Cervical cancer and screening Flashcards
cervical cancer
S/Sx
Most common symptom is none at all
No real symptoms of precancerous lesion – only symptomatic when true invasive cancer is present
Abnormal vaginal bleeding – hallmark is
post coital bleeding
Friability of the cervix – who doesn’t have that
Postmenopausal bleeding
Irregular or heavy menstruation or bleeding between cycles – this is why WebMD causes me strife ☺
cervical screening
Screening recomendations
< 21 yrs — NO screening. Actually recommend AGAINST it!!
21 – 29 yrs – Cytology every 3 years (PAP)
30 -65 yrs – hrHPV with cytology every 5 years (preferred) or cytology alone every 3 years (acceptable)
HPV primary screening
According to American Cancer Society - start screening at 25 y/o and with only HPV screening
FDA approval in 2014 Cobas test Roche; 2018 Onclarity Becton Dickinson
Primary screening with HPV at age 25
Screen every 5 years
Will lead to increased CIN3 detection however questioning increase in number of colposcopies
Issues with this are availability of FDA approved testing for HPV primary screening.
HPV testing
HPV testing is just better
In detecting CIN 2+
Cytology is about 50-80% sensitivity
HPV testing >90% sensitivity
Also cytology is not effective in adenocarcinoma or AIS detection
Cytology was read negative in over half of women 25-29 y/o with CIN3+
Although prevalence of HRHPV is 21.9% in 25-29y/o: HPV 16 is only 5.3% and HPV 18 is 1.6%
cervical screening
when to stop screening
At 65 y/o with adequate negative prior screening and no CIN2+ in last 25 years
Adequate negative screening = 3 consecutive negative paps or 2 consecutive negative HPV tests
If hysterectomy with removal of the cervix and no history of CIN2+
If has surgical history of – “freezing of the cervix” or “burned some cells” – who knows what that pathology was
Cervical cancer
basic rules of management
Colposcopy is recommended for any combination of history and current test results yielding greater than 4.0% + probability of CIN3+
Normal pap with positive other HR HPV with negative 16/18 – repap one year
ASCUS with negative HR HPV – repeat cotesting in 3 years
ASC –H, HGSIL – refer for colpo
Any HR HPV positive for genotype 16 or
18 – refer for colpo
New ASCUS with +other HRHPV or LGSIL with history of negative HR HPV (past 5 years) - repeat cotesting in 1 year (risk of
CIN3+ ~ 2%)
If no history then refer to colposcopy
anyone with an H gets colposcopy, so does HPV 16/18 bc most oncogenic
cervical cancer
Patients will ask – what they can do to make the HPV resolve faster?
No data to support immune supplements or antioxidants
Stress smoking cessation!! Strong link between persistent HPV infection and smoking!
Different algorithm for 21-24 y/o
If ASCUS with positive HR HPV or LGSIL – repeat pap in one year
If in one year – LGSIL or ASCUS then repeat pap in one year
.
Then now after 2 years of abnormal pap – if still >ASC then go to colposcopy.
Why? Most of even CIN 2 will go back to normal.
A note about CIN2 – meta analysis 1973 – 2016 of those managed conservatively – 50% regressed, 32% persisted, 18% progressed to CIN3+. Most regression occurred in the first 12 months, regression rates higher (60%) in women younger than 30 years
Other small points: AIS/AGC
AIS and AGC (Atypical Glandular Cells) – colposcopy with Endocervical Curettage (ECC) and if over 35 y/o endometrial biopsy
Atypical endometrial cells – Endometrial biopsy and ECC if negative then colposcopy
If all negative repeat yearly cotesting x 2 years
Unsatisfactory pap/ Absent TZ/endocervical cells/ Benign endometrial cells
Unsatisfactory pap – repeat in 2-4 months, ignore HPV result, treat with vaginal estrogens if atrophic
Absent TZ/endocervical cells – routine screening
Benign endometrial cells
premenopausal women – no intervention
Postmenopausal women – endometrial sampling
Colposcopy
Colposcopy is examination of the cervix, vagina and/or vulva with a colposcope.
Acetic acid (aka vinegar) is used to aid in the detection of dysplastic tissue
Biopsy and/or Endocervical Curettage is performed
Satisfactory = complete visualization of the TZ or transformation zone aka squamocolumnar junction
cervical cancer
Tx
Treatment:
Most common now is LEEP – Loop electrical excision procedure
Cold cone – to see if AIS is invasive, clean margins.
At times – hysterectomy – only for AIS or invasive carcinoma
