1. Guidelines for Cervical Cancer Screening 26th and 27th January 2010
Presented by
Dr. Nadia Sarhan

2. Cervical cancer Incidence
Cervical cancer the second most common cancer worldwide after breast cancer
Half a million new cases each year. Approximately 80% occurred in developing countries. .
Cervical cancer account to about 10% of all cancers and 9% 0f all cancer death in women.

3. Cervical cancer is the 11th most common cancer in the GCC (1998-2005).
There were 1, 314 cervical cases reported from all GCC states accounted to 1.8% from all cancer and 3.6% from cancers among females. The ASR for all GCC 3.0 per 100,000
( GCC cancer incidence, 2009).

4. Cervical cancer ranked sixth in the GCC States women, however its incidence in the lowest rank worldwide.( )
Qatar /100,000
Oman
Bahrain
UAE
Kuwait
KSA
GCC cancer incidence, 2009).

7. Age Standardized Incidence Rates (per 100,000) of cancer among Bahraini female(1998-2005)
Breast cancer
Trachea, bronchus, lung
Thyroid
Colorectal
Ovary
Cervix uteri

8. Since the Papanicolaou (Pap) smear screening test for cervical cancer was introduced in the United States in 1941, its use has significantly reduced the number of deaths related to the disease.
incidence and mortality of cervical cancer occur in 50% women who had never screened, and over 60% in women had not screened last 5 years
Despite these statistics, cervical cancer is one of the most successfully treated cancers if detected early, with a 73% 5-year survival rate in 2000 compared to a 59% 5-year survival rate in Mortality rates generally increase with age with the highest number of deaths occurring in the age groups

9. Etiology of Cervical Cancer
The primary underlying cause of cervical cancer is infection with human papilloma virus (HPV).
It usually takes 10 to 20 years for precursor lesion caused by HPV (or dysplasia) to develop into invasive cancer (WHO, 2006).
The spectrum of HPV- related genital disease ranges from
external genital warts to cervical dysplasia and malignancy

10. Etiology of Cervical Cancer
Cervical lesions, particularly CIN I and CIN II, may regress to normal; rates of regression for low grade lesions are as high as 75 percent at five years for adults and up to 91 percent at three years in adolescents .
The cervical transformation zone is the area where great majority of pre-cancers and cancers arise. The transformation zone is larger during puberty and pregnancy and (OCPs) for a long time

11. Main Objectives:
1. Early detection of cervical cancer thus allowing early intervention and treatment.
2. Reduce cervical cancer mortality and morbidity.
3. Reduce the financial burden of cervical cancer on the long run.
4. Promote women health by increasing awareness.

12. Cervical Cancer Screening in Ministry of Health Bahrain
The periodic women screening services was initiated in December It aims at early detection of cervical cancer through screening of women at the age of years.
If two smears three years apart, were negative, it should be followed by one smear every five years. Women screening committee issued a protocol for women screening services in 1995 and updated it in 1997 and 2006.
Cervical screening were opportunistic not population based, usually for women attending health centers.

13. A study done in 2003 to evaluate the occurrence of HPV infection and HPV types present among women in Kingdom of Bahrain. In addition the possible role of risk factors for HPV infection and oncogenesis.
The study showed HPV DNA was detected in 11% of women and they were HPV types 16,18,45,62 and 53 with normal cytology.

14. The risk factors found in the study
The first sexual contact was not significant in both groups.
Both groups were monogamous marriages
Over 90% of both groups non smokers
The trend of had 5 children or more not significant in positive group
The proportion of women with OCP usage was similar in both group (Hajji. A. A., 2005)

15. Relative Risks for Cervical Cancer
HIV infection Very high
Moderate dysplasia on Pap smear within past 5 yr Very high
Intercourse within 1 yr of menarche 16
No prior screening
HPV infection (depending on subtype)
Six or more lifetime sexual partners
Low socioeconomic class
Black race (compared with white race)
Smoking
Oral contraceptive use
Barrier contraceptive use

16. Risks Factor for Cervical Cancer
Women having a child at age less than 20 years
Women who have had a high number of live births are more likely to develop cervical cancer.
Having other sexually transmitted infections
having sexual partners who themselves have had multiple sexual partners.
Intrauterine devices are not linked to any increase in cervical cancer risk .

