Cervical Screening

Question 1

What is the main aim of cervical cancer screening?

Answer 1

Detect pre malignant changes rather than to detect cancer

Question 2

Who is screened and how often?

Answer 2

All women between 25 and 65
First invitation: age 25
Every 3 years from 25 to 50
Every 5 years from 50-65

After 65 selected patients only

Question 3

How is cervical screening performed?

Answer 3

Explain nature and purpose of test
Visualise cervix with speculum - are there any suspicious areas? If so continue with smear, indicate on referral form, refer for colposcopy under 2ww
Cells collected from cervix - the transformation zone with a brush, which is put in a liquid (liquid based cytology)

Question 4

How are cytology results classified?

Answer 4

Normal
Inadequate (repeat smear)
Borderline changes 20-30% CIN II-III
Mild dyskaryosis 30% CIN II-III
Moderate dyskaryosis 50-75% CINII-III
Severe dyskaryosis 80-90% CIN II-III
Suspected invasion

Question 5

What should be done if borderline or mild dyskaryosis?

Answer 5

HPV test
If positive refer for colposcopy
If negative routine recall

Question 6

What should be done if moderate or severe dyskaryosis?

Answer 6

Refer to colposcopy

Question 7

What should be done if suspected invasion?

Answer 7

Urgent colposcopy

Question 8

What is the process in Scotland?

Answer 8

Women from ages 20-60 screened every 3 years

Question 9

What is colposcopy?

Answer 9

Examination of the cervix by a colposcope - a binocular microscope which magnifies by 6-40x

Question 10

Describe the colposcopy process

Answer 10

Woman in the lithotomy position
Bivalve speculum inserted in vagina
Once cervix visualised, the transformation zone identified and painted with 5% acetic acid - this is preferentially taken up by neoplastic cells
Aceto-white areas identify abnormal areas and this enable punch biopsy to be taken to gain histological diagnosis
Iodine also used - not taken up by neoplastic cells

Question 11

If there is strong uptake of acetic acid, what can be done?

Answer 11

See and treat - perform definitive treatment in same appointment without waiting for biopsy result

Question 12

Does colposcopy detect adenocarcinoma?

Answer 12

No (it usually lies in the endocervical canal)

Question 13

Can a pregnant woman have a colposcopy?

Answer 13

Yes but not a LLETZ

Should wait until 12 w post partum until definitive treatment

Question 14

How is a Large Loop Excision of the Transformation Zone (LLETZ) performed?

Answer 14

In the colposcopy clinic under local anaesthetic using loop diathermy

Question 15

What features are suggestive of CIN or invasion?

Answer 15

Abnormal vascular pattern

Abnormal staining of tissue

Question 16

How is CIN treated?

Answer 16

LLETZ
After this treatment, woman should have smear at 6 months with high risk HPV testing
If negative can return to 3 yearly smears

Question 17

If left untreated, what percentage of CINII-III will progress to cervical cancer?

Answer 17

20-30%

Question 18

What complications of LLETZ are there?

Answer 18

Haemorrhage
Infection
Vasovagal symptoms 
Anxiety
Cervical stenosis 
Small risk of cervical incompetence and premature delivery

Question 19

When is HPV vaccine offered in UK and to whom?

Answer 19

All 12-13 year olds in school year 8
Helps protect against cervical cancer, some mouth and throat cancers, some cancers of anal and genital area and genital warts
Second dose offered 6-12 months after first

Question 20

What percentage of cervical cancers are caused by high risk type HPV?

Answer 20

99.7%

Question 21

What does the vaccination programme currently use?

Answer 21

Gardasil vaccine - protects against HPV 6,11,16,18