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cervical cancer presentation
1. Cervical Cancer and Pap Smear
Ala’a Aljohani (R1) Rasha Alofi (R1)
Supervisor:
Dr.Amani Mahrous Dr.Sami Alrehili
2. This is your day
we hope to make it:
◦Informative
◦Interesting
◦Relaxing
3. Contents:
◦Key facts
◦Risk factors
◦Role of HPV & vaccination
◦Clinical presentation
◦Screening
◦Guidelines for abnormal pap smears
◦Preventation
◦Screening for special population
◦Home massages
4. Cancer of the uterine cervix is the third most common
gynecologic cancer in the United States & second most common
type of cancer in countries that do not have access to cervical
cancer screening and prevention programs
5. The most common cervical cancer is SCC accounting for 80%
of cases
Adenocarcinoma is less common and more difficult to
diagnose because it starts higher in the cervical.
Murtagh’s General Practice 5th eddition
6. ◦In 2012, approximately 270 000 women died from cervical
cancer; more than 85% of these deaths occurring in low-
and middle-income countries.
14. 1- Human papilloma virus infection
◦ The most important risk factor for cervical cancer is infection by
the human papilloma virus (HPV).
◦HPV is mainly transmitted through sexual contact and most
people are infected with HPV shortly after the onset of sexual
activity.
◦about two-thirds of all cervical cancers are caused by HPV 16
and 18
15. Diagnostic test
◦HPV can be detected through polymerase chain
reaction testing or DNA testing
Human papilloma virus
16. Two HPV vaccines are now being marketed in many
countries throughout the world - a bivalent and a
quadrivalent vaccine.
Both vaccines are highly efficacious in preventing
infection with virus types 16 and 18.
17.
18. ◦The primary target group in most of the countries
recommending HPV vaccination is young adolescent
girls, aged 9-13.
the vaccination schedule depends on the age of the vaccine recipient:
Females <15 years at the time of first dose: a 2-dose
schedule (0, 6 months) is recommended.
◦If the interval between doses is shorter than 5 months,
then a third dose should be given at least 6 months after
the first dose.
19. ◦Females ≥15 years at the time of first dose: a 3-
dose schedule (0, 1-2, 6 months) is recommended.
◦NB: A 3-dose schedule remains necessary for those
known to be immunocompromised and/or HIV-
infected
20.
21. 2- Long-term use of oral
contraceptives (birth control pills)
taking oral contraceptives (OCs) for a long time
increases the risk of cancer of the cervix.
the risk goes back down again after the OCs are
stopped.
22. 3-Intrauterine device use
A recent study found that women who had ever used an
intrauterine device (IUD) had a lower risk of cervical cancer.
The effect on risk was seen even in women who had an IUD
for less than a year, and the protective effect remained after the
IUDs were removed.
23. ◦Women who have had 3 or more full-term pregnancies
have an increased risk of developing cervical cancer.
4-Having multiple full-term pregnancies
?
24. No one really knows why this is true.
◦ One theory is that these women had to have unprotected intercourse to
get pregnant, so they may have had more exposure to HPV.
◦ Also, studies have pointed to hormonal changes during pregnancy as
possibly making women more susceptible to HPV infection or cancer
growth.
◦ Another thought is that pregnant women might have weaker immune
systems, allowing for HPV infection and cancer growth
25. Women who were younger than 17 years when they had their
first full-term pregnancy are almost 2 times more likely to get
cervical cancer later in life than women who waited to get
pregnant until they were 25 years or older.
5-Being younger than 17 at first full-term
pregnancy
26. Other risk factors:
◦ Being overweight
◦ Multiple sexual partner
◦ A diet low in fruits and vegetables
◦ Immunosuppression
◦ Having a family history of cervical cancer
◦ Smoking
27. Clinical presentation:
Many patient with cervical cancer are asymptomatic
Symptoms if present may be :
1-Vaginal bleeding especially postcoital bleeding
2-Vaginal discharge
Murtagh’s General Practice 5th eddition
29. ◦During a routine appointment to discuss an respiratory
infection, you find that 18 year old female patient has
become sexually active for the first time. According to
current guideline, when should you begin cervical cancer
screening on this patient ?
