
What is the conventional technique for pap smears?
Exfoliated cells from transformation zone of cervix are transferred directly to a slide and fixed
What is the liquid-based technique for pap smears?
Exfoliated cells from transformation zone of cervix are transferred to a vial of liquid preservative that is processed in a lab
What percentage of pap smears have obscuring material that caused misinterpretation of results? What percentage of these cases are caused by lubricant use?
0.4% with obscuring material, one half of these possibly related to lubricant
Which pap smear screening technique (liquid-based vs conventional) has higher sensitivity, higher specificity?
No appreciable difference
What is the benefit of liquid-based pap smear compared to conventional?
Single specimen can be used for cytology, HPV testing, and testing for gc/ct infection.
Which HPV vaccines are available (what do they cover)?
Bivalent: HPV 16 and 18
Quadrivalent: HPV 16, 18, 6, and 11
9-valent: Above 4 plus additional 5 high-risk genotypes
Does the bivalent offer any protection against cervical cancers not caused by HPV 16 or HPV 18, if so how many?
Offer limited cross-protection against approximately 30% of cases of cervical cancer caused by other HPV genotypes
At what age can you start vaccinated females against HPV?
Age 9
At what age do you start cervical cancer screening in the general population? What is the exception?
21yo.
Exception of HIV positive or otherwise immunocompromised women
What % of cervical cancer occurs before age 20?
Only 0.1% (approximately 1-2 cases per year per 1,000,000 females 15-19yo)
At what age can you discontinue cervical cancer screening given previously normal testing?
65yo
For which patients >65yo would you continue cervical cancer screening?
Inadequate previous testing.
Hx CIN 2, CIN 3, or adenocarcinoma in situ (<20 yrs prior)
What are the options for cervical cancer screening based on age (method and timing) for general population?
21-29: cytology q3 yrs
30+: cotesting q5yrs or cytology q3yrs
In regards to cervical cancer screening, is cytology or HPV testing more sensitive? More specific?
HPV testing more sensitive.
Cytology more specific
Is cervical cytology better at identifying adenocarcinoma or squamous cell better?
Squamous cell
Is adenocarcinoma of the cervix better detected by cytology or HPV testing?
HPV testing
What is the definition of adequate negative prior screening test results for cervical cancer screening?
Three consecutive negative cytology results or two consecutive negative cotest results within the previous 10 years, with the most recent test performed within the past 5 years
What % of new cases of cervical cancer occur in women 65yo or older (and what % of US population does this age group represent)?
19.6% of new cases. 14.1% of US female population.
What is the median #years after HPV infection until cervical cancer occurs?
15-25years
When is it appropriate to discontinue cervical cancer screening for women who have had a hysterectomy?
If cervix removed and have never had CIN2 or higher. Do not restart screening for any reason
What is the rarest gynecologic malignancy?
Primary vaginal cancer
When should women continue to be screened for cervical cancer after a total hysterectomy?
If history of CIN2+ within the past 20years or ever cervical cancer
What guidelines are available for HPV-only screening for cervical cancer?
SGO and ASCCP interim guidelines: can do HPV only on patients 25+, q3 years. If HPV+, negative 16 and 18, do cytology. If genotyping and cytology negative follow up testing in 1 year.
Is ASCUS, HPV- associated with increased, decreased, or same risk for CIN 3+ as negative cotesting?
Increased risk, although still very low risk
What is the next step in management for women 30-65 with ASCUS, HPV- pap?
Cotesting in 3 years, followed by return to age-appropriate screening if neg results
What is the next step in management for women 30+ with NILM, HPV+ pap?
Option 1. Repeat cotesting in 12 months, if ASCUS or higher or HPV+ do colpo
Option 2. HPV genotyping, if 18 or 18 do colpo
Should patients who received HPV vaccine have different cervical cancer screening?
No
For women with HIV, when should you start cervical cancer screening?
Within 1 year of onset of sexual activity or, if already sexually active, within the first year after HIV diagnosis, but no later than 21yo
At what age do you stop cervical cancer screening in women with HIV?
Continue through a women’s lifetime, do not stop screening
At what age do you start cotesting (pap smears) for women with HIV?
30yo
How frequently do you do pap smears in women with HIV?
If < 30: three consecutive annual cytology negative paps, then q3 yrs
If >30: If cytology only same as above. For cotesting, if negative q3 yrs
With which cytology abnormalities would you perform colpo on a women with HIV?
LSIL+
What is the next step in management for woman >21yr with HIV with ASCUS, HPV+ pap?
Colpo
What is the next step in management for woman >21yr with HIV with ASCUS and no HPV testing available?
Repeat cytology in 6-12 months, colpo for anything ASCUS or worse
What is next step in management for woman <21yo with HIV with ASCUS on pap?
Repeat cytology in 6-12mo (no HPV testing)
What is recommended cervical cancer screening for patients with exposure to diethylsteilbestrol in utero?
Annual cervical cytology screening is reasonable
What is the recommendation for cervical cancer screening in patients who are immunocompromised because of non-HIV causes?
No major society recommendations exist, but reasonable to extrapolate recommendations for women with HIV infection to this group
Women with a history of treatment for CIN2 or higher are at a ***-fold increased risk for invasive disease for up to 20 years after treatment.
2.8
When should women s/p total hysterectomy, who have never had CIN2+, resume cervical cancer screening?
Never resume
