Cervical ScreeningState of the Art 2016

Dr Dirk Grothuesmannhttp://dg-maternalhealth.de/

Expected worldwide Cervical Cancer 2020

2002 2020 2020 (% Increase) (% Burden)

World493.000* 702.500 100% (+42%)

Less developed Areas 409.000 639.500 83% (+56%)

More developed Areas 83.000 92.500 17% (+11%)

Parkin and Bray, 2006*530,000 cases in 2008; Arbyn M, et al

Cervical Screening

Champions of PreventionGeorgios Nikolaou Papanikolaou *1883 –1962

Hans Hinselmann *1884 - 1959

Harald zur Hausen*1936 -

Squamoculmnar Junction

Squamoculmnar Junction

Columnar Epithelium

Squamous Epithelium

Squamoculmnar Junction

Sellors and Sankaranarayanan, 2003

Squamoculmnar Junction

Transformation Zone• The Normal TZ is located between the OSCJ and the colposcopically-

visible, new SCJ• Dynamic Area

• Carcinogenic factors (HPV, carcinogenic substances e.g. smoking) are incorporated into vulnerable immature metaplastic epithelia

Squamoculmnar Junction/ Transformation zone 1,2,3,

Visibility Line

IFCPC, 2011

ASC-US Atypical squamous cells of undetermined significance

ASC-H Atypical squamous cells – cannot exclude HSIL

The Bethesda System (TBS), 2001

THE BETHESDA SYSTEM WEBSITE ATLAS, 2003

LSIL – Low-grade Squamous Intraepithelial Lesion HSIL – High-grade Squamous Intraepithelial Lesion

The Bethesda System (TBS), 2001

AGC-Atypical Glandular Cells

The Bethesda System (TBS), 2001

TerminologyDifference between the terms cervical intraepithelial lesion and squamous intraepithelial lesion• Squamous intraepithelial lesion (SIL) is used to describe Pap test result

• SIL is not a diagnosis of precancer or cancer• A cervical biopsy is needed

• Cervical intraepithelial lesion (CIN) used to report cervical biopsy results• CIN 1 is used for mild (low-grade) changes• CIN 2 is used for moderate changes• CIN 3 is used for more severe (high-grade) changes

Moderate and high-grade changes can progress to cancer

Different Types of abnormal Pap Test Results

• Atypical squamous cells of undetermined significance (ASC-US)— mostly a sign of an HPV infection (most common abnormal test result)

• Low-grade squamous intraepithelial lesion (LSIL)—mildly abnormal.Usually is caused by an HPV infection, goes away on its own.

• High-grade squamous intraepithelial lesion (HSIL)—more serious changes in the cervix. More likely associated with precancer and cancer.

• Atypical squamous cells, cannot exclude HSIL (ASC-H)—changes that raise concern for the presence of HSIL.

• Atypical glandular cells (AGC)—Glandular cells also are present inside the uterus. Changes in glandular cells that raise concern for the presence of precancer or cancer.

Progression of CIN Categories

HIGH-GRADE SQUAMOUS LESION (HSIL) — HSIL refers to moderate to severe changes in the cells of the cervix. The risk that these abnormalities reflect precancerous changes is as high as 20.8%, and the risk of cervical cancer is as high as 1.4%

Sellors JW, Sankaranarayanan, R, 2003

What Testing is needed after an abnormal cervical Cancer Screening

Test• Repeat Pap test or Co-Test (Pap test and a test for high-risk types of

HPV)—recommended as a follow-up to some abnormal test result• HPV Test—presence of the HPV types linked to cervical cancer• Colposcopy

• Biopsy• Endocervical sampling

Adolescents Needs

• Care for contraception and STI screening/treatment• NO Pap test• No speculum examination for asymptomatic women• STI Testing can be done using urine

Rationale for Co-Testing 30 – 64

• Increased detection of prevalent CIN 3• Decreases CIN 3 in subsequent screening rounds• Enhances detection of adenocarcinoma (AIS) • Minimizes numbers of colposcopies

