Cervical Cancer Screening Flashcards by Bryce Harmon

Q

Background

A

Cervical cancer: malignancy of squamos (most common) or glandular cervical cells; progressive, predictable disease involving clearly defined precursor lesions -> well-suited for screening; incidence in US decreased by >50% since screening began

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

Epidemiology

A

> 12,000 new diagnosis of invasive cervical CA and >4200 cervical cancer deaths annually in US; incidency/mortality rates higher in ethnic minorities (Hispanics/latinos>African americans> native americans), women living in rural areas or poverty; disparities primarily mediated by decrease screening and decrease f/u care.

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

Pahtophysiology

A

Essentially all cervical CA thought to be assoc w/HPV infection, acquired through sexual contact; >90% infections clear spontaneously w/in 2-5 years, but persistent HPV can lead to dysplasia which can lead to malignancy

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

Human Papilloma Virus

Classification

A

dsDNA infecting mucocutaneous tissues; approx. 30 strains trophic for genital area; of these “low risk” strains (6, 11) generally assoc w/ anogenital warts; “high-risk” strains (16, 18) account for approx. 70% of cervical CA cases, included in HPv vaccine

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

Human Papilloma Virus

Epidemiology

A

HPV prevalence = 39% in women 18-40, decreases with increase in age; prior to HPV vaccine, lifetime incidence in US population = 80%

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

Human Papilloma Virus

Risk factors

A

Multiple sex partners, early onset sexual activity; high-risk sexual partners, hx STIs, immunosuppression (incl HIV)

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

Cytological Classification of Intraepithelial Cell Abnormalities

Squamous Cell

1

A

Atypical squamous cells (ASC) of undetermined significance (ASC-US) or high grade (ASC-H)

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

Cytological Classification of Intraepithelial Cell Abnormalities

Squamous Cell

2

A

Low-grade squamous intraepithelial lesion (LSIL); Usually assox w/active HPV infection, mild dysplasia, corresponds to cervical intraepithelial neoplasia (CIN)-1 on histology

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

Cytological Classification of Intraepithelial Cell Abnormalities

Squamous Cell

3

A

High-grade squamous intraepithelial lesion (HSIL): Mod/severe dysplasia. CIN2-3 or carcinoma in situ on histology

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

Cytological Classification of Intraepithelial Cell Abnormalities

Squamous Cell

4

A

Squamous cell carcinoma

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

Cytological Classification of Intraepithelial Cell Abnormalities

Glandular cell

1

A

Atypical glandular cells (AGC): endovervical, endometrial, NOS or favor neoplastic

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

Cytological Classification of Intraepithelial Cell Abnormalities

Glandular cell

2

A

Endocervical adenocarcinoma in situ

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

Cytological Classification of Intraepithelial Cell Abnormalities

Glandular cell

3

A

Adenocarcinoma

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

Screening modality

cytology

A

(Papanicolaou smear): sampling of endocervical/ectocervical cells; does not give histology; colposcopy + biopsy required to dx/stage dysplasia/CA

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

screening modality

HPV testing

A

Indicated in some instances as component of primary screening and to aid in risk stratification and f/u strategy

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

Screening modality

visual inspection

A

If concern for cervical malignancy on exam, refer for colposcopy regardless of cytology or HPV findings

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

Screening recommendations

<21

A

no screening

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

Screening recommendations

21-29

A

Pap q3y (do not check HPV unless for f/u of abnl pap)

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

Screening recommendations

30-65

A

PAP + HPV q5y (cotesting; preferred by ACS/ACOg) or pap q3y (cytology alone)

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

Screening recommendations

65+

A

Stop screening if pt has had adequate screening and > 20 years elaspes since resolution of CIN2-3 (if +hx)

How well did you know this?

