1. Chris Marshall Cardiff 4 th year Medical Student

2. Learning Outcomes To understand the current NHS Wales cervical screening programme. To learn the correct method for taking a smear. Gain knowledge about the epidemiology, aetiology and progression of cervical cancer. Understanding the indications and procedure for undertaking colposcopy.

3. Screening definition: A quick reminder: Offering a test to identify those individuals who are more likely to be helped than harmed by further tests or treatment to reduce the risk of disease or its complications

4. The Cervix Anatomy

5. Cervical cancer 2 nd most commonest female ca worldwide Almost 80% of cases occur in developing countries There were over 28oo cases in the UK in 2007 Approx lifetime risk for a female is 1 in 136 Highest incidence occurs in the 45-49 year age group

6. Types of Cervical cancer Squamous cell carcinoma(85%) Adenocarcinoma (15%) Smear test aims to detect early changes of squamous cell carcinoma Rare: Adenosquamous carcinoma Clear cell carcinoma Small-cell carcinoma

7. Risk Factors HPV infection (High risk types) Sexual activity (important to stress not a disease of promiscuity) Early age of first intercourse Number of partners Partner’s sexual history Non barrier methods of contraception Immunosuppression Smoking

8. Natural Hx of Squamous cell cervical cancer Virus life

9. Natural Hx of Squamous cell cervical cancer Over 100 sub-types Types 6 and 11 cause clinical warts (No risk) Types 16, 18,31,33 (and some others are oncogenic) (High Risk) Acquired by skin to skin contact takes 10 – 15 years to develop after HPV infection. Can regress at any stage up to CIN3

10. Symptoms of cervical cancer Early disease may give no symptoms May be abnormal looking/friable cervix May be symptoms postcoital bleeding postmenopausal bleeding Intermenstrual bleeding offensive bloodstained vaginal discharge dyspareunia

11. Cervical Screening Objective To reduce the incidence of and mortality from invasive cervical cancer Method By detection and possible treatment of pre-invasive cervical disease (CIN) Current test Cytological examination of exfoliated cells from cervix

12. Risk reduction in cancer Single test60% 5 yearly (20-64)84% 3 yearly (20-64)91% Annually (20-64)93%

13. HPV Vaccination From September 2008 For girls aged 12-13, with catch up over two years for girls up to 18 Delivered through schools Gardasil® and Cervarix both licensed-Cervarix in Wales 3-dose regimen over six months Reduction in Ca Cervix around 70% Will still need screening

14. Cervical Screening in Wales 230,000 women per year in Wales Target age 20-64, routine recall every 3 years High quality cytology is a highly specific screening test, with estimates of 98-99% Sensitivity estimates between 50-75%

15. Method Identify woman, ensure that she is fully informed regarding nature of test, procedure and likely results and obtain her verbal consent. · Discuss chaperone · Obtain relevant clinical details and complete the request form fully and legibly – this should include any previous abnormal results or treatment, or irregular bleeding. · Remove lid from LBC pot – check expiry date on pot · Choose the appropriate speculum for the woman. · If necessary lubricate with a minimal amount of K-Y jelly (small amount - NOT on TIP of speculum) · Identify and visualise the cervix. · Do not take the smear if unable to see the cervix or if the smear is likely to be heavily contaminated with blood or vaginal discharge. · Use “cervix brush” to sample transformation zone - insert central bristles of cervix brush into endocervical canal deep enough to allow the shorter bristles to fully contact the ectocervix. Push gently (pencil-pressure) and rotate the broom CLOCKWISE 5 times · The sample should scrape the entire circumference of the squamo-columnar junction (SCJ) at all points. · Remove the head of the cervix brush brush (Sure-path technique) and leave in the *pot · Tighten the cap on the pot · Record the woman’s name and DOB on pot · Complete smear requisition form noting sample as LBC and adding the appropriate smear taker ID code. · Place pot and request form into plastic bag · Record details of the smear in the woman’s notes. · Only forward to the laboratory if you are satisfied that the cervix has been seen and adequately sampled. · Advise the woman of how and when she will receive her test result · Advise the woman to report irregular or unusual bleeding or smelly vaginal discharge, even if the smear test is negative. Prof. A. Fiander/Dr A. Tristram 4 18/08/2011 4 · Record the smear in a log book or database so that a check can be made that the result has been received when expected.

16. Method Choose the appropriate speculum for the woman. If necessary lubricate with a minimal amount of K-Y jelly (small amount - NOT on TIP of speculum) Identify and visualise the cervix. Do not take the smear if unable to see the cervix or if the smear is likely to be heavily contaminated with blood or vaginal discharge. Use “cervix brush” to sample transformation zone - insert central bristles of cervix brush into endocervical canal deep enough to allow the shorter bristles to fully contact the ectocervix. Push gently (pencil- pressure) and rotate the broom CLOCKWISE 5 times The sample should scrape the entire circumference of the squamo- columnar junction (SCJ) at all points. · Remove the head of cervix brush (Sure-path technique) and leave in the *pot

17. Method

18. Test Results Negative- 79.5% endocervical cells with nice normal nuclei Inadequate- 9% Borderline- 5% some abnormal nuclei but not clear dyskaryosis Mild dyskaryosis- 5%. Increased nucleus:cytoplasm ≈CIN 1. 50% of changes will return to normal within 6/12 Moderate dyskaryosis- 1% +abnormal nuclei ≈CIN2 Severe dyskaryosis- 0.5%. ≈CIN 3 Glandular neoplasia- can identify adenocarcinoma of cervix, endometrium or elsewhere.

19. CIN Video

20. Colposcopy- referral 3x Borderline smears 2x Mild dyskaryosis Moderate dyskaryosis or worse 3x inadequates

21. Colposcopy- what is it? “direct magnified inspection of the surface of a woman's genital area”

22. Colposcopy- Acetic acid applied to the cervix. Abnormal dyskaryotic/dysplastic cells will stain white. A water-based solution of iodine is then gently applied to the rest of the cervix to identify the complete area of abnormality. With iodine, the normal cells stain jet black and the abnormal cells stain yellow. In most cases there is good correlation between the abnormality suggested by the cervical smear and the appearances seen through the colposcope. In cases of doubt a small biopsy can be taken from the worst looking area for analysis. Women who have an obvious abnormality at colposcopy, or who have a positive biopsy result will proceed to treatment. The most common form of treatment is called LLETZ (Large Loop Excision of the Transformation Zone.

23. Invasive Squamous Carcinoma Video

24. Summary Cervical Screening effective tool for reducing cervical cancer HPV immunisation will help reduce incidence of cervical cancer but screening still required. Screening indicates precancerous changes which guide referral to Colposcopy Colposcopy and biopsy identify dysplasia and guide treatment.