1. In the Name of God

2. Screening of Cervical Cancer Pap smear and colposcopy F.Behnamfar Gynecology Oncology Fellowship Associate Professor Isfahan University of medical Sciences Isfahan University of medical Sciences

3. Epidemiology and Risk Factors Second most common cancer among women worldwide 83% of cases in developing countries 12,200 new cases and 4210 cancer related deaths in USA,2010 50-60 million pap tests are performed in the US each year,3.5 million abnormal and 2.5 million colposcopy each year

4. Natural History External genital warts,1% Cervical intraepithelial neoplasia (CIN) Slow malignant transformation Slow malignant transformation long latency period for cervical cancer long latency period for cervical cancer CIN I,II,II CIN I,II,II

6. Papanicolaou Smear Conventional Thin layer,liquid based Cytology report includes Adequacy General categorization Epithelial cell abnormality Glandular cell abnormality

12. Abnormal pap smear ASCUS LSIL HSIL

13. Cytologic diagnosis Pap test yeilds cytologic diagnosis Diagnosis of CIN or cervical cancer requiers a tissue sample for histologic diagnosis

14. Pap Test Screening test rather than diagnostic test Sensitivity and specificity Liquid based/ conventional pap smear Effectiveness No pap in last five years, risk of cervical cancer is threefold 90% risk reduction

15. Follow up of abnormal cytology ASCUSASC-H AGC Risk for CIN 2-3 and AIS,serious precursor of adenocarcinoma LSIL(CIN I- HPV infection) HSIL

16. HPV test High risk HPV,16-18… Transient Infection Screeningtriage

19. Screening Parameters Initial screening Discontinuing screening Frequency of screening Perior hysterectomy HPV Vaccination

26. THANKS

27. Management HPV and CIN 1:Follow up(60-85% regress spontaneously in 2 years) CIN 2-3: LEEP (loop electro surgical exision of T zone) Cryo,Laser,Hysterectomy Cryo,Laser,Hysterectomy

28. Pap smear 79% reduction in cervical cancer 47-62%sensitivity(30% of cervical cancers…) Liquid based,80% sensitive Auto prep Inadequacy,repeat in 6-12 months Inadequacy,repeat in 6-12 monthsGenerally: negative for intraepithelial lesion Epithelial cell abnormality Other:glandular cell abnormalities

29. Screening Beginning at 21y,or 3y after onset of sexual activity Can stop at 70 Yearly<30 2-3 years>30(if pap&HPV neg) HPV>99%sensitive

30. Cervical Cancer 3 rd most common gyn cancer in USA Squamous most common Adenocarcinoma increasing Clinically staged Risk factors Evaluation(vaginal bleeding,post coital,irregular, post menopausal) Discharge Obvious tumor Suspicious,colposcoy biopsy,conization

31. Staging Stage I(1a1, 1a2,1b1, 1b2) StageIIStageIIIStageIV