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The Latest and Greatest on Pap Smear ScreeningSUSAN M. SHERIDAN, M.D., F.A.C.O.G
CASPER OBSTETRICAL AND GYNECOLOGIC ASSOCIATES, CASPER, WY
No conflicts to disclose
Developments Affecting Screening Guidelines� Persistent infection with HIGH RISK HPV is necessary for
development of cervical cancer
� HPV 16: most carcinogenic, accounts for 55-60% of all cervical cancer
� HPV 18 accounts for 10-15% of cervical cancers
� Greater proportion of glandular cancer, adenocarcinoma, adenosquamouscarcinoma
� 10 other HPV genotypes account for remaining 25-35%
� Approximately 90% of HPV infections are TRANSIENT
� Undetectable within 1-2 years
� Persistence of HPV 16 over 1-2 years:
� 20-30% risk of CIN 3 over 5 years
� Untreated CIN 3 has 30% probability of becoming cancer over 30 years, treated CIN 3 has 1% probability of becoming invasive
Objectives of Screening for Cervical Cancer
� Prevention of morbidity and mortality from cervical cancer
� Avoid detection and unnecessary treatment of
� Transient HPV infections
� Benign lesions likely to regress spontaneously
� Minimize harms associated with false positive tests and overtreatment
� Increased risks after LEEP
� Preterm birth (OR 1.7)
� Low birth weight (OR 1.8)
� PPROM (OR 2.7)
Enhancing Pap smear screening with HPV testing
� HPV testing has increased sensitivity compared to cytology
� Lower specificity
� Better reproducibility
� May better predict development of CIN 3+ over the next 5-15 years than cytology
� Incorporation of HPV into screening allows:
� Increased disease detection � improving benefits of screening
� Increased length of screening � decreasing harms
Obstacles to prevention of cervical cancer� Invasive cervical cancer rates are 7x higher
in low-resource, medically underserved regions
� Disease linked to socioeconomic, geographic, and racial disparities
� 50% of all cervical cancers diagnosed in women who have NEVER BEEN SCREENED
� Additional 10% occur in women not screened within the past 5 years
Cervical Cancer Screening by Age
� Women under age 21 SHOULD NOT BE SCREENED
� Regardless of age of sexual initiation or other risk factors
� Incidence of cervical cancer is rare and has not changed with increased screening over the past 4 decades
� Screening not associated with cancer prevention in this age group
� Women ages 21-29 screen with CYTOLOGY ALONE every 3 years
� HPV testing should not be used for screening
� Annual screening TRIPLES the number of colposcopies
� Minimal cancer risk reduction (3/1000 versus 5/1000)
� Reflex HPV can be added to ASCUS cytology for triage
Cervical Cancer Screening Women Aged 30-65
� Cotesting EVERY 5 YEARS with cytology and HPV �PREFERRED
� Increased detection of prevalent CIN 3+ in subsequent screening
� Enhances identification of adenocarcinoma and its precursors
� 3 year to 5 year intervals minimal change in lifetime cervical cancer risk (0.39% vs. 0.61%) with significant reduction in colposcopies
� 3 year cytology to 5 year cotesting is comparable (0.69% vs. 0.61%)
� Cytology alone EVERY 3 YEARS �ACCEPTABLE
Management of HPV Positive, Cytology Negative cotests
� Option 1: Repeat contesting in 12 months
� HPV positive at 12 months COLPOSCOPY
� Option 2: Immediate HPV genotype-specific testing for HPV 16/18 or HPV 16 alone
� HPV 16 or HPV 16/18 positive directly to COLPOSCOPY
Women Older than age 65
� 1) Evidence of adequate negative prior screening
� 2) No history of CIN 2+ in the last 20 years
�Should NOT BE SCREENED
�Screening should not resume for any reason, including new sexual partner
� Based upon extended natural history of disease, new HPV infections and newly detected CIN 3 will have insufficient time to progress to invasive cancer in the woman’s lifetime (cancer develops median of 20-25 years after infection)
Tools for following new screening guidelines and management of abnormal
tests
• asccp.org• Screening guidelines• Management guidelines
• ASCCP Mobile Consensus Guidelines for Smartphone/iPad $9.99