Cancer Screening

Question 1

What is the typical regimen for cervical cancer screening?

Answer 1

A Pap smear is offered to all women between the ages of 25 and 64 yo. Smear frequency depends on age:

• 25-49: 3-yearly screening
• 50-64: 5-yearly screening
• cervical screening cannot be offered to women over 64 yo (unlike breast screening, where patients can self-refer once past screening age)
  https: //www.passmedicine.com/review/textbook.php?s=Papanicolaou

Question 2

What special situations should be considered for cervical screening? (3)

Answer 2

1. Cervical screening in pregnancy is typically delayed until 3 months post-partum UNLESS missed screening or previous abnormal smears
2. Women who have never been sexually active have very low risk of developing cervical cancer and therefore may wish to opt-out of screening
3. Women who have had a total hysterectomy including removal of the cervix no longer need cervical screening

https://www.passmedicine.com/review/textbook.php?s=Papanicolaou

Question 3

What is the main aim of cervical screening?

Answer 3

To detect pre-malignant cells rather than to detect cancer (primary prevention)

Question 4

What is the difference between a traditional Pap test and liquid-based cytology (LBC)?

Answer 4

Pap smears involve smearing sample cells onto a slide for microscopy, while LBC involves rinsing the sample into a preservative fluid or simply removing the brush head into the sample bottle with preservative fluid

Question 5

What are the advantages of LBC over Pap? (2)

Answer 5

1. Reduced rate of inadequate smears
2. Increased sensitivity and specificity

**there is currently a move away from Pap toward LBC

Question 6

When is the recommended time to take a cervical smear?

Answer 6

Despite limited evidence to support this, the NHS recommends taking a smear around mid-cycle

Question 7

How is HPV testing incorporated into cervical screening?

Answer 7

The NHS has moved to an “HPV first” system ie a sample is tested for high-risk HPV first and then IF POSITIVE, cytological examination is performed

Furthermore, the introduction of HPV testing allows patients with mild dyskaryosis to be further risk-stratified, i.e. as HPV is such a strong risk factor patients who were HPV negative could be treated as having normal results.

https: //www.nhs.uk/conditions/cervical-screening/
https: //www.passmedicine.com/review/textbook.php?s=Papanicolaou#

Question 8

What is the protocol for a smear that tests negative for hrHPV?

Answer 8

Return to normal recall (3 or 5 years depending on age) UNLESS:

• test of cure (TOC) pathway ie individuals who have been treated for CIN1, CIN2, or CIN3 (should be invited for follow-up in 6 mo)
• untreated CIN1 pathway
• follow-up for incompletely excised cervical glandular intraepithelial neoplasia, stratified mucin producing intraepithelial lesion, or cervical cancer
• follow-up for borderline changes in endocervical cells

https://www.passmedicine.com/review/textbook.php?s=Papanicolaou#

Question 9

What is the protocol for a smear that tests positive for hrHPV?

Answer 9

Samples are examined cytologically and management is based on whether or not cytology is normal

Question 10

What is the protocol for a hrHPV (+) smear with abnormal cytology?

Answer 10

Colposcopy

Question 11

What cytological changes are considered abnormal on colposcopy? (6)

Answer 11

1. Borderline changes in the squamous or endocervical cells
2. Low-grade dyskaryosis
3. High-grade dyskaryosis (moderate)
4. High-grade dyskaryosis (severe)
5. Invasive squamous cell carcinoma
6. Glandular neoplasia

Question 12

What is the protocol for hrHPV (+) smear with NORMAL cytology?

Answer 12

Repeat test in 12 months
- if repeat test is hrHPV (-), return to normal recall
- if repeat test is still positive, repeat cytology; if cytology normal, repeat in 12 months
> if hrHPV (-) at 24 mo, return to normal recall
> if hrHPV (+) at 24 mo, colposcopy

Question 13

What is the protocol for a smear sample that is “inadequate?”

Answer 13

Repeat sample within 3 months; if two consecutive inadequate samples, colposcopy

Question 14

What is the first step in the follow-up of patients who have previously had CIN?

Answer 14

Invitation for test of cure (TOC) repeat cervical sample 6 months after treatment

Question 15

What are the high risk strains of HPV (hrHPV) associated with cervical cancer? (2)

Answer 15

Strains 16 and 18 (and 33)

**strains 6 and 11 are associated with genital warts

Question 16

Aside from hrHPV infection, what other risk factors are associated with cervical cancer? (6)

Answer 16

1. Smoking
2. COCP
3. High parity
4. Early intercourse, multiple sexual partners
5. HIV
6. Low socioeconomic status

Question 17

Under what circumstances would a woman over the age of 64 be invited for a cervical smear?

Answer 17

If one of her last 3 tests was abnormal

https://www.nhs.uk/conditions/cervical-screening/when-youll-be-invited/

Question 18

What test is used first line for bowel cancer screening?

Answer 18

FIT kit (fecal immunochemical test)

https://www.nhs.uk/conditions/bowel-cancer-screening/

Question 19

When is bowel cancer screening offered?

Answer 19

Offered to patients aged 56-74 every 2 years

Patients 75 yo and older may request a home test kit every 2 years

*one-off bowel-scope screening is no longer offered at age 55 yo (colonoscopy)

Question 20

Why is FIT preferred to FOBT for bowel screening?

Answer 20

FIT (fecal immunochemical test) screening is more specific to human blood and DOES NOT require restricted diet before taking the stool sample; FIT is also more specific to blood from the lower GIT

VS

FOBT may register animal blood (eg from red meat) as a positive test result; also false positives from vitamin C, aspirin, ibuprofen, broccoli, and turnips consumed up to 3 days before the test; FOBT is sensitive to blood from the upper GIT and is therefore less specific for bowel cancer