Cervical Cancer Screening and Human Papilloma Virus

Question 1

Objectives

Answer 1

• Review the epidemiology of cervical cancer
• Understand HV infection in relation to cervical cancer
• Review USPSTF, ACS, and ACOG cervical cancer screening guidelines for average risk women
• Recognize the Bethesda pap smear reporting system and terminology: ASCUS, LSIL, HSIL
• Download the ACSSP APP for management of abnormal paps

Question 2

HPV vaccination could prevent more than ____ of cancers caused by HPV

Cancers caused by HPV (5)

• In the US: 35,000 women and men dx’d with HPV related cancers each year
• Estimated new cases cervical ca 2020: 13,800
• Estimated deaths cervical ca 2020: 4,290
• Median age at dx cvx ca: 50

Answer 2

90%

Cervical Cancer/Precancer, Oropharyngeal Cancer, Anal Cancer, Vulvar and Vagina Cancer, Penile Cancer

Question 3

5 Year Survival Rate

Cervical Cancer =

Relative to breast and uterine cancer - in a developed world is very ____

Low and middle income countries don’t have the ____ for vaccination programs, screening, tertiary prevention (tx)

Answer 3

66.1%

uncommon

infrastructure

Question 4

Relationship between Cervical CA rate and HPV Vaccination coverage

=

Answer 4

Higher rates of cervical ca associated with lower vaccination in southern states

Question 5

US Cervical Cancer Disparities

=

Answer 5

Again we see a health disparity in incidence vs. mortality rates in different races >in AA/hispanic/native american

Question 6

WHO: Global strategy towards eliminating cervical cancer as a public health problem

“Through cost effective, evidence-based interventions, including human papilloma vaccination of girls, screening and tx of precancerous lesions, and improving access to diagnosis and treatment of invasive cancers, we can _____ cervical cancer as a public health problem and make it a disease of the ____”

Answer 6

eliminate, past

Question 7

**HPV Causes Cervical Cancer**

• >150 types: 40 infect surface epithelia and mucous membranes of genitalia
  
  • 13 types: ___ Risk/_____ (cancer causing)
  • Transmission routes (2)
• Detected in 99.7% of Cervical Cancers
  
  • ​Two High Risk Types (2), cause 70% of cervical cancers and pre-cancers
  • Two Low Risk Types (2), cause 90-100% of (1)

Answer 7

• High Risk/Oncogenic
• sexually acquired, skin to skin
• 16, 18
• 6, 11, condyloma (genital warts)

Question 8

Risk Factors for Acquiring HPV infection

• ____ age at 1st intercourse
• ____ sexual partners
• Partners w _____
• Oral ____ use
• Imm_______

Answer 8

• Early
• Multiple
• multiple partners
• contraceptive
• Immunosuppression

Question 9

Risk Factors for Persistent HPV Infection

• _____ age
• HPV ____
• Imm_____ (e.g HIV) or immunosuppression
• High P____
• ______ Predisposition (rare)
• S_____
• Diet:
• ____: CT and HSV
• Pov____
• ___ Exposure

Answer 9

• Increasing
• type
• Immunodeficiency
• Parity
• Genetic
• Smoking
• Lack of fruits/veggies: C, E, folate
• STIs
• Poverty
• DES

Question 10

Prophylactic HPV Vaccines

**APIC Rec: All children aged __-__**

• __ vaccine series: age > 15: 0, 1-2, 6 mos
• __ vaccine series: age < 15: 0, 6-12 mos
• What is the vaccine called?

Answer 10

**11-12**

• 3
• 2
• Gardasil 9

Question 11

CDC: Talking to Parents About HPV Vaccine

• Recommend HPV vaccination in the ____ ____ and on the ___ ___ you recommend other vaccines for adolescents

Answer 11

Same way, same day

You can say, “Now that your son is 11, he is due for vaccinations today to help from meningitis, HPV cancers, and whooping cough. Do you have any questions?”

