HPV screening programme/cervical smears

Question 1

What year was the cervical screening programme launched in the UK?

Answer 1

1988

Question 2

When do women in England become eligible for cervical screening and how often is cervical screening done?

Answer 2

age 25-64 women are eligible for cervical screening
age 25-49 years they have it every 3 years
age 50-64 years every 5 years

Question 3

What is the primary screening method used in cervical screening programme

Answer 3

Cervical smears are screened for Hr - HPV (strains 16 & 18)

Question 4

what strains of HPV does cervical screening detect

Answer 4

HPV 16 and 18

Question 5

If a smear detects HR - HPV what is the next test performed on the smear

Answer 5

Cytology - this aims to identify CIN (cervical intra-epithelial neoplasia) or CGIN (cervical glandular intra-epithelial neoplasia)

Question 6

what are the stages of CIN and what does CIN stand for

Answer 6

CIN I –> II –> III –> cervical cancer

CIN : cervical intra-epithelial neoplasia

Question 7

How would you explain the diagnosis of CIN to a patient

Is CIN 1/2/3 mean the patient has cervical cancer?

Answer 7

CIN is a term used to describe the presence of abnormal cells on the cervix. These cells are pre-cancerous cells and if left untreated have the potential to progress to cervical cancer. However with treatment and regular smears we can successfully treat CIN and ensure the cells are removed to reduce this risk. Hence it is vital that women attend for regular cervical screening.

Question 8

what is the aim of the cervical screening programme?

Answer 8

To reduce the incidence (number of new cases of cervical cancer) and reduce the number of people whom die from it (mortality)

Question 9

What can CGIN develop into if left untreated?

Answer 9

adenocarcinoma (CGIN is cervical glandular intra-epithelial neoplasia; CGIN is much less common than CIN and the cervical screening programme purpose is to detect CIN not CGIN but sometimes can pick it up)

Question 10

Sam is a 25 year old female who attends for her first cervical smear. The result comes back Hr-HPV positive, cytology negative. When will her next smear be due?

Answer 10

next smear in 12 months time due to HR-HPV detected

Question 11

Sam is a 26 year old female, her first smear detected HR-HPV no cell changes so she attended for a repeat smear 12 month later that has detected HR-HPV again, no cell changes. What should happen now?

Answer 11

Advise Sam that she needs to return in another 12 months for repeat smear if hrHPV still positive, even if no cytology changes at this point she would be referred to colposcopy

(i.e. two further hrHPV positive results following the initial one so 3 in total –> then colposcopy assuming cytology always remains negative)

Question 12

What percentage of cervical cancers can be prevented with regular cervical screening?

Answer 12

Up to 70% of cervical cancers can be prevented with regular cervical screening

Question 13

If everyone attended their cervical screening what percentage of cervical cancers could be prevented?

Answer 13

83%

Question 14

Who is eligible for the HPV vaccine as part of the vaccine schedule in the UK and at what age is it offered

Answer 14

boys and girls aged 12-13 years are offered the HPV vaccine at school (this protects against HPV 16 and 18 and other high risk strains of HPV). They have their second dose about 6-12 months later

Question 15

what is the median time from infection with HPV to developing CIN?

Answer 15

8-14 months

Question 16

List the risk factors for developing cervical cancer

Answer 16

being sexually active from a younger age
smoking
early pregnancy
long term COCP use
HIV infection
Not attending for regular cervical screening

Question 17

What % of the population will be infected with HPV at somepoint in their life?

Answer 17

Approximately 80% of men and women will be infected with HPV at somepoint in their lives; however the immune system can clear it, usually within 2 years

Question 18

What is the treatment for HPV

Answer 18

There is no treatment for HPV; the immune system is capable of clearing HPV usually within 2 years.

Question 19

how is HPV spread

Answer 19

through close intimate skin to skin contact; described as sexually transmitted but can be found rarely in virgins who have not had penetrative sex.

Question 20

before performing a cervical smear what information do you need to gather from the patient?

Answer 20

when was their last smear and what were the results
check they have been recalled for their smear
when was their LMP
what contraception are they on
are they on any hormones - oestrogen, tamoxifen, HRT
do they have any symptoms - e.g. abnormal bleeding, unusual vaginal discharge

Question 21

once you have taken the smear, what information needs to be recorded on the smear vial?

Answer 21

patient name, DOB and NHS number

Question 22

what type of cells is the ectocervix made up of?

Answer 22

squamous epithelium (this is the pink surface you see when you look at a cervix)

Question 23

what kind of cells is the cervical canal made up of?

Answer 23

Columnar epithelium

Question 24

at puberty where is the squamo-columnar junction

Answer 24

At the level of the external os

Question 25

Describe the changes that occur following puberty to the squamo-columnar junction

Answer 25

After puberty or during pregnancy or with exposure to oestrogen the squamo-columnar junction becomes everted. This is sometimes the ‘red’ area also called an ectropion that is visible on speculum examination. This is termed the squamo-columnar junction. This is initially made up of columnar epithelium that has lined the endocervix (cervical canal) but over times changes to squamous epithelium

Question 26

When performing a cervical smear what ‘zone’ is important to sample

Answer 26

The transformation zone: this is the 1cm surround the squamo-columnar junction

Question 27

Describe the changes that occur to the squamo-columnar junction in the post-menopausal period

Answer 27

cervical eversion reverses and the squamo-columnar junction is drawn up into the cervical canal and can be out of sight. Using a cervix brush helps to reach the area and ensure an adequate sample

Question 28

When might you consider using a endo-cervix brush rather than cervex-brush

Answer 28

when the SCJ zone is not visible, in post-menopausal women when the cervical canal is stenosed

Question 29

how do you take a smear

Answer 29

cervex-brush - rotate clockwise 5 times

Question 30

What is the cervical screening programme in Scotland and wales?

Answer 30

They have changed it to be 5 yearly for patients with a cervix aged between 25 years - 64 years

Question 31

What is NI cervical screening programme?

Answer 31

Like England they offer cervical screening to anybody that has a cervix
25-49 years: 3 yearly
50-64 years: 5 yearly

Question 32

Out of the four nations (England, Scotland, wales and NI) which is the only country able to automatically recall patients eligible for cervical or breast screening if trans male but not had top or bottom surgery

Answer 32

Scotland ( if registers on the system post 2015)

Question 33

What is breast cancer screening programme in all four nations

Answer 33

50-71st birthday, 3 yearly, will be invited between 50-53 for first mammaogram on a rolling basis unlike cervical screening where it happens in first year at 25

Question 34

How long do breast screening services hold onto mammogram records

Answer 34

8 years

Question 35

What is a mammogram

Answer 35

X-rays done on both breasts

Question 36

Who is eligible for breast sceeening

Answer 36

Cis female patients who haven’t had bilateral mastectomies
Trans male not had top surgery
Trans women/ non- binary who are on e

Question 37

Who is eligible for cervical screening

Answer 37

Cis female women aged 25-64 years
Transmen who still have a cervix or non binary still with a cervix

Question 38

What are the two oncoproteins associated with HR hpv

Answer 38

E6 and E7

Question 39

What does activation of e6 and E7 oncoproteins lead to?

Answer 39

Activation causes down regulation of tumour suppressor genes p53 and pRb