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Cervical Cancer Screening

Cervical Cancer Screening. Cristin Colford, MD April 27,2010. This is why I do this talk…. Sent: Wednesday, July 02, 2008 11:24 PM To: Colford, Cristin Subject: Questions

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Cervical Cancer Screening

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  1. Cervical Cancer Screening Cristin Colford, MD April 27,2010

  2. This is why I do this talk… • Sent: Wednesday, July 02, 2008 11:24 PMTo: Colford, CristinSubject: Questions • Hi Dr. Colford, There is another thing. I just learned from my Intern friends that I might have to do some Pap-smears? Well that was something I did once at Med school but never since then. I hope in that case I can always ask a female attending (i.e. you?) otherwise I would say the patient is better of with a gyn/obst consult.Thank you in advance, • Dr. Intern…

  3. Objectives • Review guidelines for cervical cancer screening • Review methods for cervical cancer screening • Review how to follow up abnormal results • Review our process in clinic

  4. Cases • 18 yo female. Never been sexually active. Comes in because her mom tells her she needs a pap • 45 yo female. Here for annual exam and PAP. s/p TAH for fibroids • 72 yo female. Here for annual exam and PAP. Has had yearly normal paps for at least 10 years

  5. Cervical Cancer2009www.cancer.org • 11,270 new cases of invasive cervical cancer • 4,070 women will die from cervical cancer • Death rate declined 74% from 1955 to 1992 • Most common in Hispanic women • More common in African-American than Caucasian women

  6. Cervical Cancer • Most cases in women younger than 50 • Rare in women younger than 20 • 60-80% of women diagnosed with invasive cancer have not had a PAP in last 5 years

  7. USPSTF • Recommends screening for cervical cancer in women who are sexually active and have a cervix (A recommendation) • Good evidence from multiple observational studies that screening with cervical cytology (PAP) reduces incidence of and mortality from cervical cancer • Direct evidence for optimal starting and stopping age and interval is limited. • Indirect evidence: Most benefit can be obtained by beginning at age 21 or within 3 years of onset of sexual activity and screening at least every 3 years.

  8. USPSTF • Recommends against routinely screening women older than 65 if they have had adequate screening and are not at high risk for cervical cancer (D recommendation) • Declining rates of cervical cancer in women over 65 • Increased risk of harms (false positives and invasive procedures)

  9. USPSTF • Recommends against routine screening with PAP in women who have had hysterectomy for benign disease (D recommendation) • Yield of cytology is low in women who have had hysterectomy for benign disease • Poor evidence that screening to detect vaginal cancer improves outcomes.

  10. Clinical issues to consider • Goal is to sample the transition zone • Study in Netherlands followed up no transition zone---no higher rates of cervical cancer when followed out for 3 years • Optimal age to begin is unknown • Based on HPV data, within 3 years of sexual onset • Little value in screening women who have never had sex, but high prevalence of sexual activity by ages 21 and concern that sexual history may not be accurate

  11. Clinical considerations • No direct evidence that annual screening achieves better outcomes than every 3 yr • Majority of cervical cancer cases occur in women not screened in 5 years or in those who did not have appropriate follow up for abnormal pap • Sensitivity for single pap is low (60%-80%), most US agencies recommend annual pap for 2-3 yrs before extending interval (ACOG, ACS)

  12. Thin prep or not? • Everyone else is doing it, why shouldn’t we? • Pathologists are most comfortable with liquid • Not a huge cost difference to patient • Particularly helpful for ASCUS • Reflex HPV • Don’t need to bring back to repeat pap, can automatically check off reflex hpv as sample already obtained • Studies combining HPV and cytology not cost effective • BUT new study suggest that HPV instead of cytology promising for early detection and reduced high grade changes

  13. RCT: Accuracy of liquid based compared to conventional papsRonco et al. BMJ 5/2007 • 44, 000 women aged 25-60 randomly assigned to conventional pap vs liquid based with HPV testing. • Outcome: Relative sensitivity for CIN 2 or higher with PAP result of ASCUS or higher considered positive • Results: No significant difference in sensitivity for detecting CIN 2 or greater. • Liquid based detected more CIN 1 or more lesions, but not CIN 3 or more. • Reduction in unsatisfactory cytology with liquid based