1

Not at all

2

3

4

5

Perfectly

Q

Screening recommendations

s/p complete hysterectomy for benign reasons

Study These Flashcards

A

No screening if no other RFs

Q

Screening recommendations

Immunocompromised, HIV, hx cervical Ca, hs in utero DEs exposure

Study These Flashcards

A

Annual screening indefinitely

Q

Adequate screening

Study These Flashcards

A

Defined as 3 consecutive - pap smears or 2 consecutive - pap plus HPv tests w/in 10 years, w/most recent test w/in 5 years -> return to guidelines

Q

Cytology Interpretation and Management

overview

Study These Flashcards

A

Given myriad potential results and clinical scenarios, only selected guidelines included here

Cytology Interpretation and Management Unsatisfactory (inadequate sample)

Repeat

Cytology Interpretation and Management Negative but lacking endocervical cells

Continue routine screening w/o early repeat

Cytology Interpretation and Management Negative for intraepithelial malignancy (normal)

Routine screening, PAP q3y or PAP + HPV q 5y if 30-65y

Cytology Interpretation and Management Atypical squamous cells of undetermined significance (ASC0US) in women 21-24

Repeat cytology at 12 months (preferred) or reflex HPV Reflex HPV: If HPV -: routine screening If HPV positive: repeat cytology at 12 mos 12 month cytology: Negative, ASCUS, or LSIL -> repeat in 12 mos ASC-H, AGC, HSIL -> coloposcopy 24 month cytology Negative X2 -> routine screening if ASCUs or greater -> colposcopy

Cytology Interpretation and Management ASC-US in women >24

Reflex HPV (preferred) or repeat cytology at 12 mos Reflex HPV If HPV - -> cotest at 3 y If HPV positive -> colposcopy If reflex HPV unavailable repeat cytology at 12 mos 12 month cytology Negative-> resume routine screening greater than or equal to ascus ->colposcopy

Cytology Interpretation and Management Atypical squamous cells-high grade (ASC-H)

refer for colposcopy

Cytology Interpretation and Management Low grade squamous intraepithelial lesion (LSIL) in premenopausal pt

For pts 21-24 y, repeat cytology at 12 mos 12 month cytology: Negative, ASCUS, LSIL -> repeat in 12 months ASCH, ACG, HSIL -> colposcopy 24 month cytology: Negative X2 -> routine screening ascus or greater -> colposcopy for pts >24 y: If no HPv testing or HPv + -> colposcopy If HPV -, repeat cotesting at 12 mos (preferred), but colposcopy acceptable 12 mos cytology: Negative and HPV - -> routine screening HPV + and/or greater than or equal to ascus -> colposcopy

Cytology Interpretation and Management LSIL in postmenopausal pt

Refer for colposcopy or repeat cytology at 6 and 12 months or HPV test: if + refer to colposcopy; if - repeat cytology in 12 mos

Cytology Interpretation and Management LSIL in pregnant pt

Refer for colposcopy

Cytology Interpretation and Management High grace intraepithelial lesion (HSIL)

Refer for colposcopy

Cytology Interpretation and Management Atypical glandular cells (AGC)

Refer for colposcopy, HPV test, +/- endometrial bx

Cytology Interpretation and Management AGC-endometrial

Refer for endometrial bx/ endocervical sampling

Cotesting

Using HPV w/cytology for primary screening; preferred by ASCCP and ACOG for women >30 y

Cotesting Results and Follow-up Negative for intraepithelial malignancy and HPV

Continue routine screening; repeat combined screening in 5y

Cotesting Results and Follow-up Negative for intraepithelial malignancy and HPV +

Immediate HPV genotyping for 16 or 16/18: If + -> colposcopy If - -> repeat cotesting at 12 mos Or: repeat cotesting at 12 mos If both - -> rpt cotesting at 3 y If either ascus or greater or HPV + -> colposcopy

Cotesting Results and Follow-up ASCUS and HPV -

Repeat cotesting at 3 y

Cotesting Results and Follow-up ASCUS and HPV +

colposcopy

Cotesting Results and Follow-up LSIL and HPV -

Repeat cotesting in 12 mos (preffered) or colposcopy

Cotesting Results and Follow-up LSIL and HPV +

Colposcopy

Cotesting Results and Follow-up ASCH or HSIL w/ any HPV results

colposcopy

Cotesting Results and Follow-up AGC w/ any HPv result

Colposcopy + endometrial sampling +/- endocervical sampling

Colposcopy

Identifies macroscopic changes in cervical epithelium contour, color and vasculature assoc w/ malignancy/premalignancy; accuracy varies w/experience of colposcopist

Dysplasia requires

specialist management

Dysplasia CIN1

Managed expectancly if preced by low-grade lesion or if present for <24 mos

Dysplasia CIN2-3

Managed w/ablative (cryotherapy/laser) or excisional (loop electrosurgical excision) tx

Dysplasia Cervical CA

Mgmt depends on staging, comorbidities, desire to preserve fertility