Cervical Cancer Screening Module 3 - from Massachusetts Medical Society. Copyright © 2013. Massachusetts Medical Society, 860 Winter Street, Waltham Woods Corporate Center, Waltham, MA 02451-1411

1. Cervical Cancer Screening
Module III
Techniques of Screening
Screening Guidelines
Special Screening Situations

2. Cervical Cancer Screening
Techniques of Screening
Physical Exam
Visual Inspection with Acetic Acid
Pap Smear
HPV Testing
Cervical Biopsies
Module III

3. Techniques of Screening
Physical Exam
1. Visually examine the vulva and perianal region
2. Insert the speculum into the vagina
3. Visually examine the cervix and the walls of the
vagina
4. Palpate the cervix and the walls of the vagina.
5. Palpate the parametria and uterosacral ligaments by
rectovaginal exam
Module III

4. Techniques of Screening
Visual Inspection with Acetic Acid
With the speculum in the vagina and the
cervix visualized, apply 3% acetic acid using
a sponge (ALERT: confirm that the acetic
acid has been diluted. 100% acetic acid
will cause third degree burns)
Wait 60 seconds and then visually examine .
Dysplastic lesions are nuclear dense. The
dehydration of the mucous membrane will
temporarily cause dysplastic lesions to look
white
Module III

5. Visual Inspection
Author, year of
publication, country of
study
No. of participants
Sensitivity, % (95%
CI)
Specificity, % (95%
CI)
University of
Zimbabwe/JHPIEGO [5],
1999, Zimbabwe
2148
77 (70–82)
64 (61–66)
Denny et al. 2000, South
Africa
2885
67 (56–77)
84 (82–85)
Belinson et al. [24],
2001, China
1997
71 (60–80)
74 (71–76)
Denny et al. [8], 2002,
a,c
South Africa
2754
70 (59–79)
79 (77–81)
Cronjé et al. [9], 2003,
South Africa
1093
79 (69–87)
49 (45–52)
54,981
79 (77–81)
86 (85–86)
Sankaranarayanan et al.
[25], 2004 India and
b,c
Africa
Sensitivity – 67-79% Specificity – 49-86%
Technique :Place Speculum
Apply 3-5% Acetic Acid
Wait at least 1 Minute; record Observations
Module III

6. Techniques of Screening
Pap Smear
With a spatula, rotate the spatula 360
degrees around the exocervix
With a cytobrush, place the brush within
the endocervix and rotate 360 degrees
Apply both the spatula and cytobrush to a
slide and then apply fixative
Or place spatula and cytobrush into liquid
based solution and break off the tips
Module III

7. SCREENING
 conventional cytologic sampling
 Thin layer (or liquid-based) cytology




ThinPrep (1996)
AutocytPrep (1999)
SurePath (2000)
MonoPrep (2006)
 liquid-based : other diagnostic assessments (only Thin
Prep is FDA approved )



testing for gonorrhea
chlamydia
HPV
Module III

8. Sources of potential error in the Pap smear
The clinician may not sample the area of cervical
abnormality.
The abnormal cells may not be plated on the slide or
transferred to the liquid medium.
The cells may not be adequately preserved with fixative.
The cytologist may inaccurately report the findings
The cytopathologist may not identify the abnormal cells.
Module III

9. Techniques of Screening
HPV Testing
HPV testing should be confined to testing
for high risk (oncogenic) subtypes
HPV testing for low risk (nonocogenic)
subtypes has NO role in the evaluation of
abnormal pap smears
Module III

10. HPV TESTING
p16 cytology
P16 cytology can be used as a triage test in HPV-positive
women.
P16 is a marker of HPV oncogene activity that is
independent of carcinogenic HPV tyoe
Carozzi . Lancet Oncol 2012
Of 1170 HPV positive women,493 (42%) overexpressed p16
at baseline
At baseline, 55 of these 493 women had CIN3 (9.7%)
Compared to p16 negative over expression, positive p16 had
a longitudinal sensitivity of 82.4%
Module III

11. Techniques of Screening
Colposcopy &Cervical Biopsies
Module III

12. Cervical Cancer Screening
Screening Guidelines
Screening Guidelines can be separated
into two sections
General guidelines for when to pap
smears and on whom
What follow up and intervention is
recommended based on pap sear results
Module III

13. Cervical Cancer Screening
Screening Guidelines
Guidelines are only for women at average risk for cervical cancer.
These guideline do not apply to women with:
history of cervical cancer
In Utero exposure to DES
who are immuno-compromised
organ transplantation,
chronic steroid use,
chemotherapy
HIV positive
Module III

