Cervical Cancer Screening and Human Papilloma Virus Flashcards
Objectives
- Review the epidemiology of cervical cancer
- Understand HV infection in relation to cervical cancer
- Review USPSTF, ACS, and ACOG cervical cancer screening guidelines for average risk women
- Recognize the Bethesda pap smear reporting system and terminology: ASCUS, LSIL, HSIL
- Download the ACSSP APP for management of abnormal paps
HPV vaccination could prevent more than ____ of cancers caused by HPV
Cancers caused by HPV (5)
- In the US: 35,000 women and men dx’d with HPV related cancers each year
- Estimated new cases cervical ca 2020: 13,800
- Estimated deaths cervical ca 2020: 4,290
- Median age at dx cvx ca: 50
90%
Cervical Cancer/Precancer, Oropharyngeal Cancer, Anal Cancer, Vulvar and Vagina Cancer, Penile Cancer
5 Year Survival Rate
Cervical Cancer =
Relative to breast and uterine cancer - in a developed world is very ____
Low and middle income countries don’t have the ____ for vaccination programs, screening, tertiary prevention (tx)
66.1%
uncommon
infrastructure
Relationship between Cervical CA rate and HPV Vaccination coverage
=
Higher rates of cervical ca associated with lower vaccination in southern states
US Cervical Cancer Disparities
=
Again we see a health disparity in incidence vs. mortality rates in different races >in AA/hispanic/native american
WHO: Global strategy towards eliminating cervical cancer as a public health problem
“Through cost effective, evidence-based interventions, including human papilloma vaccination of girls, screening and tx of precancerous lesions, and improving access to diagnosis and treatment of invasive cancers, we can _____ cervical cancer as a public health problem and make it a disease of the ____”
eliminate, past
**HPV Causes Cervical Cancer**
- >150 types: 40 infect surface epithelia and mucous membranes of genitalia
- 13 types: ___ Risk/_____ (cancer causing)
- Transmission routes (2)
-
Detected in 99.7% of Cervical Cancers
- Two High Risk Types (2), cause 70% of cervical cancers and pre-cancers
- Two Low Risk Types (2), cause 90-100% of (1)
- High Risk/Oncogenic
- sexually acquired, skin to skin
- 16, 18
- 6, 11, condyloma (genital warts)
Risk Factors for Acquiring HPV infection
- ____ age at 1st intercourse
- ____ sexual partners
- Partners w _____
- Oral ____ use
- Imm_______
- Early
- Multiple
- multiple partners
- contraceptive
- Immunosuppression
Risk Factors for Persistent HPV Infection
- _____ age
- HPV ____
- Imm_____ (e.g HIV) or immunosuppression
- High P____
- ______ Predisposition (rare)
- S_____
- Diet:
- ____: CT and HSV
- Pov____
- ___ Exposure
- Increasing
- type
- Immunodeficiency
- Parity
- Genetic
- Smoking
- Lack of fruits/veggies: C, E, folate
- STIs
- Poverty
- DES
Prophylactic HPV Vaccines
**APIC Rec: All children aged __-__**
- __ vaccine series: age > 15: 0, 1-2, 6 mos
- __ vaccine series: age < 15: 0, 6-12 mos
- What is the vaccine called?
**11-12**
- 3
- 2
- Gardasil 9
CDC: Talking to Parents About HPV Vaccine
- Recommend HPV vaccination in the ____ ____ and on the ___ ___ you recommend other vaccines for adolescents
Same way, same day
You can say, “Now that your son is 11, he is due for vaccinations today to help from meningitis, HPV cancers, and whooping cough. Do you have any questions?”
HPV Vaccination Quick Facts
- Safety
- 57 million doses of HPV vaccine distributed - 2013
- 22,000 Adverse events
- 92% ___ serious (pain at site, hives, fainting); serious included HA, n/v, fatigue
- Does NOT increase (1)
- Younger = _____ immune response
- non
- X sexual activity
- better immune response (when you get it before any exposure)
Screening Strategy Options
(3)**
Know that other countries (europe) don’t start screening till __ bc its very ___ and most likely will ____
Pap Test Alone Q3
HPV alone Q5
Co-testing (Pap and HPV)
30, common, will regress
All based on sensitivity and specificity and age based bc HPV is v common in young ages - concern with finding things vs. overtesting -> we are moving starting age 21/25, it will probably move up and up
ACOG Cervical Cancer Screening Guidelines 2016: Average Risk
Age to initiate?
21
HPV is Common, Cervical Cancer Uncommon
-
*Typical HPV Infection is ____
- Average episode lasts 4-20 months
- 90% regress to undetectable w/in 2 yrs P
- ______ is necessary for progression**
- 10% have ____ infx, <2% develop __**
- transient
- Persistence
- persistent, CA
**Even when someone tests positive -> HIGHLY LIKELY IT WILL REGRESS ON ITS OWN**
Long Natural History of HPV
**Average clearance __-__ mos, ___% by 2 years
6-12 mos, 90% by 2 yrs
The Cervix
- Lighter pink area made of _____ cells
- Border is called the ______ zone
- Darker red area made of ______ cells
- Opening of the cervix =
Appearance of Parous Os vs Nulliparous Os?
