1. Cervical Cancer Screening NURS 541: Women’s Healthcare – Diagnosis and Management

2. Cervical Cancer: Why do we care? Each year in the United States: ◦ 12,000 new cases of invasive cervical cancer ◦ 4000 cancer-related deaths Racially disparate ◦ Most common in racial minorities Mean age for diagnosis ◦ 48 years old

3. Anatomy of the Cervix Surface covered by stratified squamous epithelium ◦ Layers (superficial, intermediate, parabasal, basal) ◦ Modified by estrogen and progesterone Portion of the cervical canal covered by columnar epithelium ◦ Columnar epithelium is a singular layer of mucus secreting cells ◦ Columnar epithelium have cleft like folds and not really a gland ◦ Under colposcopy they appear as grapelike structures

4. Anatomy of the Cervix From www.webmd.com

5. Anatomy of the Cervix The internal os is the opening of the cervix into the uterus and the external os is the opening of the cervix into the vagina Squamocolumnar Junction (SCJ) ◦ Where the columnar cells meet the squamous cells ◦ Original or native SCJ – from birth ◦ New SCJ – the current junction  Location of SCJ depends on age and hormonal changes  Closest to the external os before puberty and in menopause

6. Anatomy of the Cervix Transformation zone (TZ) ◦ Area between the original SCJ and the new SCJ ◦ Squamous metaplasia  Normal transformation of columnar cells to stratified squamous cells

7. Anatomy of the Cervix Ectopy/Ectropion ◦ Eversion of transformation zone to the ectocervix ◦ Most often seen in times with high estrogen  Pregnancy  Oral contraceptive use  Ovulatory phase Nabothian cysts ◦ Mucus-filled cyst  Often seen in the TZ

8. Human Papilloma Virus (HPV) Non-enveloped double stranded circular DNA virus that infects and replicates in epithelial cells ◦ Almost all cervical cancers are caused by HPV ◦ 80% of sexually active individuals are infected sometime in their lifetime with HPV

9. How common is HPV? Prevalence: 20 million in the U.S. Incidence: 5.5 million new cases per year 45% of all 20-24 year olds have HPV ◦ The risk for HPV drops significantly after age 30 Strains 16, 18 Cervical cancer Strains 6, 11 Genital warts

10. Cervical Cancer Screening Papanicolaou (Pap) smear ◦ Collection of cells from the ectocervix (squamous epithelial cells) and endocervix (columnar epithelial cells)  To identify abnormal cells along the squamocolumnar junction (SCJ) ◦ Traditional and liquid-based collection methods

11. HPV testing Often done off a liquid-based Pap smear ◦ Tests for high risk types (16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, 66) ◦ Aim: to detect the prevalence of CIN 2 and 3 in the population  Pap test alone only detects 50 – 60% of CIN 2/3  HPV testing detects 90 – 95% of CIN 2/3 HPV genotyping ◦ Detects HPV type 16 and 18  HPV 16: 55% - 60% of cervical cancers  HPV 18: 10% - 15% of cervical cancers  Other genotypes: 25% - 35% of cervical cancers

12. Cervical Cancer Screening Tips Set up your area beforehand to avoid contamination of counter top, light source K-Y Jelly in small amounts, warm water for lubrication Menopausal women ◦ If the sample comes back inadequate because of insufficient cells, use vaginal estrogen (if not contraindicated) for 2 to 3 weeks before attempting another sample

13. ASCCP Screening guidelines From cap.org

14. You collected the Pap Smear -- What next?

15. The Bethesda System Result TypeDefinition NIL Negative for Intraepithelial lesion LSIL Low-grade squamous intraepithelial lesion ASCUS Atypical squamous cells of undetermined significance ASC-H Atypical squamous cells, cannot exclude high-grade lesion HSIL High-grade squamous intraepithelial lesion AGUS Atypical glandular cells of undetermined significance

16. Pap Smear Results - example

17. What to do with the results?

19. Colposcopy A diagnostic test that allows for better visualization the cervix ◦ Similar to a microscope and has three magnifications. Use of acetic acid, Lugol’s solution ◦ Highlights abnormal lesions on the cervix Biopsies and/or endocervical curettage may be taken

20. Cervical Cancer Screening: Histology CIN Cervical Intraepithelial Neoplasia CIN 1 CIN 2 CIN 3

22. How does HPV affect things? Credit: Lola Pellegrino, thehairpin.com

23. Patient Education and Counseling

24. Risk Factors for Cervical Cancer SEX ◦ Multiple sexual partners ◦ Early age at first intercourse ◦ Penetrative sex (vaginal/anal) Smoking Immunocompromise Those infected with HPV

25. The HPV vaccine Quadrivalent - types 6, 11, 16, 18 (Gardasil) Bivalent - types 16, 18 (Cervarix) Approved for 11-26 year olds Given on a 0, 1-2, 6 month schedule

26. Questions??