17. Summary of Recommendation
AGE TO START CERVICAL SCREENING According to most reference cervical screening should be initiated on all women beginning at age 21 years or within three years of onset of sexual activity. (NHS 2003, Postgraduate 2003, USPSTF 2006,ACS(2002), ACOG 2003, Michigan Cancer Consortium 2003).

18. WHO Recommendation
It recommends that the priority age group to be screened should be defined by the age-related incidence of invasive cancer of the cervix in the country.
it is recommended screening for women aged years or more, and include younger age group only when the highest-risk group been covered

19. The following groups of women should be offered screening
1. Women ages between years who never been screened.
2. Women whose previous Pap smear was reported as inadequate or showed mild abnormality.
3.Women who have abnormal bleeding after intercourse or after the menopause, or other abnormal symptoms.
4.Women who have been found abnormalities on their cervix

20. Screening frequency 
two Pap smears one year a part, followed by one every three years (CAPRE, 2004).
The USPSTF recommends screening at least every three years; ACS and ACOG advocate annual screening for women under age 30. every two to three years for women aged 30 and older who have had three consecutive normal Pap tests, or every three years if they also are tested for HPV DNA.

21. Absence of a cervical smear over the five years prior to the cancer diagnosis almost tripled the risk for invasive cervical cancer (odds ratio 2.7). (Sirovich.B.E,2009)

22. Adequate screening is defined as,
within the last 5 years the patient has had:
Two or three consecutive normal,
technically satisfactory Pap smears
AND no Pap smear indicating possible dysplasia.

23. Discountuation of cervical cancer screening
in older women is appropriate, provided women have had adequate recent screening with normal Pap results.
Cervical cancer is no more aggressive in older women than in younger and high grade lesions are rare among older women who have been previously screened
Incorporating age as one component but also possibly including life expectancy, results of prior screening, HPV status, and current sexual activity.

24. Recommendation
Periodic cervical screening for women to be started three years after the onset of sexual activity or at age of 21 years whichever comes first.
If the results were normal in the last two consecutive years, repeat the test every three years.
Those women with high risk of cervical cancer should have Pap smear annually.
Discontinuation of cervical cancer screening in older women is appropriate at age 65, provided women have adequate recent screening with normal Pap smear result.

25. In Primary Care
Because of shortage of the resources and lake of studies about the cervical cancer in the region we recommended the following:
screening of women start at the age of , if they having two or three consecutive normal,
technically satisfactory Pap smears AND no Pap smear indicating possible dysplasia to repeat test after three years.

26. Signs and symptoms
Early cervical cancer generally produces no signs or symptoms. As the cancer progresses, these signs and symptoms may appear:
Bleeding from vagina after intercourse, between periods or after menopause
Watery, bloody discharge from vagina that may be heavy and have a foul odor
Pelvic pain or pain during sexual intercourse

27. Methods for cervical screening
Screening is performed using
cervical cytology (Pap test), or a human papillomavirus (HPV) test, or a combination of the two tests.
cervical cytology (Pap test) the conventional Pap smear and the liquid-based, thin layer preparation (ThinPrep in BDF SurePath in SMC. Another liquid-based system, MonoPrep®, is no longer available.
Both used to check for any cervical cell changes, for detecting infectious, pre-malignant, and malignant processes in the transformation zone, the junction of the ecto- and endo-cervix, where cervical dysplasia and cancers arise.

28. Preparing for Pap smear
The test must be done when women not menstruating and does not have vaginal infection.
To improve the accuracy of the test results:
Schedule Pap smear appointment about 2 weeks (10-18 days) after the first day of her last menstrual period
Do not douche within 48 hours before the test.
Do not use tampons, birth control foams, jellies or other vaginal creams or vaginal medications for 48 hours before test.
Refrain from intercourse for 48 hours before the test

29. Procedure for taking Pap smear
Position the patient
Inspect the vulva, vagina and cervix
After lubricated the speculum with warm water only, separate with hand labia. insert the speculum 45 degrees and then back to normal position.