- Squamous
- Transformation
- Columnar
- Cervical os (Endocervix)
Uneven, wide, fish mouth appearance in the parous os
Nulliparous more smooth and round
Rationale for Screening Recs
- Initiate at Age ___: Incidence cervical cancer is rare (<1%) risks outweight benefits
- Initiate Age __: Incidence is rare (<1%) 20-24 most infx ____ clear HPV
- ___ vs. ___ primary screening age 25-29: high rates of transient infection in 25-29 yo v HPV testing is more
- Age 30-65: __ strategy preferred
- Age > 65: _____ on prior results, life expectancy, SDM
- Abnl pap results: poor predictive validity in this population
- High grade lesions rare with adequately previously screening pts
- 21
- 25, spontaneous
- Pap vs. HPV
- no
- depends
Special Populations: High Risk
Screening Guidelines do NOT apply
- Hx of high grade cervical ____
- Hx of cervical ____
- Hx of ____ exposure
- ____ compromise
- Any woman of any age with a _____ cervical lesion or ____ (refer for _____, regardless of pap/HPV result)
- lesion
- cancer
- DES
- Immuno
- suspicious lesion or symptoms (coloposcopy)
Premalignant Changes
What we are interested in is the presence of
-
SIL (1) or CIN (1)
- Low Grade CIN1: regress ______
- High Grade CIN2/3: _____
- Site: metaplastic _____ of the squamocolumnar _____
-
Squamous Intraepithelial Lesions or Cervical Intraepithelial Neoplasia
- spontaneously
- persist
- epithelium, junction
Result: low grade SIL -> will probably regress on its own
Pap Smear/HPV Testing
- Pt instructions before the visit: avoid in____, d_____, ____ use, vaginal ___ x 2 days prior
- Check labeling of slide or LBC vial with 2 _____
- Clinical history - may lead to “___ risk” designation and different screening _____
- Pap done ____ any bimanual exam
- Speculum: use water or gel ____ for lubrication
- intercourse, douching, tampon, meds
- identifiers
- high risk -> diff screening interval
- BEFORE
- sparingly
Liquid Based Collection
Almost all ______ We don’t really use ____ anymore
Increased opporunity to detect ___ signs of abnormality
Liquid Based Collection, don’t rly use slides anymore
early detection
Bethesda System: Specimen Adequacy: Satisfactory vs. Unsatisfactory
“_______ for Evaluation”
- Appropriate labeling and identifying information
- Relevant clinical information
- Adequate numbers of well preserved and well-visualized squamous epithelial cells
- An adequate endocervical/transformation zone component
Unsatisfactory pap =
Satisfactory
Not enough cellular material -> depending on how well you took the sample
Bethesda system vs. Birads system of breast CA screening
Bethesda System: Categorization of Cellular Component
Hopefully the results will say? (1)
(NILM) Negative for Epithelial Cell Abnormalities
ASC-US
=
- cells do not appear completely ____; not possible to determine ____ of abnormal cells
- infection with ___; symptom of (1), or (1) seen in menopause
- 10-20% of women with ASCUS may have __ 2 or 3; 1/1000 women with ASCUS may have invasive ____
Atypical squamous cells of undetermined significance
- not normal, can’t determine cause
- HPV vs. Benign growth (cyst or polyp) vs. Low hormonal levels in menopause
- CIN 2/3, Cancer
LSIL
=
- HPV ____ infection (____ abnormal cells CIN_)
- Bi____ and K_____
- Lesion involves the intitial ____ of the epithelial layer
Low-grade squamous intraepithelial lesion
- transient (mildly abnormal, CIN1)
- Binucleation and Koilocytes
- one/third of epithelial layer
HSIL
=
- HPV ____ infection
- ____ abnormal cells (CIN_) or _____ abnormal cells (CIN__/____ in situ)
- Nuclear _____, H_____
High-grade squamous intraepithelial lesion
- persistent
- Moderately abnormal CIN2, Severely abnormal CIN3/carcinoma
- enlargement, hyperchromatic
ASC-H
=
- May be a ____ to cervical cancer if not ____
- What is needed? What test? (1)**
Atypical Squamous Cells - Cannot Exclude HSIL
precursor to cancer if not treated
More testing/follow up - COLPOSCOPY
When you can’t exclude high grade -> whatever age needs to be followed up
Colposcopy
When do we use it? What is it?
Follow up to pap: microscope and biopsy
Cervical Cancer Screening Methods: HPV Primary Screening (Woman 25+)
Don’t worry too much about this slide
Treatment Options: Precancerous Lesions (High Grade CIN 2/3) and Carcinoma in Situ
- ____surgery
- ____ Ablation
- _____ Excision (LEEP)
- Cold-____ Conization
- Follow up: _____ surveillance at regular _____
- _____ and ______ to predict/prevent progression under investigation
- Cryosurgery
- Laser
- Loop
- Knife
- Lifelong, intervals
- Biomarkers, Vaccines
Bethesda System: Descriptive Diagosis
for ____ and other ___-neoplastic findings
Pretty much you’ll also get report on presence of _______
infections, non-neoplastic
microorganisms
ASCCP Interim Guidance for Timing of Diagnostic and Treatment Procedures for Patients with Abnormal Cervical Screening Tests
In light of covid 19-pandemic, and in settings where all non-essential medical office visits and elective procedures have been suspended, ASCCP recommends the following
- Individuals with low grade cervical cancer screening tests may have _____ of diagnostic evals up to 6-12 months
- Individuals with high-grade cervical screening tests should have documented ____ to ___ and diagnostic evaluation scheduled within 3 months
- Individuals with high-grade cervical disease without suspected invasive disease should have documented attempts to ____ and procedures scheduled within __ months
- Individuals with suspected invasive disease should have contact attempted within __ wks and evalation within 2 of that contact (4 wsk from initial report or referral)
- postponement
- attempts to contact
- contact, 3m
- 2 wks
