Screening Relevant to Sexual and Reproductive Health Flashcards
Describe the epidemiology and aetiology of CIN
HPV responsible for 99% of CINs
HPV double stranded DNA, 8 genes
HPV 16+18 responsible for 2/3 of cases of HPV infection
90% of HPV infections self-resolve
Name some risk factors for having HPV
- Increased number of sexual partners
- Immunocompromised
- Smoking
- Prolonged OCP
Describe the regression and progression rates of CIN 1, 2, and 3
CIN 1 - 57% regress, 11% progress, 1% turn to invasive carcinoma
CIN 2 - 42% regress, 22% progress, 5% turn to invasive carcinoma
CIN 3 - 32% regress, >12% turn into invasive carcinoma
Describe the aetiology of VIN
Usual type / low grade
- HPV (mainly 16)
- Smoking
- Immunodeficiency
- Usually pre-menopausal
- Low risk of SCC
High grade / differentiated
- High risk of SCC (2-14%)
- Associated with lichen sclerosis and planus
How is VIN managed?
- Wide local excision
- Imiquimod 5%
- Vulvectomy
Describe vaginal intraepithelial neoplasia (VaIN)
- Most common in 50-60 year olds who have had previous VIN/CIN
- Risk factors include CIN, immunocompromised, DES exposure, radiotherapy
- Occurs in upper 1/3 of vagina usually
- Incidental finding
- Management: WLE, imiquimod cream 5%
Describe penile intraepithelial neoplasia (PIN)
Erythroplasia of Queyrat / Bowens
Rare
Aetiology/risk factors
- Uncircumcised men >50
- HPV 16
- Lichen planus or LS
- Smoking
- Chronic irritation from urine/injury/friction
Diagnosis
- Red plaques on glans or under foreskin, itchy, painful, ulcerated, bleeding
Management
- Biopsy to confirm
- Imiquimod / 5-fluorouracil/ cryo / laser / excision
- 10-30% would develop into SCC
Describe anal intraepithelial neoplasia
Rare
HPV 16
Anal canal has same SCJ as cervix
Risk factors
- HIV / immunocompromised
- Receptive anal sex
- VIN/CIN history
Diagnosis
- Itching, discharge, scaly area, can be asymptomatic
Management
- Laser, imquimod, f-fluorouracil
What criteria must be met for a screening programme to happen?
- Condition is important health problem and natural history understood
- Test must be simple, acceptable, and able to conduct on large populations
- Must be treatment available for the condition
- Must be financially viable; cost effective
- Must be evidence-based
- Must not cause harm
How is a UK screening programme approved?
National Screening Committee
- Make recommendations based on evidence
Ministers
- Make decisions and set policy
NHS England
- Implements the screening programme
UK HSA
- Quality assurance, commissioning, public health awareness, education and guidance, collect KPI data
Describe the NHS cervical screening pathway
HPV primary triage - cytology - colposcopy
Age 25-49: every 3 years
Age 50-65: every 5 years
>65 only if one of last 3 smears were abnormal OR if never had one OR if last smear was under age 50
What cervical screening is offered to HIV +ve individuals?
Annual
What is DES exposure and what change has that led to cervical screening?
DES (diethylstilbestrol) was used to prevent miscarriage / pre-term delivery before 1971
- Daughters and granddaughters of DES exposed patients are at increased risk of clear cell cancer of cervix and vagina
- DES exposure in utero caused abnormal uterine tract formation and these women have annual colposcopy
- No change to cervical screening
Describe the histology of CIN
CIN 1: changes in basal 3rd epithelium +/- HPV changes
CIN 2: changes in basal 2/3 of epithelium and marked nuclear atypia
CIN 3: changes to entire epithelium
Describe the UK breast screening programme
- Mammograms
- Every 3 years from 50 years old to 71st birthday
- Prevents 1300 deaths a year
- However, for every death prevented, 3 women are treated for a cancer which would not have harmed them
What breast screening is offered to high risk individuals?
BRCA carriers - surveillance screening
- Age 25 to 39: annual MRI
- Age 40 to 50: annual MRI and mammography
- Age over 50: annual mammography
Describe the UK bowel screening programme
- FIT kit (faecal immunochemical test)
- Every 2 years from age 50 to 74
- Reduces risk of dying from bowel cancer by 25%
- 2400 bowel cancer deaths prevented each year
- 2% positive and need colonoscopy
How is the bowel cancer screening programme different for high risk individuals?
- Familial adenomatous polyposis (nearly 100%, have annual colonoscopy)
- HNPCC/Lynch syndrome (80% risk) - annual colonoscopy from 25 to 75 years
- Strong family history - single colonoscopy aged between 35 and 45, repeated at 55 and then normal screening
- IBD - colonoscopy 10 years after diagnosis and then normal screening
Why is there not a national prostate cancer screening programme?
PSA is not specific enough
Levels are affected by ejaculation, DRE, prostate biopsy
PSA can be used if symptoms of prostate cancer, or to monitor response to treatment in prostate cancer
If raised PSA - TRUS biopsy +/- MRI
Describe the HPV vaccination programme
Boys and girls aged 12/13 in year 8 have first dose, and then second 6-24 months later
MSM eligible up to 45 years, 2 dose schedule (except if HIV, stick to 3 dose schedule)
HPV 6+11 = genital warts
HPV 16+18 = 80% of cervical cancer (and anal/penile)
HPV 31, 33, 45, 52, 58 = additional 15% of cervical cancers
Gardasil 9 has all of the above
Which HPV strains does Gardasil 9 protect against?
6, 11, 16, 18, 31, 33, 45, 52, 58
