Cervical Cancer Screening Flashcards
Background
Cervical cancer: malignancy of squamos (most common) or glandular cervical cells; progressive, predictable disease involving clearly defined precursor lesions -> well-suited for screening; incidence in US decreased by >50% since screening began
Epidemiology
> 12,000 new diagnosis of invasive cervical CA and >4200 cervical cancer deaths annually in US; incidency/mortality rates higher in ethnic minorities (Hispanics/latinos>African americans> native americans), women living in rural areas or poverty; disparities primarily mediated by decrease screening and decrease f/u care.
Pahtophysiology
Essentially all cervical CA thought to be assoc w/HPV infection, acquired through sexual contact; >90% infections clear spontaneously w/in 2-5 years, but persistent HPV can lead to dysplasia which can lead to malignancy
Human Papilloma Virus
Classification
dsDNA infecting mucocutaneous tissues; approx. 30 strains trophic for genital area; of these “low risk” strains (6, 11) generally assoc w/ anogenital warts; “high-risk” strains (16, 18) account for approx. 70% of cervical CA cases, included in HPv vaccine
Human Papilloma Virus
Epidemiology
HPV prevalence = 39% in women 18-40, decreases with increase in age; prior to HPV vaccine, lifetime incidence in US population = 80%
Human Papilloma Virus
Risk factors
Multiple sex partners, early onset sexual activity; high-risk sexual partners, hx STIs, immunosuppression (incl HIV)
Cytological Classification of Intraepithelial Cell Abnormalities
Squamous Cell
1
Atypical squamous cells (ASC) of undetermined significance (ASC-US) or high grade (ASC-H)
Cytological Classification of Intraepithelial Cell Abnormalities
Squamous Cell
2
Low-grade squamous intraepithelial lesion (LSIL); Usually assox w/active HPV infection, mild dysplasia, corresponds to cervical intraepithelial neoplasia (CIN)-1 on histology
Cytological Classification of Intraepithelial Cell Abnormalities
Squamous Cell
3
High-grade squamous intraepithelial lesion (HSIL): Mod/severe dysplasia. CIN2-3 or carcinoma in situ on histology
Cytological Classification of Intraepithelial Cell Abnormalities
Squamous Cell
4
Squamous cell carcinoma
Cytological Classification of Intraepithelial Cell Abnormalities
Glandular cell
1
Atypical glandular cells (AGC): endovervical, endometrial, NOS or favor neoplastic
Cytological Classification of Intraepithelial Cell Abnormalities
Glandular cell
2
Endocervical adenocarcinoma in situ
Cytological Classification of Intraepithelial Cell Abnormalities
Glandular cell
3
Adenocarcinoma
Screening modality
cytology
(Papanicolaou smear): sampling of endocervical/ectocervical cells; does not give histology; colposcopy + biopsy required to dx/stage dysplasia/CA
screening modality
HPV testing
Indicated in some instances as component of primary screening and to aid in risk stratification and f/u strategy
Screening modality
visual inspection
If concern for cervical malignancy on exam, refer for colposcopy regardless of cytology or HPV findings
Screening recommendations
<21
no screening
Screening recommendations
21-29
Pap q3y (do not check HPV unless for f/u of abnl pap)
Screening recommendations
30-65
PAP + HPV q5y (cotesting; preferred by ACS/ACOg) or pap q3y (cytology alone)
Screening recommendations
65+
Stop screening if pt has had adequate screening and > 20 years elaspes since resolution of CIN2-3 (if +hx)
Screening recommendations
s/p complete hysterectomy for benign reasons
No screening if no other RFs
Screening recommendations
Immunocompromised, HIV, hx cervical Ca, hs in utero DEs exposure
Annual screening indefinitely
Adequate screening
Defined as 3 consecutive - pap smears or 2 consecutive - pap plus HPv tests w/in 10 years, w/most recent test w/in 5 years -> return to guidelines
Cytology Interpretation and Management
overview
Given myriad potential results and clinical scenarios, only selected guidelines included here