14. Screening Guidelines
When to perform pap smear
Do not screen before age 21 years
Screening should start at age 21
Screening guidelines are age dependent
Annual pap smears in women without a history of
premalignant or malignant lower genital disease are no
longer recommended
Recommended Screening practices should not change
on the basis of HPV vaccination status
Module III

15. PREVALENCE OF CIN 3 OR GREATER BY AGE
MOORE 2008
CIN3 OR
GREATER
LESS THAN CIN 3
TOTAL
<50 YEARS
189 (71%)
77 (29%)
266
>50 YEARS
51 (59%)
35 (41%)
86
TOTAL
240
112
352
Patients older
than 50 had
Signif higher
Prevalence CIN3
Module III

16. Vaccination Against HPV
Recommend routine HPV vaccination for females aged
11 to 12 years
Recommend routine vaccination for females aged 13 to
18 years to “catch-up” those who missed earlier
screening
Insufficient data to recommend for or against universal
vaccination of females aged 19 to 26 years
Module III

17. Screening Guidelines
When to perform pap smear
Ages 21- 29 years: PAP SMEAR screening every three
years
No screening HPV testing
HPV testing only for evaluation of atypical squamous
cells of uncertain significance
Module III

18. Screening Guidelines
When to perform pap smear
Ages 30 – 65 years:
screening with both PAP SMEAR and HPV testing
every five years (preferred)
Or PAP SMEAR testing every three years (accepted)
Module III

19. Screening Guidelines
When to perform PAP SMEAR
Ages greater than 65: No Further Pap Smear Testing
who have had > 3 consecutive normal pap tests
or > 2 consecutive negative HPV tests and pap tests in
last 10 years with the most recent pap occurring within
the last 5 years
or women who have had hysterectomies for benign
disease
Module III

20. Cervical Cancer Screening
Screening Guidelines
In 2012 the American Society for
Colposcopy and Cervical Pathology
(ASCCP) published new guidelines for
management of pap smear results
Guidelines should never replace clinical
judgment
Module III

21. ASCCP Guidelines
Guidelines for management of abnormal pap smears
are different by the following age categories:
Ages 21- 24
Ages over 30
Guidelines for management of abnormal pap smears
are different for the pregnant woman (see screening:
special situations)
Module III

22. ASCCP Guidelines
Unsatisfactory Cytology
Repeat pap smear after 2 to 4 months
Refer to colposcopy for persistently unsatisfactory pap
smears
http://www.asccp.org/Portals/9/docs/Algorithms%207.30.1
3.pdf (Page 4)

23. ASCCP Guidelines
Absent Endocervical Cells
For ages 21-29: perform routine screening
For ages > 30 : HPV testing
http://www.asccp.org/Portals/9/docs/Algorithms%207.30
.13.pdf (Page 5)

24. ASCCP Guidelines
Age > 30: Cytology Negative & HPV positive
For HPV 16 and 18: colposcopy
Repeat co-testing in one year is acceptable
http://www.asccp.org/Portals/9/docs/Algorithms%207.30
.13.pdf (Page 6)

25. Risk of HSIL with + HPV HR
2% (52 of 2562 over 10 years) Khan 2005
3% (88 of 2941 over 10 years) Castle 2002
1.2% (30 or 2562 over 10 years) Miller 2002
Module III

26. ASCCP Guidelines
ASC - US
Repeat pap smear in one year, if ASC-US again: refer
to colposcopy
OR
Upfront HPV testing, if HPV positive: refer to
colposcopy
http://www.asccp.org/Portals/9/docs/Algorithms%207.30
.13.pdf (Page 7)

27. ASCCP Guidelines
Ages 21-24 – ASC-US or LSIL
HPV testing:
If HPV negative: return to routine testing
If HPV positive: repeat pap smear in one year
http://www.asccp.org/Portals/9/docs/Algorithms%207.30.
13.pdf (Page 8)

28. ASCCP Guidelines
ASC-US ages 21-24
Initial Management
Cytology alone in 12 months is preferred
Reflex HPV testing acceptable
If HPV positive, repeat cytology one year
If HPV negative, return to routine screening with
cytology alone in three years
Module III

29. ASCCP Guidelines
LSIL
If LSIl and HPV negative, repeat pap smear in one year
If LSIL and HPV positive: refer to colposcopy
http://www.asccp.org/Portals/9/docs/Algorithms%207.30.13.p
df (Page 9)

30. ASCCP Guidelines
ASC-H
Refer all ASC-H to colposcopy
http://www.asccp.org/Portals/9/docs/Algorithms%207.30.13.p
df (Page 11)

