Cervical Cancer Screening and Sexually Transmitted Infections Case Studies.

Cervical Cancer Screening and Sexually Transmitted Infections Case Studies

VETERANS HEALTH ADMINISTRATION

Joyce, a 32-year-old returning veteran, comes in for a Well Woman visit. She has a history of an “abnormal Pap” before her deployment which was two years ago.

Vital signs: 5 feet 6 inches tall, 141 lbs., HR 75, RR 17, temp 97.9 F, BP 122/82, non-smoker.

Case Study 1

Q1: Joyce’s Pap smear results come back as “ASC-US (atypical squamous cells of undetermined significance)”. What would you do next?

A. If liquid-based cytology was used, await reflex HPV testing results. If positive, refer to colposcopy.

B. Refer immediately to colposcopy.

C. Repeat Pap test in 6 months.

Q1: Joyce’s Pap smear results come back as “ASC-US (atypical squamous cells of undetermined significance)”. What would you do next?

A. If liquid based cytology was used, await reflex HPV testing results. If positive, refer to colposcopy.

B. Refer immediately to colposcopy

C. Repeat Pap test in 6 months

Discussion Points

• Option A: Reflex testing for HPV (if liquid cytology is used, or if a separate sample is collected at time of Pap) is preferred for patient convenience and cost-effectiveness

− Women who test HPV negative: risk of harboring CIN 2/3+ is less than 2%; can perform co-testing in 3 years

− Women who test HPV positive: refer for colposcopy due to 15-27% chance of CIN 2/3+ (unless under the age of 25 where repeat testing in 1 year is suggested)

• Option B: Proceeding immediately to colposcopy is no longer recommended

Discussion Points

• Option C: If reflex HPV testing is not available, a follow-up Pap in 1 year is an option. If one-year FU is ASCUS or worse, colposcopy is recommended.

− The rate of loss to follow-up is substantial:1. Loss of 15–25% in research settings 2. Loss of 54–81% in clinical practice settings

Q2: Joyce asks about her chance of having cervical cancer. Based on her ASCUS and HPV neg test results, how will you respond?

A. <1%

B. 1-5%

C. 6-10%

D. >10%

Q2: Joyce asks about her chance of having cervical cancer. Based on her ASCUS and HPV neg test results, how will you respond?

A. <1%

B. 1-5%

C. 6-10%

D. >10%

The risk of cancer is very low (0.1–0.2%), and the risk of CIN 2/3+ for any individual patient is also low (2%)

Discussion

Q3: What if Joyce’s Pap smear results come back as “L-SIL (low-grade squamous intraepithelial lesion)? Co-testing was not performed. What is your next step?

Use the table on the next slide to guide your decision.

A. Repeat Pap smear immediately

B. Repeat Pap smear in 6 months

C. Refer for colposcopy

Pap result CIN1 CIN2/3 Cancer

Normal Pap up to 10% <1% 0.25%

ASC-US, HPV neg <10% <1.5% <0.01%

Normal Pap, HPV+ <1.1% <0.08%

ASC-US, HPV+ 50-60% 7-18% <0.1%

LGSIL 50-60% 2-19% 0.16%

HGSIL 20% up to 70% 7%

Management options for L-SIL result, no co-testing:A.Repeat Pap smear immediatelyB.Repeat Pap smear in 6 monthsC.Refer for colposcopy

VETERANS HEALTH ADMINISTRATION12

B. Repeat Pap smear in 6 months

C. Refer for colposcopy

Q3: What if Joyce’s Pap smear results come back as “L-SIL (low-grade squamous intraepithelial lesion)? Co-testing was not performed. What is your next step?

An L-SIL diagnosis is associated with a positive test result for high-risk HPV in most women (83% of the women with L-SIL cytology according to the ALTS study*). Therefore, reflex HPV testing is of limited value for triaging colposcopy. There is a high incidence of CIN 2 and 3 in patients with L-SIL (15% and 30% respectively). However, for women under the age of 25 with L-SIL, regardless of HPV status, immediate colposcopy is not recommended.

Discussion

*The ASCUS/LSIL Study (ALTS) Group. J Natl Cancer Inst, 2000: 92:397-402.

Q.4: What if Joyce’s Pap smear results come back as H-SIL (high-grade squamous intraepithelial lesion)? What is your next step?

Use the table on the next slide to guide your decision.

A.Repeat Pap smear immediately

B.Repeat Pap smear in 6-12 months

C.Refer to Gynecology for colposcopy and/or other procedures

Pap result CIN1 CIN2/3 Cancer

Normal Pap up to 10% <1% 0.25%

ASC-US, HPV neg <10% <1.5% <0.01%

Normal Pap, HPV+ <1.1% <0.08%

ASC-US, HPV+ 50-60% 7-18% <0.1%

LGSIL 50-60% 2-19% 0.16%

HGSIL 20% up to 70% 7%

Management options for H-SIL result:A.Repeat Pap smear immediatelyB.Repeat Pap smear in 6-12 monthsC.Refer to Gynecology for colposcopy and/or other procedures

B. Repeat Pap smear in 6-12 months

C. Refer to Gynecology for colposcopy and/or other procedures

Q.4: What if Joyce’s Pap smear results come back as H-SIL (high-grade squamous intraepithelial lesion)”? What is your next step?

