Cervical_Cancer_Screening_Results_Flashcards
What is the current approach in the NHS for cervical cancer screening?
The NHS uses an HPV first system where samples are tested for high-risk HPV strains first. Cytological examination is only performed if the HPV test is positive.
How are negative hrHPV results managed?
Negative hrHPV results lead to a return to normal recall unless under specific pathways like test of cure, untreated CIN1 pathway, follow-up for CGIN/SMILE, or follow-up for borderline changes in endocervical cells.
What happens if the hrHPV test is positive but cytology is normal?
If hrHPV is positive but cytology is normal, the test is repeated at 12 months. If still positive without cytological abnormalities, another repeat test occurs at 24 months. If still positive, colposcopy is recommended.
What are the management steps for positive hrHPV with abnormal cytology?
If hrHPV is positive with abnormal cytology, the patient is referred for colposcopy. Abnormal results include borderline changes, low-grade dyskaryosis, high-grade dyskaryosis, and invasive carcinoma.
What is the procedure if a cervical sample is inadequate?
If a sample is inadequate, it is repeated in 3 months. If two consecutive samples are inadequate, a colposcopy is recommended.
What is the test of cure pathway?
The test of cure pathway involves inviting individuals treated for CIN1, CIN2, or CIN3 to have a repeat cervical sample taken 6 months after treatment to ensure the absence of high-risk HPV.
What is the most common treatment for CIN?
The most common treatment for CIN is large loop excision of the transformation zone (LLETZ), which may be performed during the initial colposcopy visit or later. Cryotherapy is an alternative treatment.
summary
Cervical cancer screening: interpretation of results
The cervical cancer screening programme has undergone a significant evolution in recent years. For many years the smears were examined for signs of dyskaryosis which may indicate cervical intraepithelial neoplasia - management was based solely on the degree of dyskaryosis. The introduction of HPV testing allowed patients with mild dyskaryosis to be further risk-stratified, i.e. as HPV is such a strong risk factor patients who were HPV negative could be treated as having normal results.
The NHS has now moved to an HPV first system, i.e. a sample is tested for high-risk strains of human papillomavirus (hrHPV) first and cytological examination is only performed if this is positive.
Management of results
Negative hrHPV
return to normal recall, unless
the test of cure (TOC) pathway: individuals who have been treated for CIN1, CIN2, or CIN3 should be invited 6 months after treatment for a test of cure repeat cervical sample in the community
the untreated CIN1 pathway
follow-up for incompletely excised cervical glandular intraepithelial neoplasia (CGIN) / stratified mucin producing intraepithelial lesion (SMILE) or cervical cancer
follow-up for borderline changes in endocervical cells
Positive hrHPV
samples are examined cytologically
if the cytology is abnormal → colposcopy
this includes the following results:
borderline changes in squamous or endocervical cells.
low-grade dyskaryosis.
high-grade dyskaryosis (moderate).
high-grade dyskaryosis (severe).
invasive squamous cell carcinoma.
glandular neoplasia
if the cytology is normal (i.e. hrHPV +ve but cytologically normal) the test is repeated at 12 months
if the repeat test is now hrHPV -ve → return to normal recall
if the repeat test is still hrHPV +ve and cytology still normal → further repeat test 12 months later:
If hrHPV -ve at 24 months → return to normal recall
if hrHPV +ve at 24 months → colposcopy
If the sample is ‘inadequate’
repeat the sample in 3 months
if two consecutive inadequate samples then → colposcopy
The follow-up of patients who’ve previously had CIN is complicated but as a first step, individuals who’ve been treated for CIN1, CIN2, or CIN3 should be invited 6 months after treatment for a test of cure repeat cervical sample in the community.
Treatment of CIN
Large loop excision of transformation zone (LLETZ) is the most common treatment for cervical intraepithelial neoplasia. LLETZ may sometimes be done during the initial colposcopy visit or at a later date depending on the individual clinic. Alternative techniques include cryotherapy.
A 29-year-old female has a cervical smear test as part of the UK cervical cancer screening programme. Her results return as hrHPV positive. The sample is examined cytologically, which shows normal cells.
As per guidelines, the cervical smear test is repeated 12 months later, which is still hrHPV positive. Cytology is repeated, which again shows normal cells.
What is the most appropriate action?