Pretest family medicine
30. ◦You are seeing a 55 year old patient for her annual physical
examination. she has been married to her husband for 32 years
and reports that both have been monogamous. Records indicate
that she has had normal pap smear every 1to 2 years for the last
20 years and has never had abnormal pap smear. At what age
is it appropriate to discontinue pap screening on this patient ?
Pretest family medicine
31. Screening
◦Pap smear
is method of cervical cancer screening
◦Clinical Considerations:
PATIENT POPULATION:
This recommendation statement applies to all women who have a
cervix, regardless of sexual history.
http://www.aafp.org/afp/2012/0615/p1186.html
32. Cervical Cancer Screening Guidelines for Average-Risk women:
American College of
Obstetricians and
Gynecologists (ACOG)
2012
U.S. Preventive
Services Task Force
(USPSTF)
2012
American Cancer Society
(ACS), American Society
for Colposcopy and
Cervical Pathology
(ASCCP), and American
Society for Clinical
Pathology (ASCP)
2012
Age 21 regardless of the age of
onset of sexual activity.
Women aged <21 years should
not be screened regardless of age
at sexual initiation and other
behavior-related risk factors
(Level A evidence).
Age 21.
(A recommendation)
Recommend against
screening women aged
<21 years
(D recommendation).
Age 21.
Women aged <21 years
should not be screened
regardless of the age of
sexual initiation or other
risk factors.
When to
start
screening
34. (ACOG)(USPSTF)(ACS), (ASCCP), (ASCP)
Aged >65 years with adequate
screening history.
Women with a history of
CIN2, CIN3, or AIS should
continue routine age-based
screening for at least 20 years
(Level A evidence).
Aged >65 years with adequate
screening history and are not
otherwise at high risk for
cervical cancer
(D recommendation).
Aged >65 years with adequate
screening history.
Women with a history of CIN2 or
a more severe diagnosis should
continue routine screening for at
least 20 years.
When to
stop
screening
Women who have had a
hysterectomy (removal of the
cervix) should stop screening
and not restart for any reason
(Level A evidence).
Recommend against screening
in women who have had a
hysterectomy (removal of the
cervix)
(D recommendation).
Women who have had a total
hysterectomy (removal of the
uterus and cervix) should stop
screening.
Women who have had a supra-
cervical hysterectomy (cervix
intact) should continue screening
according to guidelines.
Screening
post-
hysterecto
-my
35. Cervical Cancer Screening Guidelines for Average-Risk Women
(ACOG)(USPSTF)(ACS), (ASCCP),
(ASCP)
Women who have received
the HPV vaccine should be
screened according to the
same guidelines as women
who have not been
vaccinated
(Level C evidence).
The possibility that
vaccination might reduce the
need for screening with
cytology alone or in
combination with HPV testing
is not established. Given these
uncertainties, women who
have been vaccinated should
continue to be screened.
Women at any age with a
history of HPV vaccination
should be screened
according to the age
specific recommendations
for the general population.
Screening
among those
immunized
against HPV
16/18
36. Screening for special population :
◦HIV patient
◦pregnant leady
◦women with total hysterectomy
37. 1- WOMEN WITH RISK FACTORS
◦ Women with human immunodeficiency virus infection should be screened with
cytology twice in the year after diagnosis, even if younger than 21 years, and
annually thereafter.
◦ Because women who have been treated for CIN 2 or higher have nearly a threefold
increased risk of invasive disease for 20 years after treatment, they should receive
annual, age-based screening during the 20 years after treatment or spontaneous
regression, even if they reach 65 years of age.
http://www.aafp.org/afp/2012/0615/p1186.html
38. 2-Pregnant leady
◦If due, cervical cancer is still recommended and can be
safely performed until 24 weeks gestation .
◦Pap test have not been associated with an increase rate of
miscarriage in 1st & 2nd trimesters.
Murtagh’s General Practice 5th edition
39. 3-WOMEN WHO HAVE HAD A TOTAL
HYSTERECTOMY
Routine screening should be discontinued and not restarted for
any reason in women who have had a hysterectomy with
removal of the cervix and who have no history of CIN 2 or
higher. The risk of developing vaginal cancer in this group is
low, and continued screening is not effective.
http://www.aafp.org/afp/2012/0615/p1186.html
43. PREVENTION:
The rate of cervical cancer has declined significantly in
settings in which cervical cancer screening is employed.
