Primary and Secondary Prevention of Cervical Cancers

Question 1

Major types of cervical epithelial cells

Answer 1

• Ectocervix → Stratified, non keratinizing, squamous epithelium; abundant cytoplasm, dark pyknotic nucleus
• Endocervix → Columnar, mucous secreting, epithelium; may appear in a “honeycomb” array, with distinct cell membranes due to cytoplasmic mucin.

Question 2

cells present?

Answer 2

• top of image = mature squamous cells (ectocervix)
• lower left corner = columnar glandular cells (endocervix)

Question 3

HPV virus types/risks

Answer 3

• Warts: 6, 11 (low risk)
• Dysplasia:16, 18, others (high risk)
• Carcinoma: 16, 18, others (high risk)

Question 4

Squamous changes in cervical dysplasia

Answer 4

• Spectrum of cervical intraepithelial neoplasia (CIN) from left to right:
• Normal squamous epithelium for comparison;
• CIN I with koilocytotic atypia;
• CIN II with progressive atypia in all layers of the epithelium;
• CIN III (carcinoma in situ) with diffuse atypia and loss of maturation.

Question 5

Benign cytology pap smear results and histologic appearance

Answer 5

• Normal ==> Normal histology
• ASC = Atypical squamous cells. ASC and more = Colposcopy ==> No direct translation on histo
• ASC-H = Atypical squamous cells cannot exclude HSIL ==> No direct translation on histo

Question 6

Characteristics of LSIL on cytology pap smear results and histologic appearance

Answer 6

• LSIL → Low grade squamous intraepithelial lesion
  
  • 50% will be normal
  • 40% will be CIN I
  • 10% will be CIN II - III
• Usual histo appeareance: CIN I (1.4m)

Question 7

Characteristics of HSIL on cytology pap smear results and histologic appearance

Answer 7

• HSIL → High grade squamous intraepithelial lesion
  
  • 30% will be normal
  • 30% will be CIN I
  • 30% will be CIN II - III
• Usual histo = CIN II* - III* (330k)

Question 8

Most common histologic types of invasive cervical carcinoma

Answer 8

• Squamous cell carcinoma - precursor CIN if HPV related
• Cervical adenocarcinoma - precursor is adenocarcinoma in situ (AIS)

Question 9

Gardisil: antigenic components and viral types covered

Answer 9

• Antigens
  
  • Quadrivalent L1 virus-like particle (VLP) - yeast
• Viral types
  
  • HPV 6 / 11 / 16 / 18

Question 10

Cervarix: antigenic components and viral types covered

Answer 10

• Bivalent virus like particle - yeast
• 16, 18

Question 11

Gardisil: efficacy

Answer 11

• Prophylactic efficacy of 98.8% in the reduction of genital warts, CIN 2, CIN 3 and adenocarcinoma in situ if woman is naive
• previously exposed => overall reduction of 44 % in disease related to other HPV types
• Males: Studies have demonstrated 90% efficacy in the prevention of external genital warts in males aged 16 – 23

Question 12

Cervarix: efficacy

Answer 12

• Seroconversion to the HPV types included in the vaccine is 100% and protection against CIN 2 and 3 and adenocarcinoma caused by HPV types 16 and 18 is 93%.
• Somehow gives better protection for another strain of HPV (31, 45) that causes cancer

Question 13

Provider impact on HPV vaccine administration

Answer 13

• Most likely to recommend when providers have a positive attitude about the behavior, when they feel their opinion is supported by trusted colleagues and professional organizations, and when they feel they have control over its implementation.
• Recommendation ↑ with age of patient, due to informed consent. Unfortunately, this ↓ efficacy if they become sexually active

Question 14

Parental impact on HPV vaccine administration

Answer 14

• Mostly receptive
• Biggest concern - “How will this affect my child’s sexual behavior?”
• Regression - down to the rest of the population
• Disinhibition - or even worse way too much sex.
• Parents from highly eclectic, subgroups reported being less likely to vaccinate

Question 15

Young adults impact on HPV vaccine administration

Answer 15

• Studies in this population find that HPV vaccination is generally well accepted.
• One survey provided 340 college students with information about HPV found that
• 75% of women and 33% of men would agree to a vaccination covering HPV 16 & 18.
• Acceptance rates ↑ to 90% and 75% when coverage was broadened to include HPV 6 and 11.
• The intention to receive the vaccine was greater among participants scoring higher on an HPV knowledge test and with more than five lifetime sexual partners.

Question 16

Issues involving vaccination (to HPV) in HIV positive

Answer 16

• potential differences between vaccination strategies targeted at infants born with HIV and those who acquire it later in life.
• The point in their HIV infection at which they are vaccinated
• Preexisting exposure to HPV
• Viral loads
• CD 4 counts
• The potential role of highly active antiretroviral therapy

Question 17

Trends in cervical cancer screening recommendations

Answer 17

• Less screening
• Start later
• Screen less often
• Eliminate certain groups entirely (pts who have undergone hysterectomy, >65y.o)
• Add co-testing (cytology plus HPV)

Question 18

2009 recommendations for cervical cancer screening

Answer 18

• Cervical cancer screening should begin at age 21 years.
  
  • Exception: HIV+
• screening every 2 years for women between the ages of 21 and 29 years.
• Women may extend the interval to every 3 years if the following are true:
  
  • They are ≥ 30 years of age
  • They have had three consecutive negative cervical cytology screening test results
  • They have no history of CIN 2/CIN 3
  • They are not HIV infected
  • They are not immunocompromised
  • They were not exposed to DES in utero.