Colposcopy
Return to routine recall
Repeat the test in 3 months
Repeat the test in 6 months
Repeat the test in 12 months
Repeat the test in 12 months
Cervical cancer screening: if 1st repeat smear at 12 months is still hrHPV +ve → repeat smear 12 months later (i.e. at 24 months)
Important for meLess important
Cervical smear tests performed as part of the NHS cervical screening programme are first tested for high-risk HPV (hrHPV). If hrHPV positive, cytology is performed; if this shows normal cells then the cervical smear test is repeated in 12 months time. If this repeat test is still positive for hrHPV but cytology normal, as in this case, she should have another repeat test in a further 12 months. Therefore, repeating the test in 12 months is the correct answer.
Colposcopy is not indicated here as cytology showed normal cells.
Returning this patient to routine recall is not appropriate- this would lead to a repeat smear in 3 years time. She requires a repeat smear in 12 months time due to positive hrHPV.
Repeating the test in 3 or 6 months is too soon, and therefore not appropriate.
A 26-year-old woman attends her GP for her cervical cancer screening results. She had a hrHPV-positive result one year ago. This was recently repeated and was reported as hrHPV negative.
The patient is sexually active but has had no new sexual partners in the past year. She has a family history of endometrial cancer and has been vaccinated against HPV.
When should she next be called for screening?
Colposcopy
No further smear needed
Repeat screening at 12 months
Repeat screening at 3 months
Return to routine recall
Return to routine recall
Cervical cancer screening: if 1st repeat smear at 12 months is now hrHPV -ve → return to routine recall
The correct answer is to return to routine recall. In this case, as the first repeat smear at 12 months is now negative, the appropriate step is to return to a routine call. Her family history of endometrial cancer and the fact that she has been vaccinated against HPV do not affect how often this patient will require cervical screening.
Colposcopy is incorrect. This answer would be appropriate if the repeat testing was hrHPV positive and cytology was abnormal. Colposcopy allows the cervix to be visualised and biopsy to be taken for further testing. Abnormal cells may be removed by large loop excision of the transformation zone at the same time as the colposcopy.
No further smear needed is incorrect. NHS guidance is that people with a cervix should attend screening when called between the ages of 25 and 64. This woman should continue to attend when called for while she is within this age bracket.
Repeat screening at 12 months is incorrect. This would be appropriate if the sample was positive for HPV but cytology was normal.
Repeat screening at 3 months is incorrect. This would be appropriate if the initial sample was inadequate to obtain a repeat sample.
A 28-year-old woman had attended for her routine cervical smear which is performed without any issues. The GP receives the result of smear that it was positive for high-risk HPV but there was no evidence of cytological abnormalities.
What is the most appropriate next step?
Refer for colposcopy
Repeat cervical smear in 3 months
Repeat cervical smear in 3 years
Repeat cervical smear in 6 months
Repeat cervical smear in 12 months
Repeat cervical smear in 12 months
Cervical cancer screening: if sample is hrHPV +ve + cytologically normal → repeat smear at 12 months
Repeating the cervical smear in 12 months is correct because her first smear under routine recall was positive for high-risk strains of human papillomavirus (hrHPV) but showed no cytological abnormalities. Therefore under current guidance she should have a repeat smear at 12 months.
Colposcopy is not correct as it is not indicated. It would be indicated if either she had a hrHPV positive smear with cytological evidence of dyskaryosis, she has 3 successive annual smears that are hrHPV positive but with no cytological evidence of dyskaryosis, or she has 2 smears that are inadequate 3 months apart.
Repeating a cervical smear after 3 months is not correct because it is indicated if the first smear is not adequate.
Repeating the cervical smear in 3 years is not correct because it would be in line with returning her to routine recall under the cervical screening programme. As hrHPV has been detected, routine recall is not appropriate.
Repeating a cervical smear after 6 months is incorrect as it would usually be indicated as a test of cure following treatment for cervical intraepithelial neoplasia.
Sarah is a 28-year-old woman who attended for cervical screening 1 week ago. She is well with no past medical history.
Her result is positive for high-risk human papillomavirus (hrHPV). Cervical cytology has returned as inadequate.
What is the most appropriate next step?
Referral for colposcopy
Repeat HPV testing in 1 week
Repeat sample in 3 months
Return to routine recall every 3 years
Repeat sample in 12 months
Repeat sample in 3 months
Cervical cancer screening: if smear inadequate then repeat in 3 months
Important for meLess important
NICE guidelines for cervical screening state:
‘If the high-risk human papillomavirus (hrHPV) test result is unavailable or cytology is inadequate at any screening episode in the pathway ‘ the sample is repeated in no less than 3 months.’
Therefore repeating the sample in 3 months is the correct answer.