Question 12

HPV Vaccination Quick Facts

• Safety
  
  • 57 million doses of HPV vaccine distributed - 2013
  • 22,000 Adverse events
  • 92% ___ serious (pain at site, hives, fainting); serious included HA, n/v, fatigue
• Does NOT increase (1)
• Younger = _____ immune response

Answer 12

• non
• X sexual activity
• better immune response (when you get it before any exposure)

Question 13

Screening Strategy Options

(3)**

Know that other countries (europe) don’t start screening till __ bc its very ___ and most likely will ____

Answer 13

Pap Test Alone​ Q3

HPV alone Q5

Co-testing (Pap and HPV)

30, common, will regress

All based on sensitivity and specificity and age based bc HPV is v common in young ages - concern with finding things vs. overtesting -> we are moving starting age 21/25, it will probably move up and up

Question 14

ACOG Cervical Cancer Screening Guidelines 2016: Average Risk

Age to initiate?

Answer 14

21

Question 15

HPV is Common, Cervical Cancer Uncommon

• *Typical HPV Infection is ____
  
  • ​Average episode lasts 4-20 months
  • 90% regress to undetectable w/in 2 yrs P
• ______ is necessary for progression**
• 10% have ____ infx, <2% develop __**

Answer 15

• transient
• Persistence
• persistent, CA

**Even when someone tests positive -> HIGHLY LIKELY IT WILL REGRESS ON ITS OWN**

Question 16

Long Natural History of HPV

**Average clearance __-__ mos, ___% by 2 years

Answer 16

6-12 mos, 90% by 2 yrs

Question 17

The Cervix

• Lighter pink area made of _____ cells
• Border is called the ______ zone
• Darker red area made of ______ cells
• Opening of the cervix =

Appearance of Parous Os vs Nulliparous Os?

Answer 17

• Squamous
• Transformation
• Columnar
• Cervical os (Endocervix)

Uneven, wide, fish mouth appearance in the parous os

Nulliparous more smooth and round

Question 18

Rationale for Screening Recs

• Initiate at Age ___: Incidence cervical cancer is rare (<1%) risks outweight benefits
• Initiate Age __: Incidence is rare (<1%) 20-24 most infx ____ clear HPV
• ___ vs. ___ primary screening age 25-29: high rates of transient infection in 25-29 yo v HPV testing is more
• Age 30-65: __ strategy preferred
• Age > 65: _____ on prior results, life expectancy, SDM
  
  • Abnl pap results: poor predictive validity in this population
  • High grade lesions rare with adequately previously screening pts

Answer 18

• 21
• 25, spontaneous
• Pap vs. HPV
• no
• depends

Question 19

Special Populations: High Risk

Screening Guidelines do NOT apply

• Hx of high grade cervical ____
• Hx of cervical ____
• Hx of ____ exposure
• ____ compromise
• Any woman of any age with a _____ cervical lesion or ____ (refer for _____, regardless of pap/HPV result)

Answer 19

• lesion
• cancer
• DES
• Immuno
• suspicious lesion or symptoms (coloposcopy)

Question 20

Premalignant Changes

What we are interested in is the presence of

• SIL (1) or CIN (1)
  
  • Low Grade CIN1: regress ______
  • High Grade CIN2/3: _____
• Site: metaplastic _____ of the squamocolumnar _____

Answer 20

• Squamous Intraepithelial Lesions or Cervical Intraepithelial Neoplasia
  
  • ​spontaneously
  • persist
• epithelium, junction

Result: low grade SIL -> will probably regress on its own

Question 21

Pap Smear/HPV Testing

• Pt instructions before the visit: avoid in____, d_____, ____ use, vaginal ___ x 2 days prior
• Check labeling of slide or LBC vial with 2 _____
• Clinical history - may lead to “___ risk” designation and different screening _____
• Pap done ____ any bimanual exam
• Speculum: use water or gel ____ for lubrication

Answer 21

• intercourse, douching, tampon, meds
• identifiers
• high risk -> diff screening interval
• BEFORE
• sparingly

Question 22

Liquid Based Collection

Almost all ______ We don’t really use ____ anymore

Increased opporunity to detect ___ signs of abnormality

Answer 22

Liquid Based Collection, don’t rly use slides anymore

early detection

Question 23

Bethesda System: Specimen Adequacy: Satisfactory vs. Unsatisfactory

“_______ for Evaluation”

