Screening for Cervical Cancer

What is a Pap Smear?

Ø “Papanicolaou test” - 1941
• Dr. Babes & Dr. Papanikolaou
Ø Medical screening method
• Detect premalignant and malignant processes of cervix.
• Prevent progression of abnormal cells to cancer.
• This is NOT a diagnostic test!



How to perform a Pap smear…
Ø Conventional smear
Ø Liquid Based smear
Pap Smear
Ø Sample cervix cells from transformation zone.
• junction of endocervix and ectocervix



Ø Sent to cytology for review of cells.

Ø Classified according to Bethesda System.

Ø Squamous Cell
• Atypical squamous cells (ASC)
l Undetermined Significance (ASC-US)
l Not exclude High Grade (ASC-H)
• Low Grade Squamous Intraepithelial lesion (LSIL)
• High Grade Squamous Intraepithelial lesion (HSIL)
• Squamous Cell Carcinoma

Ø Glandular Cell
• Atypical Glandular cells (AG)
l Undetermined Significance (AG-US)
l Favors Neoplasm
• Adenocarinoma In Situ (AIS)
• Adenocarcinoma


Management of Cervical Dysplasia
Ø Squamous Cells;
l ASCUS
• HPV testing (+ refer, - repeat Pap)
• Repeat Pap in 6 months, if normal, no referral.
• If repeat Pap abnormal, Colposcopy & Cx Bx.
• If HSIL, treat with excision or ablation.

l ASC-H
• HPV test, Colposcopy, Cx Bx & Endocervical Bx.
• If HSIL, treat with excision or ablation.


Ø Squamous Cells;
l LSIL
• In adolescents, just repeat Pap q6-12 months.
• Non-adolescent, HPV test, Colposcopy & Cx Bx.
• If LSIL, repeat Pap 6-12 months.
• If HSIL, treat with excision or ablation.

l HSIL
• HPV test, Colposcopy, Cx Bx, & Endocervical Bx.
• If HSIL present, excision (LEEP) or ablation (cryotherapy).




Ø Glandular Cells;
l AGUS
• HPV screen, Colposcopy, & Endometrial Biopsy

l Adenocarcinoma in situ
• Colposcopy, Endocervical & Endometrial Biopsy
• Diagnostic Excisional Procedure
Dysplasia and HPV
Ø Infection with high risk strains
• 16, 18, 31, 33, 39, 45, 51


Ø Spectrum of HPV;
• Condyloma Acuminata
• Cervical Dysplasia
• Cervical Cancer


HPV
Ø Risk Factors;
l Early onset of intercourse.
l Multiple sexual partners.
l Sex partners who have had multiple partners.
l Cigarette smoking (increase risk X 4).
l Immunosuppression.

Ø Currently HPV vaccinations exist!!
l Reduce incidence of dysplasia and cervical cancer.



ACOG Guidelines for Pap Smears
Ø Start Pap screen at age 21 or 3 years after onset of sexual intercourse.
Ø Stop Pap screen in older women is based on each individual.
Ø Annual screen for women under 30, reduce frequency every 2-3 years for women over 30 with 3 consecutive normal Pap test and negative HPV screen.


Ø Discontinue Pap screen for women with hysterectomy for benign disease.
Ø Pap screen should be combined with HPV testing in women over 30, no more then every 3 years.
Cervical Cancer
Ø 2nd most common cancer among women in developing countries.
l 75% decrease incidence/mortality in developed world (Pap smear)

Ø Risk Factors;
l Early onset of sexual activity
l Multiple sexual partners
l High-risk sexual partner
l History of sexually transmitted diseases
l Smoking (not adenocarcinoma)
l High parity
l Immunosuppression
l Low socioeconomic status
l Prolonged use of oral contraceptives
l Hx of vaginal or vulvar cancer
Cervical Cancer
Ø Signs & Symptoms;
l Abnormal Vaginal Bleeding
l Postcoital Bleeding
l Vaginal Discharge (watery, mucoid, purulent, malodorous).

Ø Types of Cervical Cancer;
l Squamous Cell Cancer
l Adenocarcinoma (Glandular)

Staging of Cervical Cancer
(FIGO)
Ø 0 Carcinoma in situ.
Ø I Cervix carcinoma confined to uterus.
Ø II Cervix carcinoma invades beyond uterus but not to pelvic wall or to the lower third of vagina.
Ø III Tumor extends to pelvic wall and/or involves the lower third of vagina, and/or causes hydronephrosis or nonfunctioning kidney.
Ø IV Tumor extends beyond true pelvis or has involved bladder or rectum
Treatment of Cervical Cancer
Ø Early Stage (I – II)
l Radical Hysterectomy plus pelvic/paraaortic lymphadenectomy with or without adjuvant chemoradiotherapy.
l Radiation Therapy.


**Depends on age, childbearing, disease stage, comorbidities, patient & physician preference.
Treatment of Cervical Cancer

Ø Locally Advanced Disease (II – IV)
l Primary Radiation Therapy with concomitant chemotherapy.

Cervical Cancer Follow Up…
Ø Follow Up;
l Clinical evaluation every three months for one year, every four months for one year, every six months for three years and then annually.
l Annual chest x-ray.
l Other radiographic images (CT, PET scan), as clinically indicated.