31. ASCCP Guidelines
Ages 21-24 -ASC-H
If colposcopy is negative, repeat pap smear and
colposcopy every six months for two years
If HSIL is found, acceptable to monitor for one year. If
lesion is persistent for one year, treat with excision
http://www.asccp.org/Portals/9/docs/Algorithms%207.30.13.p
df (Page 12)

32. ASCCP Guidelines
HSIL
Immediate LEEP or colposcopy
http://www.asccp.org/Portals/9/docs/Algorithms%207.30.13.p
df (Page 13)

33. ASCCP Guidelines
AGC
All women with AGC need colposcopy
Women > AGC also need an endometrial biopsy
http://www.asccp.org/Portals/9/docs/Algorithms%207.30.13.p
df (Page 14)

34. ASCCP
Subsequent management of AGC after
colposcopy
For CIN 2 but no glandular lesion, manage per
ASCCP guideline
For negative biopsies, repeat pap and HPV testing
yearly for two years
For preinvasive glandular lesion, treat by excisional
biopsy
http://www.asccp.org/Portals/9/docs/Algorithms%207.30.13.p
df (Page 15)

35. Histologic Outcome after Atypical Glandular Cells
Obstet Gynecol 2010; 115:243-248
Age < 50 years
Age < 50 years
Age > 50 years
Age > 50 years
HPV neg
(n=656)
HPV pos
(n=269)
HPV neg
(n=420)
HPV pos
(n=497)
CIN 2
10
34
4
9
CIN 3
3
42
1
5
Cervical
4
adenoca in situ
29
1
4
Cervical SCC
2
10
1
6
Cervical
adenoca
0
7
1
2
Endometrial
atypical
10
0
10
0
Endo CA
10
3
44
0
Other cancers
0
0
6
0

36. ASCCP Guidelines
Biopsy: CIN I
No treatment
Repeat pap smear and HPV testing in one year
http://www.asccp.org/Portals/9/docs/Algorithms%207.30.13.p
df (Page 16)

37. ASCCP Guidelines
Biopsy: CIN I after Pap ASC-H or HSIL
Treatment not recommended
Repeat pap smear and HPV testing yearly for two years
http://www.asccp.org/Portals/9/docs/Algorithms%207.30.13.p
df (Page 17)

38. ASCCP Guidelines
Ages 21-24 – Biopsy CIN I
Treatment not recommended
After ASC-US or LSIL pap: Repeat pap smear
After ASC-H or HSIL pap: repeat pap smear and
colposcopy every six months for one year
If colposcopy is inadequate: excisional procedure
http://www.asccp.org/Portals/9/docs/Algorithms%207.30.13.p
df (Page 18)

39. ASCCP Guidelines
Biopsy: CIN 2-3
Recommend excisional procedure
http://www.asccp.org/Portals/9/docs/Algorithms%207.30.13.p
df (Page 19)

40. ASCCP Guidelines
Young women, Biopsy: CIN 2-3
Excisional procedure
OR
Pap smear and colposcopy every six months for one
year
http://www.asccp.org/Portals/9/docs/Algorithms%207.30.13.p
df (Page 20)

41. ASCCP Guidelines
Biopsy: AIS
Excisional procedure
Hysterectomy is preferred treatment
http://www.asccp.org/Portals/9/docs/Algorithms%207.30.13.p
df (Page 21)

42. Cervical Cancer Screening
Special Screening Situations
Immunosuppression
Pregnancy
After Hysterectomy
After Treatment for Cervical Cancer
After Pelvic Radiation
Challenging Anatomy
History of Sexual Assault
In Utero DES (diethylstilbestrol) exposure
Module III

43. Special Screening Situations
Immunosuppression
Human Immunodeficiency Virus
Organ Transplant
Chronic Steroid Use
Module III

44. Immunosuppression
Human Immunodeficiency Virus
Women with HIV infection are at high risk
for preinvasive lower genital tract disease
and cervical cancer
They are high risk for persistent HPV
infections
They should be screened by PAP SMEAR
twice in the first year and then yearly
thereafter
Module III

45. Immunosuppression
Organ Transplant
Women who are on high dose
immunosuppressants are at high risk for
lower genital tract neoplasia
They should be screened by PAP SMEAR
twice in the first year and then yearly
thereafter
Module III

46. Immunosuppression
Chronic Steroid Use
Chronic steroid use can lead to a
reduction in the clearance of HPV
infection
They should be screened by PAP SMEAR
twice in the first year and then yearly
thereafter
Module III