30. HOW TO OBTAIN A SAMPLE 
For both methods, cells are obtained from the external surface of the cervix (ectocervix) and the cervical canal (endocervix) to evaluate the transformation zone (squamocolumnar junction), the area at greatest risk for neoplastic.
Conventional pap:
The slide is then rapidly fixed to avoid air-drying; the usual fixatives are either ethyl ether plus 95 percent ethyl alcohol or 95 percent ethyl alcohol alone

31. the conventional Pap smear

32. Liquid based cytology (LBC)
Insert the cervical broom (spatula) into the cervical os which brushes cell from the neck of the womb and rotate 5 times.
The head of the spatula where cells are lodged is broken off into a small glass vial containing preservative fluid and tightly cap the vial.
The sample is sent to the laboratory where it is spun and treated to remove obscuring material, such as mucus, blood, or pus. A thin layer of the cells is deposited onto slide. The slide is examined by a cytologist.

34. Collection device 
Cotton tipped swabs should be avoided because they collect fewer endocervical cells and do not detect CIN as well as other devices

35. In women at high risk for vaginal cancer because of in utero diethyl stilbestrol exposure, additional samples from the anterior and posterior fornices should be obtained.

36. any lesion that is raised, friable, or has the appearance of condyloma should be biopsied, regardless of previous cytology results or other risk factors for cervical cancer. the only exception is a diagnosis of Nabothian cyst by an experienced examiner

39. Liquid-based cytology advantages over conventional cytology
lower incidence of inappropriate fixation and drying artifact, and less cellular obscuration on the slide resulting in fewer unsatisfactory tests.
Liquid-based and conventional cytology equally well for detection of HSIL, but liquid-based methods perform better for detection of glandular abnormalities, ASCUS, and LSIL .
opportunity to re-test the liquid preparation HPV

40. FACTORS THAT INTERFERE WITH SAMPLING
Menses or other genital tract bleeding
Interval between Pap tests 
Gel lubricants and other contaminants
Vaginal intercourse, douching, and tampon use 

41. Screening Women with special circumstances
Immune-compromised
HIV
Women who have sex with women
If women never sexually active, her chance to develop cervical is very low.
Prior hysterectomy

42. Indication for screening frequency for pregnant women should be same as for women who are not pregnant. Interpretation of Pap smear result during pregnancy is more difficult, so the pregnant woman should be advised to retain for screening 12 weeks after giving birth
acute infection, appropriate treatment should be given and cervical cancer screening should be deferred until the infection has resolved.

43. Risk from screening
discomfort and inconvenience, psychosocial consequences.
costs Annual spending on cervical cancer screening is estimated to exceed $7.5 billion.
adverse health outcomes; Some studies found an association between cold knife conization and preterm delivery (RR 2.59, 95% CI ) and low birth weight (RR 2.53,

44. HPV can be accurately detected using DNA–based testing.
HPV testing plays a vital role in cervical cancer screening programs. HPV testing, either alone or in combination with cervical cytology, has been shown in multiple studies to be more sensitive than cervical cytology alone in detecting high or low grade cervical. HPV testing has better specificity in women over age 30 than in younger women

45. Risk of cervical cancer with HPV
High-risk (oncogenic or cancer-associated)
types Common types: 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68, 69, 82
Low-risk (non-oncogenic) types Common types: 6, 11, 40, 42, 43, 44, 54, 61, 72, 81
Data from: at:

46. The external cervical os is round and small in a nulliparous woman.

47. Cervicitis is an inflammation of the uterine cervix.

48. Cervicitis is suspected if the cervix is erythematous, edematous, or easily friable. Classic mucopurulent cervicitis (thick yellow-green pus) in the cervical os

49. Cervicitis:
Take swab for culture

50. ectopy erythroplasia Postmenopausal cervix

51. Abnormal cervix:
Take swab for culture

52. Cervical polyp:
Benign condition no medical intervention required

53. Cervical cancer

54. Cervical cancer

55. Treatment options for HPV infection
Although there is currently no medical cure for HPV infection the lesions and warts these viruses cause can be treated. Methods commonly used to treat lesions include:
Cryosurgery (freezing that destroys tissue).
LEEP (loop electrosurgical excision procedure, the removal of tissue with hot wire loop).
Conventional surgery

56. The end of part 1

57. Management of abnormal Pap Smear

58. SPECIEMEN ADEQUACY
Absence of an endocervical cell/transformation zone (EC/TZ) component to repeat Pap test in 12 months and not to wait longer.
A specimen is considered "partially obscured" when 50 to 75 percent of the epithelial cells cannot be visualized. Specimens in which more than 75 percent of the cells are obscured are designated unsatisfactory. Women with partially obscuring blood or inflammation should have a repeat test in six months.

