CERVICAL SCREENING ANGELIKA KAUFMANN, ST4, UHCW, MEDICAL STUDENT INDUCTION, 2015

OUTLINE  Cervical cancer  HPV  Screening in general  Cervical screening  The cervix  Smear results  Colopscopy

CERVICAL CANCER  new cases world wide/year  80% in the developing world  2800 cervical cancer cases in the UK/ year  Cervical screening saves approximately lives a year in England

RISK FACTORS FOR CERVICAL CANCER  HPV infection (99%)  Persistent HPV infection  High viral load  Smoking (increases risk x2)  Multiple sexual partners  Immunosuppression (HIV)  Low socio-economic status  prolonged use of oral contraceptive pill  number of pregnancies (higher number of pregnancies = higher risk).

HPV (HUMAN PAPILLOMA VIRUS)  Over 100 HPV subtypes  Low risk:6+ 11, causing anogenital warts + respiratory papillomatosis  High risk: (31, 33): oncogenic, causing:  Cervical cancer  Anal cancer  Oral cancer  Endemic, 95% of sexually active women will have HPV at some point in their life  Majority of women will gain immunity and fight off HPV

HPV VACCINATION  VLPs= “ virus like particles” (don’t contain DNA, non-infective)  UK: start of immunisation in yrs yrs old girls + catch up thereafter  Cervarix (bivalent) – HVP  Switched to Gardasil in 2012: quadrivalent  3 doses over 6 months (0/2/6 months)  Herd immunity  Long-term studies  ? Need for booster

WHO CRITERIA FOR SCREENING  The condition sought should be an important health problem for the individual and community  There should be an accepted treatment or useful intervention for patients with the disease  The natural history of the disease should be adequately understood  There should be a latent or early symptomatic stage  There should be a suitable and acceptable screening test or examination  Facilities for diagnosis and treatment should be available  There should be an agreed policy on whom to treat as patients  Treatment started at an early stage should be of more benefit than treatment started later  The cost should be economically balanced in relation to possible expenditure on medical care as a whole  Case finding should be a continuing process and not a once and for all project

CERVICAL SCREENING IN THE UK  Organised way  Failsafe mechanisms to ensure abnormal results are acted upon  Standards and Quality control of  The screener  The laboratories  Cyto- and Histopathologist  Colposcopists

LIQUID BASED CYTOLOGY LBC used in the UK since Oct % unsatisfactory smears

NHS CERVICAL SCREENING PROGRAMME (NHSCSP)  Liquid based cytology (LBC)  Since 2003 (England)  Age 25-50: every 3 years  Age 51-65: every 5 years  Scotland + Wales:  Smears before the age of 25 could lead to unnecessary increased cervical treatment with potential negative consequences for future child bearing  Sensitivity 70%  10% false negative smears

CERVICAL SCREENING PROGRAMME 2  Disabled women  Women of ethnic minorities: communication/ leaflets/ information  Lesbian/ bisexual women advised to be screened (“low risk, but not no risk”)  Post hysterectomy  Women with sub-total hysterectomy still require cervical screening  Indication of hysterectomy: ie FU required for persistent CIN (vault smears)

CERVIX  Ectocervix: multiple layers non-keratinizing stratified SQUAMOUS epithelium  Endocervix: single layer COLUMNAR epithelium  Transformation zone = area where columnar epithelium has undergone metaplasia to become squamous epithelium. Between the new and original squamo-columnar junction (Type 1/2/3).

TRANSFORMATION ZONE-COLPOSCOPIC VIEW External os Glandular epithelium/ectropion On ectocervix in Puberty Pregnancy Few weeks post natal (baby girl) New squamo-columnar junction Original squamo-columnar junction TRANSFORMATION ZONE

SMEAR TEST RESULTS DYSKARIOSIS is a cytological diagnosis:  increased nuclear:cytoplasmic ratio  mitotic figures  nuclear pleomorphism  nuclear hyperchromasia  HPV features  koilocytosis (vacuolated cells)  hyperkeratosis  multinucleation

SMEAR TEST RESULTS  Normal  Borderline change (with high risk HP)  In squamous or endocervical cells  Low grade dyskariosis  High grade dyskariosis (moderate)  High grade dyskariosis (Severe)  ?glandular neoplasia of endocervical type  ?Glandular neoplasia (non-cervical)  Invasive disease Refer to colposcopy

TESTING FOR HPV  Cytology and HPV, currently being implemented  If high risk HPV positive, refer to colposcopy.  HPV as test of cure  HPV as primary test as precursor of cytology(currently being evaluated)

COLPOSCOPY  Chaperone/ nurse  Communication!!  Ascitic acid (3%)  Iodine  Colposcope

COLPOSCOPY IMAGES Normal cervix CIN Punctations Mosacicism Normal cervix Iodine negative

CIN (CERVICAL INTRAEPTHELIAL NEOPLASIA) = histological diagnosis  CIN 1 – bottom 1/3 abnormal  CIN 2- bottom 2/3 abnormal  CIN 3- full thickness abnormality CIN2 CIN3 CIN 1CIN 2CIN 3 Regress57%43%32% Persist32%35%56% Progress11%22% Invasive carcinoma 1%5%>12%

TREATMENT OF CIN CIN1  low malignant potential  will usually resolve spontaneously  encourage woman to quit smoking  if persistent may be treated (excision/ablation) CIN 2/3  higher malignant potential  standard treatment is excisional biopsy  offer 'see-and-treat' treatment  Treatment: excisional (ie LLETZ: large loop excision of transformation zone)

COLPOSCOPY IN PREGNANCY  Defer routine screening (12 weeks postpartum).  Difficult examination, only to be done by experienced colposcopist.  Oedematous cervix  Increased vascularity  Ectropion (hyperoestrogenism)  Aim: to exclude invasive disease.  Biopsy only to exclude invasive lesions.  If known smear abnormalities, arrange postpartum follow-up (3–4 months post delivery).

CASE 26 year old woman, first smear, referred with high grade-dyskariosis  How would you explain the smear test result?  What would you like to do next?  How do you explain the examination/ treatment?