47. Special Screening Situations
Pregnancy
Pap smear is performed at first prenatal
visit and at the six week post partum visit
Abnormal Pap smears are evaluated in a
similar manner to non-pregnant women
Module III

48. Special Screening Situations
Pregnancy: ASC-US pap
Identical to non-pregnant women
It is acceptable to defer colposcopy until 6
weeks postpartum
Endocervical curettage is unacceptable
For pregnant women with no cytologic,
colposcopic , or histologic findings of CIN,
postpartum follow-up is recommended
Module III

49. ASCCP Guidelines
Pregnant with LSIL
Colposcopy in pregnancy
Treatment of all preinvasive lesions delayed until after
delivery
http://www.asccp.org/Portals/9/docs/Algorithms%207.30.13.p
df (Page 10)

50. Special Screening Situations
After Hysterectomy
Cervical cancer screening is not indicated if
removal of cervix or entire uterus in women
with no history of cervical cancer or
preinvasive disease.
Women who have undergone a subtotal
hysterectomy with preservation of the cervix
should follow screening recommendations
of average risk women
Module III

51. Special Screening Situations
After Treatment for Cervical Cancer
No age cut off for stopping screening
Women should undergo pap smears every 3 to 4
months for the first two years after treatment for
cervical cancer.
Pap smear screening is performed every 6
months from years 2 to 5 after treatment
Annual pap smear screening five years after
treatment
Module III

52. Special Screening Situations
After Pelvic Radiation
There is a higher risk of radiation induced
malignancies after pelvic radiation.
Annual pap smear screening should be
performed in women who receive pelvic
radiation for all cancer types (lymphoma,
cervical cancer, endometrial cancer, rectal
and anal cancer)
Module III

53. Special Screening Situations
Challenging Anatomy
Vaginismus
Vaginal Atrophy
Pelvic Floor Prolapse
Vaginal Agglutination
Cervical Stenosis
Obesity
Module III

54. Challenging Anatomy
Vaginismus
Vaginismus is the painful and
involuntary contraction of vaginal
muscles
Causes: sexual assault, vulvar vestibulitis,
inflammatory conditions of the pelvic
floor such as diverticulitis
Adequate pelvic examination and pap
smear may require an examination under
anesthesia
Module III

55. Challenging Anatomy
Vaginal Atrophy
Consideration should be given to a short
course of estrogen vaginal cream prior to
performing a pap smear
Module III

56. Challenging Anatomy
Pelvic Floor Prolapse
Uterine prolapse can place the cervix at
the introitus leading to trauma and
cornification of the cervix
Module III

57. Challenging Anatomy
Vaginal Agglutination
Vaginal agglutination can occur after
radiation, trauma, surgery, and infection
Evaluation by examination under
anesthesia should be considered
Use of vaginal dilators and estrogen
vaginal cream should be considered
Module III

58. Challenging Anatomy
Cervical Stenosis
Cervical stenosis is defined as the inability
to place a cutip or cytobrush within the
endocervix
There is increased risk of a false negative
pap smear
Recommendation:
Dilation of cervix
In a postmenopausal woman, consideration
of a transvaginal ultrasound to evaluate the
endometrial cavity for fluid
Module III

59. Challenging Anatomy
Obesity
Obesity can in some women lead to
difficulty examining the cervix due to
discomfort, vaginal wall redundancy, or
increased vaginal length.
Sensitive use of larger speculums and
retraction of the labia by an assistant can be
helpful in optimally postioning the
speculum to visualize the cervix
Module III

60. Special Screening Situations
History of Sexual Assault
Women who have survived the trauma of sexual
assault should be screened for sexually
transmitted disease including HIV testing.
For women who are older than age 30, high risk
HPV testing should be offered.
Consideration should be given for a pap smear
regardless of the timing of their previous pap
smear test within six months of sexual assault for
women older than age 21 years.
Module III

61. Special Screening Situations
In Utero DES (diethylstilbestrol) exposure
The cohort of women exposed to
Utero DES were born before 1980.
In-
They have a twofold increased risk of
cervical dysplasia
Based on clinician judgment, they should be
screened at least every three years if they
have had three consecutive normal pap
smears
Module III

62. CERVICAL CANCER
SCREENING
MODULE III
CONCLUSIONS
-This module summarizes the screening recommendations
for the average risk patient.
-The full algorithms can be reviewed on the asccp website:
http://www.asccp.org/Guidelines
-Providers must be cognizant of special screening situations
and tailor evaluation to each patient, their particular
anatomy, and their particular risk factors.