Cervical Cancer Screening Updates

1. Cervical Cancer Screening Updates Dr. GORDON JOHNSON

2. Faculty /Presenter Disclosure • Faculty: gordonjohnson • Relationships with commercial interests: • Grants/Research Support: none to disclose • Speakers Bureau/Honoraria: none to disclose • Consulting Fees: none to disclose • Independent contractor to dynalifeDX diagnostic laboratories • Other: NONE TO DISCLOSE

3. Disclosure of Commercial Support • This program has received financial support from DYNALIFEDX in the form of EDUCATIONAL PROGRAM • This program has received in-kind support from DYNALIFEDX in the form of LOGISTICAL SUPPORT • Potential for conflict(s} of interest: • DR. GORDON JOHNSON Has received NO HONOURARIUM AND IS IN A CONTRACTUAL AGREEMENT WITH DYNALIFEDX • DYNALIFEDX PROVIDES LABORATORY SERVICES WHICH WILL BE DISCUSSED IN THIS PROGRAM.

4. Mitigating Potential Bias • DYNALIFEDX OPERATES IN ACCORDANCE WITH ALBERTA HEALTH SERVICES, TESTING AND SOLUTIONS ARE A DIRECT RESULT OF PROVINCIAL STANDARDS.

5. Guideline for Screening for Cervical CancerAlberta, Canada

6. Issues • Failure to be screened and being under-screened continue to be major risk factors for cervical cancer in Alberta. • Over-screening is resulting in excess investigations and inefficient use of resources and potential harm to women. • The impact of newer technologies such as liquid based cytology, human papillomavirus (HPV) testing, and the HPV vaccine is evolving.

7. Recruitment • Widespread Pap testing in Alberta during the past 40 years has resulted in a substantial reduction in cervical cancer mortality. Yet currently, about 30% of Alberta women have not been screened during the preceding 3 years. • Women who have never been screened or are screened irregularly are most at risk for cervical cancer. • Improving cervical screening coverage will reduce mortality further, regardless of the technology used.

8. Screening Test& Initiation All laboratories in Alberta have converted to liquid-based cytology. Liquid-based cytology facilitates reflex HPV testing in certain circumstances, which can minimize repeat testing and women’s apprehension concerning Pap test results. Cervical cancer screening should begin at age 21 or approximately 3 years after first intimate sexual activity, whichever occurs later. Note: Intimate sexual activity includes intercourse as well as digital or oral sexual activity involving the genital area with a partner of either gender.

9. Screening Interval • Within 5 years, screen with three negative Pap tests at least 12 months apart and then extend the screening interval to every 3 years. • More frequent interactions with health care providers may be necessary for periodic health exams and screening for sexually transmitted infections (STI). These visits do not necessitate cervical cancer screening unless the woman is due. • For women older than 69 who have never been screened, screen with three annual Pap tests. If results are negative and satisfactory, discontinue screening.

10. Increased Surveillance • Some women, because of increased risk or past cervical disease, require more vigilant surveillance. Continue to screen annually. • Women who have ever had biopsy confirmed high-grade squamous intraepithelial lesions (HSIL), adenocarcinoma in situ (AIS) or invasive cervical cancer. Women with these conditions who undergo hysterectomy should have vault smears annually thereafter. • Women with immunosuppression who have ever been sexually active. This includes women with human immunodeficiency virus (HIV/AIDS), lymphoproliferative disorders, organ transplantation, and women taking long-term corticosteroids (see Risk Factor section for more information).

11. Discontinuing Screening Screening may be discontinued for: • Women who have had a hysterectomy with the cervix removed for BENIGN DISEASE, as long as there is adequate pathological documentation that the cervix has been removed completely. • Women older than 69 years who have had at least three consecutive satisfactory and negative Pap tests at the recommended screening interval in the last 10 years.

12. Special Circumstances Women under 21 years of age with abnormal results: • Routine screening in this age group is not recommended. Dysplastic lesions in this age group are most likely to resolve spontaneously. • If women younger than 21 years are screened, referrals for colposcopy should be minimized while carefully monitoring for progression. • In women younger than 21 years with either ASC-US or LSIL, HPV DNA testing is unacceptable and if inadvertently performed, should not influence management.

13. Pregnant women: • Screen according to the guidelines, however care should be taken not to over-screen. There is no need to perform Pap tests during pre-natal and post-partum visits unless the woman is otherwise due for screening. • If ASC-US or LSIL is detected during pregnancy, do not repeat the Pap test until 6 months post-partum. More advanced lesions should be managed according to the guidelines.

14. Women currently being assessed by a colposcopy clinic: • Should not undergo additional Pap testing until discharged from colposcopy (this includes those women who do not show up for their appointments) Women who have undergone subtotal hysterectomy and retained their cervix: • Continue with screening according to the guidelines. Women ≥40 years with cytologically benign endometrial cells. These women should undergo endometrial sampling if: • They have abnormal bleeding • They are asymptomatic and post-menopausal • Also consider endometrial sampling if the woman is asymptomatic, pre-menopausal and at increased risk for endometrial cancer due to chronic estrogen stimulation

15. Women who have received the HPV vaccine: Continue with screening. The HPV vaccine is approved in Canada for females 9-26 years of age. It should be recommended to unimmunized women according to NACI guidelines that currently recommend the following: • The HPV vaccine should be offered to females before they become sexually active to ensure maximum benefit. The primary age group recommended is 9 to 13 years. • Females 14 to 26 should also be offered the vaccine. Women may potentially benefit regardless of prior sexual activity, Pap test abnormalities or a known HPV infection. • HPV vaccine is NOT recommended for pregnant women or females under nine years. • For women older than 26 years, consider its use on a case by case basis.

16. Optimal Specimen Collection • Advise the patient to avoid, where possible, the use of contraceptive creams and jellies, douching, intravaginal medication and sexual intercourse for 24 hours before the test. • Advise the patient to avoid scheduling her appointment during menses, but do not defer for abnormal bleeding. • Follow collection instructions provided by the manufacturer.

17. • Pap testing should be done BEFORE other cervical procedures including STI testing, IUD insertion, etc. so that the diagnostic cells needed for the Pap test are not removed. • Pap tests should not be repeated within 3 months of prior Pap tests or other cervical procedures to allow time for epithelial regeneration. • The presence of endocervical cells is not necessary for the sample to be “satisfactory for evaluation” as per Bethesda 2001. An adequate number of squamous epithelial cells is required.

18. Questions ???