Cervical Cancer Screening Dale Akkerman Ob/Gyn, Burnsville office

Remember Goal of cervical cancer screening program is to detect neoplasia to allow intervention to prevent early invasive cervical cancer and to reduce mortality Goal is not to prevent any or all abnormal cytologic reports

Cervical Cancer Screening No screening before age 21 regardless of age of onset of sexual activity Screening every two years between ages of 21-29 and every three years after age 30 after three consecutive normal Pap tests. Stop screening between ages 65-70 if no abnormal Pap tests in 10 years.

Caveat Does not apply to women who are immunosuppressed, HIV positive, have been exposed to DES in utero, or have prior history of CIN 2/3+ Source: American Cancer Society and ACOG

Sources for Abnormal Pap Smear Management Definitive reference for abnormal Pap smear management is ASCCP (American Society for Colposcopy and Cervical Pathology). May download guidelines at asccp.org Simplification found in Initial Management of Abnormal Cervical Cytology. May download at icsi.org

Concept of CIN-2/3+ CIN (cervical intraepithelial neoplasia) is a histologic, not cytologic diagnosis Various cytologic reports are meant to convey more accurately the cytopathologist’s concern that a patient’s lesion has risk of CIN-2, CIN-3, AIS, or cervical cancer

CIN-2/3+ (continued) This significant risk is referred to as CIN-2/3+ Screening results which suggest a high probability of CIN-2/3+ should alert the clinician the patient needs immediate and thorough evaluation to rule out gynecologic malignancy

Concept of Equivalent Risk Presence of HPV+ DNA in an ASC cytology result carries an equivalent risk of CIN-2/3+ as an LSIL cytology result Hence, these results should be managed similarly (colposcopy and ongoing follow-up for adult women)

Special Case: Pregnancy Only diagnosis which alters clinical management of the pregnancy is invasive cancer If screening suggests high risk for CIN-2/3+, patient should undergo colposcopy without endocervical sampling If low risk for CIN-2/3+, either colposcopy as above or wait 8-12 weeks postpartum

Special Case: Younger Women Spontaneous resolution of CIN-1 and CIN-2 occurs at 70% and 50% rates Most HPV+ infections resolve within 24 months Risk of invasive cancer approaches zero For these reasons, no cervical cancer screening is recommended for patients age 20 or younger

ASCUS (Atypical Squamous Cells) Need to known HPV status Concern centers on high-risk subtypes (HPV+) Risk of CIN-2/3+ is 5-10%

ASCUS, HPV negative (HPV-) This Pap smear is considered normal Repeat Pap smear in 12 months If persistent for two years, consider referral for evaluation of findings: source of inflammation or rare circumstance of HPV subtype not in current testing profile

ASCUS, HPV positive (HPV+) Colposcopy Endocervical sampling if no lesion visualized or if colposcopic exam is unsatisfactory

ASCUS and HPV+: Colposcopy shows no CIN Cytology in 6 and 12 months OR Only HPV testing in 12 months If cytology ≥ ASC or HPV +, repeat colposcopy If cytology normal or HPV-, return to routine screening

LSIL (Low-grade squamous Lesion) Colposcopy 15-30% risk CIN-2/3+ 80% HPV+ Endocervical sampling if colposcopic exam unsatisfactory except for pregnant patients

LSIL: CIN-2/3+ Per ASCCP guidelines

LSIL: No CIN-2/3+ Cytology at 6 and 12 months OR Only HPV testing at 12 months If cytology ≥ ASC or HPV +, repeat colposcopy If cytology normal or HPV-, return to routine screening

ASC-H (cannot exclude HSIL) Colposcopy If no CIN-2/3+, manage as LSIL: no CIN- 2/3+ If CIN-2/3+, manage as per ASCCP guidelines

Pregnant, ASCUS or LSIL Preferably immediate colposcopy or defer at least 6 weeks after delivery (better 8-12 weeks postpartum) If colposcopy during pregnancy shows no CIN-2/3+, do follow-up screening postpartum

HSIL (High-grade squam lesion) Up to 95% risk for CIN-2/3+ Either colposcopic exam or immediate LEEP are acceptable options No LEEP for pregnant women

HSIL: no CIN-2/3+ If unsatisfactory colposcopy, perform diagnostic excisional procedure (LEEP) If satisfactory, may observe with colposcopy and cytology at 6 and 12 months OR perform diagnostic excisional procedure (LEEP) If negative cytology X 2, routine screening If HSIL, needs diagnostic excision (LEEP)

AGC (Atypical Glandular Cells) Several subtypes for this cytologic class Also includes AIS (adenoca in situ) For any subtype, need colposcopy; HPV testing; endocervical and endometrial sampling ICSI guidelines streamline ASCCP recommendations

Subsequent Management for AGC Numerous arms and options Refer to ASCCP guideline for particular plan of action based on initial cytology report: AGC favor neoplasia, AGC (NOS), AGC favor endometrial origin, AGC favor endocervical origin, AIS

BEC (Benign Endometrial Cells) Only reported if patient age 40 or older Determine if patient has irregular bleeding, risk factors for endometrial cancer, or if patient is postmenopausal If “yes” for any of these categories, patient needs endometrial sampling Otherwise repeat cytology in 12 months

Risk Factors for Endometrial Ca Tamoxifen or other SERM use Family or personal history of ovarian, breast, colon or endometrial cancer Chronic anovulation Obesity Prior endometrial hyperplasia

Primary HPV Testing Patient ≥ 30 years old Cytology must be negative and no recent change in sexual partner If HPV-, routine screening not needed for at least 3 years If HPV +, repeat cytology and HPV testing in 12 months

Primary HPV testing, HPV+ If both repeat cytology and HPV-, routine screening no sooner than 3 years If cytology negative and HPV+, needs colposcopy If cytology abnormal, follow usual category algorithm

HPV Vaccination Minimum age is 9 years old There is a quadrivalent vaccine (HPV4) for prevention of cervical, vaginal and vulvar cancer and genital warts There is a bivalent vaccine (HPV2) for prevention of cervical cancer Best administered before exposure to HPV from sexual contact

HPV Vaccination, continued Typically administer first dose to females at age 11 or 12 Second dose 1-2 months after first dose and third dose 6 months after first dose (minimum of 24 weeks between first and third dose) Can administer to females between ages of 13 and 18

HPV Vaccination, continued Can do catch-up immunization to age 26 Relatively older females typically have only one strain of HPV and will benefit from the vaccination series HPV4 can be administered as a three-dose series to males aged 9 to 18 to prevent genital warts

HPV Vaccination, continued If pregnancy occurs during series, postpone subsequent doses until after pregnancy completed No evidence of increased fetal abnormalities or fetal wastage from exposure

HPV Vaccination Reactions Alum agent causes 85% to complain of pain and 25% to have redness at site Syncopal episodes not greater than for other vaccinations in same age group 70% of syncopal episodes occur in first 15 minutes; patient should recline for than span of time Source: icsi.org