Screening for Ages 21 - 29

• Cytology every 3 years• HPV testing should not be done for screening

• Not as a component of Co testing• Not as a standard alone screening

Rational of avoiding HPV test among Women Ages 21 - 29

• Prevalence of carcinogenic HPV approaches 20% in teens and early 20s

• Most carcinogenic HPV resolve without intervention• Identifying carcinogenic HPV that will resolve spontaneously will lead

to repeated call-back, anxiety and interventions without benefit

Screening for Women Ages 30 - 64

• Cytology plus HPV (Co-testing) every 5 years is preferred

• Cytology every 3 years is acceptable

Rationale for Co-testing Ages 30 -64

• Increased detection of CIN 3• Decreased CIN 3 in subsequent screening rounds• Enhances detection of adenocarcinoma in situ (AIS)• Minimizes the increased numbers of colposcopies

Why not Co-testing all Women Ages 30 – 64

Lack of access to co-testing• Financial• Logistical

Cytology remains effective but:• Requires more frequent visits• Requires more colposcopies for equivocal results

Managing ASC-US/HPV negative tests

“Women with ASC-US cytology and negative HPV test result should continue screening with age-specific guidelines “

• CIN 3 od ASC-US/HPV neg < 2% is below threshold for colposcopy

Managing HPV+/Cytology- Cotests

Women contesting HPV+/Cytology- :

• Repeat Cotesting in 12 month• Immediate HPV genotype specific testing for HPV 16/18

Direct referral to colposcopy not indicated

Repeat Cotest in 12 Month

• If either test is positive, refer to colposcopy• If both tests are negative return to routine screening

Immediate HPV Genotyping

• If HPV 16 or HPV 16/18 are positive refer to Colposcopy• If HPV 16 or HPV 16/18 are negative repeat cotest in 12

month• If ether repeat test is positive: Colposcopy• If both test are negative return to routine screening

When to stop ScreeningStop screening at 65 with adequate negative screening (no CIN in last 20 years)

This means:• 3 consecutive Pap screenings • 2 consecutive neg. HPV tests

Stop Screening at 65

Screening “should not resume even it woman reports having a new sexual partner”

When not to stop: • If history of CIN2, CIN3, AIS (in these cases at least 20 years screening)

ASCCP Guidelines, 2012

Cervical Cancer Screening and Follow Up

The American College of Obstetricians and Gynecologists, 2016

Cervical Cancer Screening and Follow Up

Cervical Cancer Screening and Follow Up

LiteratureArbine et al, 2011, Worldwide burden of cervical cancer in 2008. Ann Oncol, 22(12), 2675 - 86

ASCCP Guidelines, 2012, from http://www.asccp.org/guidelines

Sellors JW, Sankaranarayanan, R, 2003, Colposcopy and Treatment of Cervical Intraepithelial Neoplasia: A Beginners’ Manual, from http://screening.iarc.fr/doc/Colposcopymanual.pdf

Parkin DM and Bray, 2006, Chapter 2: The burden of HPV-related cancers, Vaccine, 31;24 Suppl 3:S3/11-25

IFCPC, IFCPC Nomenclature 2011, from http://www.ifcpc.org/en/healthcare-professionals/resource-material/2011-ifcpc-nomenclature

THE 2001 BETHESDA SYSTEM, from http://nih.techriver.net/bethesdaTable.php

2011 Colposcopic Terminology of the International Federation for Cervical Pathology and Colposcopy, Bornstein, j et al., OBSTETRICS & GYNECOLOGY, 120, (1), 166- 172 from http://jgcs21.umin.jp/colposcopy_02.pdf

2012 Updated Consensus Guidelines for the Management of Abnormal Cervical Cancer Screening Tests and Cancer Precursors, Steward ML et al., 2013, Journal of Lower Genital Tract Disease, Volume 17, Number 5, 2013, S1YS27

The American College of Obstetricians and Gynecologists, 2016, Abnormal Cervical Cancer Screening Test Results, FAQ187, from http://www.acog.org/Patients/FAQs/Abnormal-Cervical-Cancer-Screening-Test-Results

THE BETHESDA SYSTEM WEBSITE ATLAS, 2003, from http://nih.techriver.net/

Aim of my Project

Dr. Dirk Grothuesmann ConsultancyImproving Maternal Health and Gynecology Services by Training Health Care Providers: Relaying on standardized training modules I teach evidence-based obstetrical procedures, gynecology surgery and related evaluation tools to local personnel in developed and developing countries. Completing the programs offered, skills gained enable to serve women in need in any requested setting.http://dg-maternalhealth.de/index2.html

http://dg-maternalhealth.de/

Dr Dirk Grothuesmann

Consultancy