Transcript Cervical cancer screening - Family Practice Residency

Guidelines for Cervical
Cancer Screening
26th and 27th January 2010
Presented by
Dr. Nadia Sarhan
Cervical cancer Incidence
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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.
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Cervical cancer is the 11th most
common cancer in the GCC (19982005).
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).
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Cervical cancer ranked sixth in the GCC States
women, however its incidence in the lowest rank
worldwide.(1998-2005)
Qatar
8.4/100,000
Oman
7.8
Bahrain
6.5
UAE
5.9
Kuwait
4.5
KSA
2.2
GCC cancer incidence, 2009).
Age Standardized Incidence Rate (ASR) of
Cervical Cancer in the GCC States, 1998-2005
9
ASR per 100,000
8
7
6
5
4
3
2
1
0
KSA
Kuwait
UAE
Bahrain Oman
Qater
GCC
A
q
Fi
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n
Ku d
wa
it
UA
Ba E
hr
Pa ain
kis
Au tan
str
al i
a
US
A
O
m
an
UK
Q
a
Th te r
ail
a
G nd
am
bia
I
Co n dia
lo m
b ia
Ira
KS
ASR per 100,000
comparision of ASR of cervical cancer in the GCC states
with selected countries
40
35
30
25
20
15
10
5
0
Age Standardized Incidence Rates
(per 100,000) of cancer among
Bahraini female(1998-2005)
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Breast cancer
Trachea, bronchus, lung
Thyroid
Colorectal
Ovary
Cervix uteri
53.4
12.2
8.2
8.7
8.5
6.5
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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.
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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
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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 1950. Mortality rates
generally increase with age with the highest number
of deaths occurring in the 75-79 age groups
Etiology of Cervical Cancer
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The primary underlying cause of cervical cancer is
infection with human papilloma virus (HPV).
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It usually takes 10 to 20 years for precursor lesion
caused by HPV (or dysplasia) to develop into
invasive cancer (WHO, 2006).
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The spectrum of HPV- related genital disease ranges
from
external genital warts to cervical dysplasia and
malignancy
Etiology of Cervical Cancer
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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
Main Objectives:
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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.
Cervical Cancer Screening in
Ministry of Health Bahrain
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The periodic women screening services was
initiated in December 1992. It aims at early detection
of cervical cancer through screening of women at
the age of 35-64 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.
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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.
The risk factors found in the study
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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)
Relative Risks for Cervical
Cancer
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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
10
HPV infection (depending on subtype) 2.5-30
Six or more lifetime sexual partners
5
Low socioeconomic class
5
Black race (compared with white race)
2.5
Smoking
2
Oral contraceptive use
1.2-1.5
Barrier contraceptive use
0.6
Risks Factor for Cervical Cancer
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Women having a child at age less than 20 years
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Women who have had a high number of live births are more
likely to develop cervical cancer.
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Having other sexually transmitted infections
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having sexual partners who themselves have had multiple
sexual partners.
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Intrauterine devices are not linked to any increase in cervical
cancer risk .
Summary of Recommendation
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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).
WHO Recommendation
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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 35-54 years or more, and include
younger age group only when the highestrisk group been covered
The following groups of women should be
offered screening
1. Women ages between 25-65 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
Screening frequency
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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.
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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)
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.
Discountuation of cervical
cancer screening
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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.
Recommendation
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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.
In Primary Care
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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 30-64
, 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.
Signs and symptoms
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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
Methods for cervical screening
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Screening is performed using
cervical cytology (Pap test), or a human
papillomavirus (HPV) test, or a combination of the
two tests .
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cervical cytology (Pap test) the conventional Pap
smear and the liquid-based, thin layer preparation
(ThinPrep in BDF SurePath in SMC. Another liquidbased system, MonoPrep®, is no longer available.
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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.
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
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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
Procedure for taking Pap smear
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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.
HOW TO OBTAIN A SAMPLE
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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 airdrying; the usual fixatives are either ethyl ether
plus 95 percent ethyl alcohol or 95 percent ethyl
alcohol alone
the conventional Pap smear
Liquid based cytology (LBC)
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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.
Collection device
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Cotton tipped swabs should be avoided
because they collect fewer endocervical
cells and do not detect CIN as well as
other devices
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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.
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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
Liquid-based cytology
advantages over conventional
cytology
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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
FACTORS THAT INTERFERE
WITH SAMPLING
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Menses or other genital tract
bleeding
Interval between Pap tests
Gel lubricants and other
contaminants
Vaginal intercourse, douching, and
tampon use
Screening Women with special
circumstances
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Immune-compromised
HIV
Women who have sex with women
If women never sexually active, her
chance to develop cervical is very low.
Prior hysterectomy
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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.
Risk from screening
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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 1.80-3.72)
and low birth weight (RR 2.53, 1.19-5.46
HPV can be accurately
detected using DNA–based
testing.
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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
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
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Data from: at: www.cancer.gov/cancertopics/factsheet/Risk
The external cervical os is round
and small in a nulliparous woman.
Cervicitis is an inflammation of the
uterine cervix.
Cervicitis is suspected if the cervix is
erythematous, edematous, or easily friable.
Classic mucopurulent cervicitis (thick
yellow-green pus) in the cervical os
Cervicitis:
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Take swab for culture
ectopy erythroplasia Postmenopausal cervix
Abnormal cervix:
Take swab for
culture
Cervical polyp:
Benign condition no medical intervention
required
Cervical cancer
Cervical cancer
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
The end of part 1
Management of
abnormal Pap Smear
SPECIEMEN ADEQUACY
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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.
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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
Infection/ Organisms
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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.
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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.
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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.
Inflammatory
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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
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
Management of women (pre-menopausal,
post-menopausal and immune compromised
(HIV) with ASC-US
Repeat test twice
6 and 12 months
If both negative
If ASC-US or more
Normal screening
interval
Referred for
coloposcopy
Adolescent women
Atypical squamous cellsOf
undetermined Significance (ASC-US)
Low- grade squamous intraepithelial
lesion (LSIL) Encompassing Hpv
,mild dysplasia / (CINI )
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
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
TECHNIQUES FOR FOLLOW-UP
OF ABNORMALITIES
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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
Endocervical curettage
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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
Loop electrosurgical excision
procedure
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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.
Cold knife conization
1.Descripency between
cytology and
histopathology
2.+ve Endocervical
curettage
3.Unsatisfactory
colposcopy.
4.Microinvasive discease.
Prevention of cervical cancer
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HPV vaccine
Sexual contact
Stop smoking
OCP
Vaccine research
The HPV vaccine (Gardasil)
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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 sixmonth 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