1. Copyright © 2005, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum Screening for Cervical Cancer Management of the Abnormal Pap smear DOC Clinic report Author: Amy Shaheen, MD Assistant Professor of Clinical Medicine Duke University Medical Center

2. Copyright © 2005, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum How often should Pap smears be done? The American Cancer Society and ACOG both recommend that initial testing should be performed annually, then screening interval can be increased to every 2-3 in women with 3 or more consecutive normal results who are 30 years and older. (ACOG Practice Bulletin: clinical management guidelines for obstetrician-gynecologists. Number 45, August 2003. Cervical cytology screening. Obstet Gynecol 2003 Aug;102(2):417-27.) The USPSTF recommends the screening interval can be 2-3 years in all women of any age who have had at least 2 normal annual pap smears.

3. Copyright © 2005, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum At what age do I begin screening? Opinions vary on age at which the first pap should be done. ACOG recommends screening by 3 years after onset of sexual activity, or at age 21, whichever comes first. (previously recommended age 18). USPSTF recommends within 3 yrs of onset of sexual activity or age 21. Hysterectomy for benign disease: The USPSTF recommends against screening. They state that yield of cytologic testing is low, and there is poor evidence to suggest screening for vaginal cancer improves outcomes. The ACOG also states such women may discontinue testing.

4. Copyright © 2005, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum Begin Screening (2) High-risk patients: Patients with previous cervical cancer, HIV, immunosuppression, or DES exposure while in utero. –Most guidelines simply suggest more frequent screening. –ACOG states regarding women with previous CIN: “Women who have had such a hysterectomy but who have a history of abnormal cell growth (classified as CIN 2 or 3) should be screened annually until they have three consecutive, negative vaginal cytology tests; then they can discontinue routine screening.”

5. Copyright © 2005, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum At what age do I stop screening? “The USPSTF recommends against routinely screening women older than age 65 if they have had adequate recent screening with normal Pap smears and are not at otherwise high risk for cervical cancer.” ACS calls for cessation of testing in non-high-risk women at age 70. ACOG does not set an upper age limit due to limited studies of older women.

6. Copyright © 2005, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum What do I do with abnormal results? Guidelines that follow are taken from 2001 Consensus guidelines for the management of women with cervical cytological abnormalities, JAMA 2002 287(16): 2120-9 To devise these guidelines, a panel of 121 experts in the diagnosis and management of cervical cancer precursors were assembled. They were invited to participate in a consensus conference, and developed the guidelines after a formal review of the literature, and obtaining input from the professional community through internet bulletin boards.

7. Copyright © 2005, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum What do I do with abnormal results? (2) Unsatisfactory- repeat in 2-4 months; if test repeatedly unsatisfactory, perform additional evaluation with colposcopy/ biopsy as appropriate. One study showed that women with unsatisfactory Paps are more likely to have cancer on follow-up that those with satisfactory Paps. (Ransdell JS et al. Cancer 1997 Jun 25;81(3):139-43) Endocervical cells not present- Opinion varies, but testing can probably safely be performed again in 12 months. Repeat testing in 6 months should be done if previous pap with ASCUS, neoplasia or unexplained glandular abnormality, HPV + for high-risk type in past 12 months, immunosuppression, poor visualization or sampling of the endocervical canal, or insufficient frequency of previous screening.

8. Copyright © 2005, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum What do I do with abnormal results? (3) Blood/ inflammation present- if obscuring of the results and one of the above high-risk concerns, repeat in 6 months.

9. Copyright © 2005, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum What do I do with abnormal results? (4) Intraepithelial/ other cellular abnormalities –ASC-US (Atypical squamous cells of undetermined significance) – repeat cervical cytologic testing, colposcopy, or DNA testing for high-risk types of HPV are all acceptable methods for managing women with ASC-US. Women who test positive for HPV DNA should be referred for colposcopy. Women who test negative may receive cytologic screening again in 12 months. If repeat cytologic screening is the desired option, then interval should be 4-6 months until 2 consecutive negative results are obtained. [see chart below for special circumstances: pregnant, postmenopausal and immunosuppressed women] Rationale: risk of invasive cervical cancer in women with ASC-US is extremely low (0.1-0.2%) The finding of ASC is poorly reproducible among even expert cytologists.

10. Copyright © 2005, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum What do I do with abnormal results? (5) oASC-H (atypical squamous cells, cannot exclude HSIL) - refer for immediate colposcopic evaluation oAtypical glandular cells – “Colposcopy with endocervical sampling is recommended for women with all subcategories of AGC, with the exception that women with atypical endometrial cells should initially be evaluated with endometrial sampling. Endometrial sampling should be performed in conjunction with colposcopy in women older than 35 years with AGC and in younger women with AGC who have unexplained vaginal bleeding. Colposcopy with endocervical sampling is also recommended for women with AIS [Adenocarcinoma in situ]”

11. Copyright © 2005, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum What do I do with abnormal results? (6) oLSIL (low-grade squamous intraepithelial lesion) – the majority of women with this result have either no cervical lesion, or CIN-1 which often spontaneously regresses. For this reason, women have often just been followed with serial cytology evaluations, however, the 2001 consensus panel recommends referral for colposcopy. Exceptions include postmenopausal women, pregnant women, and adolescents. (please see JAMA article for details) oHSIL (high-grade intraepithelial lesion) – refer for colposcopy and endocervical assessment.

12. Copyright © 2005, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum Review questions A 35 y.o. woman comes into your office to discuss family planning. She has been in a monogamous relationship with her current partner for 9 years, and they have both been tested for HIV infection and are negative. She hopes to become pregnant and plans to discontinue using condoms. Her most recent Pap test was 1 year ago and was normal. She has had annual pap tests for the past 15 years that have all been normal. (go to the next slide to continue)

14. Copyright © 2005, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum The correct answer is in 2 years. She can be safely screened at an interval of 3 years, but had her last Pap 1 year ago, so 2 years is correct.

15. Copyright © 2005, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum Review questions (continued) An asymptomatic 48 y.o. woman undergoes her annual physical exam. She had a vaginal hysterectomy for uterine leiomyoma 4 years ago. She has had vaginal pap smears every 3 years, all of which have been normal. (go to the next slide to continue)

17. Copyright © 2005, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum The correct answer is to discontinue pelvic exams and Pap smears. There is no evidence that pelvic exams detect ovarian cancer

18. Copyright © 2005, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum Click here to look at a table that summarizes the management of an abnormal Pap smearClick here to look at a table that summarizes the management of an abnormal Pap smear Please complete the course evaluation here.course evaluation here.

19. Copyright © 2005, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services Duke Internal Medicine Residency Curriculum References Wright et al. 2001 Consensus guidelines for the management of women with cervical cytological abnormalities. JAMA 2002 287(16): 2120-9. Berg et al. “Screening for Cervical Cancer: Recommendations and Rationale”. U.S. Preventive Services Task Force. Jan. 2003 ACOG Practice Bulletin: clinical management guidelines for obstetrician-gynecologists. Number 45, August 2003. Cervical cytology screening. Obstet Gynecol 2003 Aug;102(2):417-27 UpToDate Online 12.2 “Management of the abnormal Papanicolaou smear.” Ransdell JS et al. Cancer 1997 Jun 25;81(3):139-43.