• Appropriate labeling and identifying information
• Relevant clinical information
• Adequate numbers of well preserved and well-visualized squamous epithelial cells
• An adequate endocervical/transformation zone component

Unsatisfactory pap =

Answer 23

Satisfactory

Not enough cellular material -> depending on how well you took the sample

Bethesda system vs. Birads system of breast CA screening

Question 24

Bethesda System: Categorization of Cellular Component

Hopefully the results will say? (1)

Answer 24

(NILM) Negative for Epithelial Cell Abnormalities

Question 25

ASC-US = * cells do not appear completely \_\_\_\_; not possible to determine ____ of abnormal cells * infection with \_\_\_; symptom of (1), or (1) seen in menopause * 10-20% of women with ASCUS may have __ 2 or 3; 1/1000 women with ASCUS may have invasive \_\_\_\_

Answer 25

**Atypical squamous cells of undetermined significance** * not normal, can't determine cause * HPV vs. Benign growth (cyst or polyp) vs. Low hormonal levels in menopause * CIN 2/3, Cancer

Question 26

LSIL = * HPV ____ infection (\_\_\_\_ abnormal cells CIN\_) * Bi\_\_\_\_ and K\_\_\_\_\_ * Lesion involves the intitial ____ of the epithelial layer

Answer 26

**Low-grade squamous intraepithelial lesion** * transient (mildly abnormal, CIN1) * Binucleation and Koilocytes * one/third of epithelial layer

Question 27

HSIL = * HPV ____ infection * ____ abnormal cells (CIN\_) or _____ abnormal cells (CIN\_\_/\_\_\_\_ in situ) * Nuclear \_\_\_\_\_, H\_\_\_\_\_

Answer 27

**High-grade squamous intraepithelial lesion** * persistent * Moderately abnormal CIN2, Severely abnormal CIN3/carcinoma * enlargement, hyperchromatic

Question 28

ASC-H = * May be a ____ to cervical cancer if not \_\_\_\_ * What is needed? What test? **(1)\*\***

Answer 28

**Atypical Squamous Cells - Cannot Exclude HSIL** precursor to cancer if not treated More testing/follow up - **COLPOSCOPY** **When you can't exclude high grade -\> whatever age needs to be followed up**

Question 29

Colposcopy ## Footnote When do we use it? What is it?

Answer 29

Follow up to pap: **microscope and biopsy**

Question 30

Cervical Cancer Screening Methods: HPV Primary Screening (Woman 25+) ## Footnote Don't worry too much about this slide

Answer 30

Question 31

Treatment Options: Precancerous Lesions (High Grade CIN 2/3) and Carcinoma in Situ ## Footnote * \_\_\_\_surgery * ____ Ablation * _____ Excision (LEEP) * Cold-\_\_\_\_ Conization * Follow up: _____ surveillance at regular \_\_\_\_\_ * _____ and ______ to predict/prevent progression under investigation

Answer 31

* Cryosurgery * Laser * Loop * Knife * Lifelong, intervals * Biomarkers, Vaccines

Question 32

Bethesda System: Descriptive Diagosis ## Footnote for ____ and other \_\_\_-neoplastic findings Pretty much you'll also get report on presence of \_\_\_\_\_\_\_

Answer 32

infections, non-neoplastic microorganisms

Question 33

ASCCP Interim Guidance for Timing of Diagnostic and Treatment Procedures for Patients with Abnormal Cervical Screening Tests ## Footnote In light of covid 19-pandemic, and in settings where all non-essential medical office visits and elective procedures have been suspended, ASCCP recommends the following 1. Individuals with low grade cervical cancer screening tests may have _____ of diagnostic evals up to 6-12 months 2. Individuals with high-grade cervical screening tests should have documented ____ to ___ and diagnostic evaluation scheduled within 3 months 3. Individuals with high-grade cervical disease without suspected invasive disease should have documented attempts to ____ and procedures scheduled within __ months 4. Individuals with suspected invasive disease should have contact attempted within __ wks and evalation within 2 of that contact (4 wsk from initial report or referral)

Answer 33

1. postponement 2. attempts to contact 3. contact, 3m 4. 2 wks