  14. Meta-analysis: Liquid compared to conventional cytologyArbyn et al. Obstet Gyn 2008 • Meta-analysis of seven studies that compared liquid to conventional pap using gold standard of colposcopy concludes that liquid based compared to conventional cytology revealed no statistically significant difference in se or sp. Except lower sp in liquid based with ascus. • HSIL • Liquid based se 57.1% Sp 97% • Conventional se 55.2%, sp 96.7% • LGSIL • Liquid based se 79.1%, sp 78.8% • Conventional se 75.6%, sp 81.2% • ASCUS • Liquid based se 90.4%, sp 64.6% • Conventional se 88.2%, sp 71.3%

  15. RCT Conventional Vs LiquidSiebers, et al. JAMA 2009 • Cluster RCT • Practices randomly assigned liquid or conventional • Study personnel blinded to type of cytology • 90,000 women • Ages 30-60 • Q5yrs • Netherlands • No significant difference between liquid and conventional

  16. How to do a pelvic exam • http://content.nejm.org/cgi/video/356/26/e26/

  17. What to do with an abnormal PAP? • ASCUS • LGSIL • HGSIL

  18. Atypical Squamous Cells of Undetermined Significance • 2 million paps yearly • Of patients with cytology finding of ASCUS • 80.5% had normal biopsy • 12.8% had Grade 1 CIN • 6.6% had Grade 2 CIN • 0.1% had Invasive Cancer

  19. Options for Management of ASCUS • Repeat cytology • Immediate colposcopy • Reflexive HPV DNA testing

  20. Reflex HPV testing with ASCUS • ASCUS-LSIL Triage Study (ATLS) • Determined that Reflex HPV compared to repeating PAP had equivalent sensitivity and slightly increased specificity. • If high risk HPV detected, refer for colposcopy • If no high risk HPV detected, return to routine screening interval • Reduce number of women undergoing colposcopy by identifying high risk patients • Reduce costs, reduce patient anxiety

  21. Cost Effectiveness of liquid based cytology with reflex HPV testing in women over 30 Bidus et.al, Obstet Gynecol. • Triennial screening with liquid based cytology and reflex HPV for ASCUS ($95,300 per year of life saved) • Triennial combined screening with HPV and cytology for women 30 and over ($228, 700 per year of life saved) • Annual combined HPV and cytology ($2,215,100 per year of life saved)

  22. ASCUS follow up

  23. Refer for immediate colpo • LGSIL • HGSIL

  24. Following up PAPs in clinic • New system 3/01

  25. Interns mapped the process and made suggestions. We made revisions… • Kiran Venkatesh • Amanda Allen • Tara O’Brien • Jacob Kurlander

  26. Start our new process • March 1st. • Theressa Brown will send letters to patients with normals. • She will contact you via Webcis if there is an infection to be addressed. • Robin Woodford will address abnormals, • communicate via webcis • Please inform your patients. • She will help you refer to gyn follow to completion.

  27. Trich on PAPWhat to do? • Liquid based paps have low sensitivity (61%) but high specificity (99%). • So if see Trich on pap, treat • Metronidazole 2 grams po x 1 • Or metronidazole 500 mg bid x 7 days

  28. BV on pap • Not reliable diagnostic method. • Not associated with CIN • Would need clinical symptoms to warrant treatment

  29. Case 1 18 yo female. Never been sexually active. Comes in because her mom tells her she needs a pap -All recommendations say that she does not need a pap until sexually active or age 21 (? Do you need a pap if you are 30 and never have had intercourse?)

  30. Case 2 • 45 yo female. Here for annual exam and PAP. s/p TAH for fibroids • If no history of CIN, no PAP

  31. Case 3 • 72 yo female. Here for annual exam and PAP. Has had yearly normal paps for at least 10 years • USPSTF and ACS say that you can stop after a discussion between patient and provider. ACOG cites limited evidence for setting age limit

  32. HPV testing instead of cytologyRonco et al, Lancet Oncology, Jan 2010 • HPV based screening more effective than cytology for preventing invasive cervical cancer • For women >35, HPV based testing increased detection of CIN2 and 3 in first round, decreased incidence in second round • But in younger women, overdiagnosis of CIN-2 which regresses • 3000 additional colposcopies in HPV compared to cytology group. • 332 additional per cancer prevented • Promising….perhaps instead of direct referral to colposcopy there could be some repeat testing interval to determine persistent HPV and then refer to colpo

  33. Next step • What is our cervical cancer screening rate? • How to improve? • Visit planners….

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