1. Cervical Cancer Screening
Dale Akkerman
Ob/Gyn, Burnsville office

2. 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

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

4. 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

5. 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

6. 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

7. 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

8. 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)

9. 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

10. 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

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

12. 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

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

14. 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

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

16. LSIL: CIN-2/3+
Per ASCCP guidelines

17. 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

18. 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

19. 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

20. 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

21. 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)

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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