Repeating HPV testing in 1 week will not change ongoing management as we know already that Sarah is positive for hrHPV and requires an adequate cervical cytology result.
Colposcopy is indicated if there are two consecutive inadequate results.
Repeat the sample in 12 months would be inappropriate as this would be a lengthy wait between samples. Similarly, returning Sarah to routine recall is incorrect as Sarah requires an adequate cytology result.
A 47-year-old patient has asked to discuss the result of her latest smear test. It demonstrated normal cytology and was negative for high-risk human papillomavirus (hrHPV). Her previous smear 12 months prior demonstrated normal cytology but was positive for hrHPV.
What should you advise the patient following her latest smear test result?
Routine colposcopy referral
Return to routine recall in 3 years time
Return to routine recall in 5 years time
Repeat HPV test in a further 12 months
Repeat HPV test in a further 24 months
Return to routine recall in 3 years time
Cervical cancer screening: if 1st repeat smear at 12 months is now hrHPV -ve → return to routine recall
This patient can return to routine recall which is every 3 years from age 25-49 years or every 5 years from age 50-64 years.
If the repeat test was positive again this would warrant a repeat HPV test in 12 months.
Colposcopy referral would be indicated if there was dyskaryosis on a cytology sample.
A 29-year-old female undergoes a cervical smear test as part of the UK cervical screening programme. Her results come back as hrHPV positive.
The sample is examined cytologically, which is reported as normal.
What is the most appropriate action?
Colposcopy
Return to normal recall
Repeat the test within 3 months
Repeat the test in 6 months
Repeat the test in 12 months
Repeat the test in 12 months
Cervical cancer screening: if sample is hrHPV +ve + cytologically normal → repeat smear at 12 months
Cervical smear tests performed as part of the NHS cervical screening programme should first be tested for high-risk HPV (hrHPV). If negative for hrHPV, they are returned to normal recall. If hrHPV positive, they are then examined cytologically. If cytology is abnormal, colposcopy should be performed. However, if cytology is normal, the test should be repeated in 12 months.
There is no requirement to perform colposcopy in this case as her cytology results are normal. Colposcopy is performed if cytology is abnormal.
Return to normal recall is incorrect as this would lead to a repeat smear test in 3 years time, which is too long. As her hrHPV was positive she is has a higher risk, therefore a repeat smear test should be repeated sooner, in 12 months.
There is no indication to repeat the test within 3 months, this is too soon.
Repeating the test in 6 months would also be inappropriate as this is too soon.
A 31-year-old woman has requested a telephone consultation to discuss her cervical smear results.
She had a cervical smear test as part of the routine screening programme and is currently asymptomatic.
Her previous cervical smear was 3 years ago and was normal.
Her results are as follows:
High-risk human papillomavirus (hrHPV): POSITIVE.
Cytology: NEGATIVE.
What is the next step in her management?
Repeat cervical smear in 3 months
Repeat cervical smear in 12 months
Repeat cervical smear in 3 years
Routine referral to colposcopy
Urgent referral to colposcopy
Repeat cervical smear in 12 months
Cervical cancer screening: if sample is hrHPV +ve + cytologically normal → repeat smear at 12 months
Repeat cervical smear in 12 months is the correct answer. Individuals who are positive for high-risk human papillomavirus (hrHPV) and receive a negative cytology report as part of routine primary HPV screening should have the HPV test repeated at 12 months.
If HPV testing is negative at 12 months, individuals can be safely returned to routine recall.
Individuals who remain hrHPV positive, cytology negative at 12 months should have a repeat HPV test in a further 12 months.
Individuals who become hrHPV negative at 24 months can be safely returned to routine recall.
Individuals who remain hrHPV positive, cytology negative or inadequate at 24 months should be referred to colposcopy.
Repeat cervical smear in 3 months is an incorrect answer. If the hrHPV test result is unavailable or cytology is inadequate then the sample is repeated in no less than 3 months, this would not be the case for this patient because the results are available and cytology is negative.
Repeat cervical smear in 3 years is an incorrect answer. If the hrHPV test result is negative the patient is returned to routine cervical screening every 3 years if aged 25 to 49 years (every 5 years if aged 50 to 64 years). As the hrHPV result is positive, it would not be appropriate to wait this long for a repeat smear.
Routine referral to colposcopy is an incorrect answer. Only patients with abnormal cytology will be referred to colposcopy. In this case, it is not needed due to the normal cytology.
Urgent referral to colposcopy is an incorrect answer. Patients are only referred urgently if the cytology reports cervical cancer, which is not the case for this patient.