Cytology Interpretation and Management
Unsatisfactory (inadequate sample)
Repeat
Cytology Interpretation and Management
Negative but lacking endocervical cells
Continue routine screening w/o early repeat
Cytology Interpretation and Management
Negative for intraepithelial malignancy (normal)
Routine screening, PAP q3y or PAP + HPV q 5y if 30-65y
Cytology Interpretation and Management
Atypical squamous cells of undetermined significance (ASC0US) in women 21-24
Repeat cytology at 12 months (preferred) or reflex HPV
Reflex HPV:
If HPV -: routine screening
If HPV positive: repeat cytology at 12 mos
12 month cytology:
Negative, ASCUS, or LSIL -> repeat in 12 mos
ASC-H, AGC, HSIL -> coloposcopy
24 month cytology
Negative X2 -> routine screening
if ASCUs or greater -> colposcopy
Cytology Interpretation and Management
ASC-US in women >24
Reflex HPV (preferred) or repeat cytology at 12 mos
Reflex HPV
If HPV - -> cotest at 3 y
If HPV positive -> colposcopy
If reflex HPV unavailable repeat cytology at 12 mos
12 month cytology
Negative-> resume routine screening
greater than or equal to ascus ->colposcopy
Cytology Interpretation and Management
Atypical squamous cells-high grade (ASC-H)
refer for colposcopy
Cytology Interpretation and Management
Low grade squamous intraepithelial lesion (LSIL) in premenopausal pt
For pts 21-24 y, repeat cytology at 12 mos
12 month cytology:
Negative, ASCUS, LSIL -> repeat in 12 months
ASCH, ACG, HSIL -> colposcopy
24 month cytology:
Negative X2 -> routine screening
ascus or greater -> colposcopy
for pts >24 y:
If no HPv testing or HPv + -> colposcopy
If HPV -, repeat cotesting at 12 mos (preferred), but colposcopy acceptable
12 mos cytology:
Negative and HPV - -> routine screening
HPV + and/or greater than or equal to ascus -> colposcopy
Cytology Interpretation and Management
LSIL in postmenopausal pt
Refer for colposcopy or
repeat cytology at 6 and 12 months or
HPV test: if + refer to colposcopy; if - repeat cytology in 12 mos
Cytology Interpretation and Management
LSIL in pregnant pt
Refer for colposcopy
Cytology Interpretation and Management
High grace intraepithelial lesion (HSIL)
Refer for colposcopy
Cytology Interpretation and Management
Atypical glandular cells (AGC)
Refer for colposcopy, HPV test, +/- endometrial bx
Cytology Interpretation and Management
AGC-endometrial
Refer for endometrial bx/ endocervical sampling
Cotesting
Using HPV w/cytology for primary screening; preferred by ASCCP and ACOG for women >30 y
Cotesting Results and Follow-up
Negative for intraepithelial malignancy and HPV
Continue routine screening; repeat combined screening in 5y
Cotesting Results and Follow-up
Negative for intraepithelial malignancy and HPV +
Immediate HPV genotyping for 16 or 16/18:
If + -> colposcopy
If - -> repeat cotesting at 12 mos
Or: repeat cotesting at 12 mos
If both - -> rpt cotesting at 3 y
If either ascus or greater or HPV + -> colposcopy
Cotesting Results and Follow-up
ASCUS and HPV -
Repeat cotesting at 3 y
Cotesting Results and Follow-up
ASCUS and HPV +
colposcopy
Cotesting Results and Follow-up
LSIL and HPV -
Repeat cotesting in 12 mos (preffered) or colposcopy
Cotesting Results and Follow-up
LSIL and HPV +
Colposcopy
Cotesting Results and Follow-up
ASCH or HSIL w/ any HPV results
colposcopy
Cotesting Results and Follow-up
AGC w/ any HPv result
Colposcopy + endometrial sampling +/- endocervical sampling
Colposcopy
Identifies macroscopic changes in cervical epithelium contour, color and vasculature assoc w/ malignancy/premalignancy; accuracy varies w/experience of colposcopist
Dysplasia requires
specialist management
Dysplasia
CIN1
Managed expectancly if preced by low-grade lesion or if present for <24 mos
Dysplasia
CIN2-3
Managed w/ablative (cryotherapy/laser) or excisional (loop electrosurgical excision) tx
Dysplasia
Cervical CA
Mgmt depends on staging, comorbidities, desire to preserve fertility