59. A specimen is considered "unsatisfactory" for evaluation to repeat Pap test within two to four months .If the cells are obscured by inflammation and a specific infection is identified, treatment should be given before repeating the Pap test.
Findings of endometrial cells are usually benign, but if the finding is not associated with menses or occurs after menopause, it may indicate a risk for an endometrial abnormality

60. Infection/ Organisms
Trichomonas: treat if on liquid-based, but Conventional Pap smears, the diagnosis should be confirmed by wet prep.
Bacterial vaginosis; cervical cytology is not a reliable diagnostic method for bacterial vaginosis, so it need confirmation with clinical testing before treatment.

61. Actinomyces typically in women who have an intrauterine device
Reactive changes/inflammation; The cervical cytology sampling does not need to be repeated unless the patient is HIV positive, in which case it should be repeated in four to six months.

62. Hyperkeratosis : is negative cervical cytology test (
Hyperkeratosis : is negative cervical cytology test (? related to infection or trauma with inflammation, use of a diaphragm). We repeat the cervical cytology test in 6 to 12 months. If hyperkeratosis persists, treatment with topical estrogen may resolve the finding, but no treatment is necessary.

63. Inflammatory
Mild
Moderate and sever evaluate for gonorrhea, Chlamydia, KOH if +ve treat and repeat after 3 months
If –ve repeat after 6 months
Persistent refereed to colposcopy

64. EPITHELIAL CELL ABNORMALITIES:- SQUAMOUS CELLS
Atypical squamous cells Of undetermined Significance (ASC- US) The presence of infection or reactive changes After treatment of the infection, evaluation of ASC-US is performed

65. Management of women (pre-menopausal, post-menopausal and immune compromised (HIV) with ASC-US

67. Adolescent women
Atypical squamous cellsOf undetermined Significance (ASC-US)
Low- grade squamous intraepithelial lesion (LSIL) Encompassing Hpv ,mild dysplasia / (CINI )

69. -with features suspicious of invasion (if invasion is suspected)
High grade squamous Intraepithelial Lesion (HSIL) Encompassing Moderate and sever dysplasia, CIS, CINII,CINIII.
-with features suspicious of invasion (if invasion is suspected)
Squamous cell carcinoma

70. EPITHELIAL CELL ABNORMALITIES:- GLANDULAR CELLS
Atypical glandular cells (AGC) Specify endocervical, endometrial or glandular cells not otherwise specified (NOS)  Atypical glandular cells, favour neoplastic (specify endocervical or not specified) Endocervical adenocarcinoma in situ (AIS) Adenocarcinoma

72. TECHNIQUES FOR FOLLOW-UP OF ABNORMALITIES
Colposcopy 
 After application of acetic acid, visual examination of the cervix under magnification using a colposcope allows identification of specific areas with epithelial changes. The most severely abnormal areas are biopsy to determine the histological diagnosis. This is an office procedure that is performed during a pelvic examination without the need for anesthesia

73. Endocervical curettage
 or sampling (ECS) using a brush or curette is performed in patients with ASC-H, HSIL, AGC, adenocarcinoma in situ (AIS), some cases of LSIL, if ablative treatment is contemplated, and in those with an unsatisfactory colposcopic examination.
ECC is not performed in pregnancy

74. Loop electrosurgical excision procedure
 The loop electrosurgical excision procedure (LEEP), also called large loop excision of the transformation zone (LLETZ), utilizes a very thin wire in the shape of a loop and modern electrosurgical generators that allow accurate and selective blending of the current. The loops are available in a variety of sizes, allowing individualization and avoidance of excessive excision.

75. Cold knife conization 
1.Descripency between cytology and histopathology
2.+ve Endocervical curettage
3.Unsatisfactory
colposcopy.
4.Microinvasive discease.

76. Prevention of cervical cancer
HPV vaccine
Sexual contact
Stop smoking
OCP

77. Vaccine research The HPV vaccine (Gardasil)
The vaccine, Gardasil®, protects against four HPV types, (types 6, 11, 16, and 18) which together cause 70% of cervical cancers and 90% of genital warts. given to girls/women, ages 9-26 years. The vaccine is given through a series of three shots over a six-month period.
About 30 % of cervical cancer will not be prevented by the vaccine, so it will be important for women to continue getting screened for cervical cancer.
Also, the vaccine does not prevent about 10 % of genital warts