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Pocket Primary Care > Cervical Cancer Screening > Flashcards

Cervical Cancer Screening Flashcards

1
Q

Background

A

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

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2
Q

Epidemiology

A

> 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.

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3
Q

Pahtophysiology

A

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

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4
Q

Human Papilloma Virus

Classification

A

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

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5
Q

Human Papilloma Virus

Epidemiology

A

HPV prevalence = 39% in women 18-40, decreases with increase in age; prior to HPV vaccine, lifetime incidence in US population = 80%

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6
Q

Human Papilloma Virus

Risk factors

A

Multiple sex partners, early onset sexual activity; high-risk sexual partners, hx STIs, immunosuppression (incl HIV)

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7
Q

Cytological Classification of Intraepithelial Cell Abnormalities

Squamous Cell

1

A

Atypical squamous cells (ASC) of undetermined significance (ASC-US) or high grade (ASC-H)

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8
Q

Cytological Classification of Intraepithelial Cell Abnormalities

Squamous Cell

2

A

Low-grade squamous intraepithelial lesion (LSIL); Usually assox w/active HPV infection, mild dysplasia, corresponds to cervical intraepithelial neoplasia (CIN)-1 on histology

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9
Q

Cytological Classification of Intraepithelial Cell Abnormalities

Squamous Cell

3

A

High-grade squamous intraepithelial lesion (HSIL): Mod/severe dysplasia. CIN2-3 or carcinoma in situ on histology

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10
Q

Cytological Classification of Intraepithelial Cell Abnormalities

Squamous Cell

4

A

Squamous cell carcinoma

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11
Q

Cytological Classification of Intraepithelial Cell Abnormalities

Glandular cell

1

A

Atypical glandular cells (AGC): endovervical, endometrial, NOS or favor neoplastic

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12
Q

Cytological Classification of Intraepithelial Cell Abnormalities

Glandular cell

2

A

Endocervical adenocarcinoma in situ

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13
Q

Cytological Classification of Intraepithelial Cell Abnormalities

Glandular cell

3

A

Adenocarcinoma

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14
Q

Screening modality

cytology

A

(Papanicolaou smear): sampling of endocervical/ectocervical cells; does not give histology; colposcopy + biopsy required to dx/stage dysplasia/CA

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15
Q

screening modality

HPV testing

A

Indicated in some instances as component of primary screening and to aid in risk stratification and f/u strategy

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16
Q

Screening modality

visual inspection

A

If concern for cervical malignancy on exam, refer for colposcopy regardless of cytology or HPV findings

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17
Q

Screening recommendations

<21

A

no screening

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18
Q

Screening recommendations

21-29

A

Pap q3y (do not check HPV unless for f/u of abnl pap)

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19
Q

Screening recommendations

30-65

A

PAP + HPV q5y (cotesting; preferred by ACS/ACOg) or pap q3y (cytology alone)

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20
Q

Screening recommendations

65+

A

Stop screening if pt has had adequate screening and > 20 years elaspes since resolution of CIN2-3 (if +hx)

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21
Q

Screening recommendations

s/p complete hysterectomy for benign reasons

A

No screening if no other RFs

22
Q

Screening recommendations

Immunocompromised, HIV, hx cervical Ca, hs in utero DEs exposure

A

Annual screening indefinitely

23
Q

Adequate screening

A

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

24
Q

Cytology Interpretation and Management

overview

A

Given myriad potential results and clinical scenarios, only selected guidelines included here

25
Q

Cytology Interpretation and Management

Unsatisfactory (inadequate sample)

A

Repeat

26
Q

Cytology Interpretation and Management

Negative but lacking endocervical cells

A

Continue routine screening w/o early repeat

27
Q

Cytology Interpretation and Management

Negative for intraepithelial malignancy (normal)

A

Routine screening, PAP q3y or PAP + HPV q 5y if 30-65y

28
Q

Cytology Interpretation and Management

Atypical squamous cells of undetermined significance (ASC0US) in women 21-24

A

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

29
Q

Cytology Interpretation and Management

ASC-US in women >24

A

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

30
Q

Cytology Interpretation and Management

Atypical squamous cells-high grade (ASC-H)

A

refer for colposcopy

31
Q

Cytology Interpretation and Management

Low grade squamous intraepithelial lesion (LSIL) in premenopausal pt

A

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

32
Q

Cytology Interpretation and Management

LSIL in postmenopausal pt

A

Refer for colposcopy or
repeat cytology at 6 and 12 months or
HPV test: if + refer to colposcopy; if - repeat cytology in 12 mos

33
Q

Cytology Interpretation and Management

LSIL in pregnant pt

A

Refer for colposcopy

34
Q

Cytology Interpretation and Management

High grace intraepithelial lesion (HSIL)

A

Refer for colposcopy

35
Q

Cytology Interpretation and Management

Atypical glandular cells (AGC)

A

Refer for colposcopy, HPV test, +/- endometrial bx

36
Q

Cytology Interpretation and Management

AGC-endometrial

A

Refer for endometrial bx/ endocervical sampling

37
Q

Cotesting

A

Using HPV w/cytology for primary screening; preferred by ASCCP and ACOG for women >30 y

38
Q

Cotesting Results and Follow-up

Negative for intraepithelial malignancy and HPV

A

Continue routine screening; repeat combined screening in 5y

39
Q

Cotesting Results and Follow-up

Negative for intraepithelial malignancy and HPV +

A

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

40
Q

Cotesting Results and Follow-up

ASCUS and HPV -

A

Repeat cotesting at 3 y

41
Q

Cotesting Results and Follow-up

ASCUS and HPV +

A

colposcopy

42
Q

Cotesting Results and Follow-up

LSIL and HPV -

A

Repeat cotesting in 12 mos (preffered) or colposcopy

43
Q

Cotesting Results and Follow-up

LSIL and HPV +

A

Colposcopy

44
Q

Cotesting Results and Follow-up

ASCH or HSIL w/ any HPV results

A

colposcopy

45
Q

Cotesting Results and Follow-up

AGC w/ any HPv result

A

Colposcopy + endometrial sampling +/- endocervical sampling

46
Q

Colposcopy

A

Identifies macroscopic changes in cervical epithelium contour, color and vasculature assoc w/ malignancy/premalignancy; accuracy varies w/experience of colposcopist

47
Q

Dysplasia requires

A

specialist management

48
Q

Dysplasia

CIN1

A

Managed expectancly if preced by low-grade lesion or if present for <24 mos

49
Q

Dysplasia

CIN2-3

A

Managed w/ablative (cryotherapy/laser) or excisional (loop electrosurgical excision) tx

50
Q

Dysplasia

Cervical CA

A

Mgmt depends on staging, comorbidities, desire to preserve fertility

Pocket Primary Care (18 decks)

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