In addition, human papillomavirus (HPV) vaccination
had been introduced to reduce the incidence of cervical
neoplasia.
44. ◦Do the woman still need regular cervical cancer
if she has gotten the HPV vaccine?
http://m.acog.org/About-ACOG/ACOG-Districts/District-II/Cervical-Cancer-1
45. ◦Yes, HPV vaccination helps prevent infection. It is not a cure
for an HPV infection. Women who have been vaccinated still
need to have regular screening as recommended for their age
group
46. ◦If the pt has HPV, does it mean she will
get cancer?
http://m.acog.org/About-ACOG/ACOG-Districts/District-II/Cervical-Cancer-1
47. ◦No, Most people get HPV infection, but very few get
cervical cancer
◦In most cases, HPV infection goes away on its own
◦Sometimes, the HPV infection does not go away after many
years. This type is called “persistent”. It can lead to cervical
cancer
48. Home massages :
◦ Cervical cancer is the easiest gynecologic cancer to prevent, with regular screening tests
and follow-up
◦ Invasive cervical cancer is almost unknown in women under the age of 20, and very rare
before age 25.
◦ On average, cervical cancer takes at least a decade to develop from a focus of a cervical
squamous intraepithelial lesion.
◦ The incidence of cervical cancer has been decreased significantly through the screening
procedures of the Pap smear, colposcopy and colposcopically directed cervical biopsy.
doctors believe that a woman must be infected with HPV in order to develop cervical cancer. Although this can mean infection with any of the high-risk types
Only for women
http://www.who.int/immunization/diseases/hpv/en/
Two HPV vaccines are now being marketed in many countries throughout the world - a bivalent and a quadrivalent vaccine.
Both vaccines are highly efficacious in preventing infection with virus types 16 and 18, which are together responsible for approximately 70% of cervical cancer cases globally. The vaccines are also highly efficacious in preventing precancerous cervical lesions caused by these virus types. The quadrivalent vaccine is also highly efficacious in preventing anogenital warts, a common genital disease which is virtually always caused by infection with HPV types 6 and 11. Data from clinical trials and initial post-marketing surveillance conducted in several continents show both vaccines to be safe
In one study, the risk of cervical cancer was doubled in women who took birth control pills longer than 5 years, but the risk returned to normal 10 years after they were stopped.
No one really knows why this is true. One theory is that these women had to have had unprotected intercourse to get pregnant, so they may have had more exposure to HPV. Also, studies have pointed to hormonal changes during pregnancy as possibly making women more susceptible to HPV infection or cancer growth. Another thought is that pregnant women might have weaker immune systems, allowing for HPV infection and cancer growth
1-Overweight women are more likely to develop adenocarcinoma of the cervix.
3-Cervical cancer may run in some families. If your mother or sister had cervical cancer, chances of developing the disease are 2 to 3 times higher than if no one in the family had it. Some researchers suspect that some instances of this familial tendency are caused by an inherited condition that makes some women less able to fight off HPV infection than others. In other instances, women from the same family as a patient already diagnosed could be more likely to have one or more of the other non-genetic risk factors previously described in this section
What’s the difference between a Pap test and an HPV test?
A Pap test is used to find cell changes or abnormal cells in the cervix. (These abnormal cells may be pre-cancer or cancer, but they may also be other things.) Cells are lightly scraped or brushed off the cervix. They are processed, and then looked at under a microscope to see if the cells are normal or if changes can be seen. The Pap test is a very good test for finding cancer cells and cells that might become cancer.
Human papilloma virus (HPV) is a virus that can cause cervix cell changes. The HPV test checks for the virus, not cell changes. The test can be done at the same time as the Pap test, with the same swab or a second swab. You won’t notice a difference in your exam if you have both tests. A Pap test plus an HPV test (called co-testing) is the preferred way to find early cervical cancers or pre-cancers in women 30 and older.
An HPV DNA test has been approved by the FDA to be used without a Pap test to screen for cervical cancer. At this time, the American Cancer Society is considering the evidence supporting the use of this test for screening and may issue updates to our screening guidelines in 2015. Other testing (which could include a Pap test) would be needed if HPV is found.
This recommendation statement does not apply to women who have received a diagnosis of a high-grade precancerous cervical lesion or cervical cancer, women with in utero exposure to diethylstilbestrol, or women who are immunocompromised (such as those who are HIV positive).