Among women with H-SIL cytology results, greater than 70% have been reported to have CIN2 or CIN3, and 1-5% harbor invasive cancer. Therefore, a referral to a gynecologist for colposcopy is essential.

Discussion

Joyce, continued…Q5. Six months later, Joyce presents with complaints of itching and vaginal discharge. What are possible diagnoses?

A. Bacterial vaginosis

B. Candidiasis

C. Trichomoniasis

D. Physiologic discharge (diagnosis of exclusion)

E. Atrophic vaginitis (resulting from relative lack of estrogen in young women, i.e., low-dose OCP)

F. All of the above

Q5. Six months later, Joyce presents with complaints of itching and vaginal discharge. What are the possible diagnoses?

B. Candidiasis

C. Trichomoniasis

F. All of the above

Q6. What components in the history and physical exam might help you distinguish between these diagnostic possibilities?

• Sexual history to distinguish between infections that are sexually transmitted and other reproductive tract infections

• Query any recent antibiotic use, diabetes, or immunosuppression (make candida more likely)

• Inspect the vulva, looking for areas of erythema, edema, ulceration or chronic vulvar skin changes. Palpate with a cotton-tipped applicator to elicit areas of tenderness.

• Inspect the vagina and cervix

• Assess the color, consistency, and odor of discharge

Q6. What components in the history and physical exam might help you distinguish between these diagnostic possibilities?

Q7. What are the next diagnostic steps?

A. Vaginal pH

B. Amine (whiff test)

C. Potassium hydroxide (KOH) smear

D. Normal saline microscopy

E. BD AffirmTM point of care testing

F. All of the above

A. Vaginal pH

B. Amine (whiff test)

C. Potassium hydroxide (KOH) smear

D. Normal saline microscopy

E. BD AffirmTM testing

F. All of the above

Q7. What are the next diagnostic steps?

• Obtain specimens from lateral vaginal wall for laboratory evaluation. Evaluations should include vaginal pH, amine (whiff) test, saline and 10% potassium hydroxide (KOH) smears for microscopic examination.

• Normal pH (< 4.5) rules out bacterial vaginosis, whereas pH > 4.5 has a limited differential diagnosis.

• Perform whiff test for amines by placing a drop of 10% KOH on vaginal secretions and checking for fishy odor.

• Saline microscopy permits identification of trichomonads and clue cells.

• BD AffirmTM can identify candida species, trichomonas vaginalis, and gardnerella vaginalis. Turnaround time may vary by facility.

Discussion

Q8. Your exam reveals a positive whiff test and a pH >5. What is the most likely diagnosis?

B. Candidiasis

C. Trichomoniasis

Q8. Your exam reveals a positive whiff test and a pH >5. What is the most likely diagnosis?

B. Candidiasis

C. Trichomoniasis

Q9. What treatment is least effective?

A. Oral Metronidazole

B. Topical Metronidazole

C. Clindamycin

D. Tinidazole

E. Triple sulfa

Q9. What treatment is least effective?

A. Oral Metronidazole

B. Topical Metronidazole

C. Clindamycin

D. Tinidazole

E. Triple sulfa

Q10. Which of the following would you NOT do if Joyce’s symptoms don’t improve?

A. Re-evaluate for cure

B. Re-evaluate for another cause of vaginitis

C. Recommend douching

D. Query about unprotected sex

Q10. Which of the following would you NOT do if Joyce’s symptoms don’t improve?

A. Re-evaluate for cure

B. Re-evaluate for another cause of vaginitis

C. Recommend douching

D. Query about unprotected sex

Q11. Your exam reveals vulvar edema, erythema, and a cheesy white discharge. What is the most likely diagnosis?

B. Candidiasis

C. Trichomoniasis

Q11. Your exam reveals vulvar edema, erythema, and a cheesy white discharge. What is the most likely diagnosis?

B. Candidiasis

C. Trichomoniasis

Q12. Which treatment would you NOT consider?

A. Topical imidiazole

B. Topical metronidazole

C. Oral fluconazole

A. Topical imidiazole

B. Topical metronidazole

C. Oral fluconazole

Q12. Which treatment would you NOT consider?

Discussion Point

• Oral fluconazole is good if Joyce has already tried topical imidiazole

• Also, topical treatment is messy and the oral fluconazole is a one-dose pill

Q13. Which of the following would you do if Joyce’s symptoms don’t improve?

A. Obtain a culture to confirm type of candida

B. Assess for risk factors that potentially promote candida

C. Treat the infection for longer period of time

Q13. Which of the following would you do if Joyce’s symptoms don’t improve?

A. Obtain a culture to confirm type of candida

B. Assess for risk factors that potentially promote candida

C. Treat the infection for longer period of time

All options are feasible.

• Option A: May be dealing with another type of candida (candida tropicalis or candida glabrata) which doesn’t respond well to fluconazole. Obtain a culture to confirm type of candida.

• Option B: Many women have risk factors that could promote candida. Assess for antibiotic use (e.g., acne treatment), change to a different/low-dose OCP, assess for diabetes mellitus and confirm that she is well controlled.

• Options C and D: May need to treat infection for a longer period of time (repeat doses of fluconazole on day 4/7).

• Consider treating Joyce’s partner.

Discussion Points

Q14. Your exam reveals a frothy, yellow-green discharge with erythematous punctuate lesions on the cervix. Whiff test is negative and pH is normal. What is the most likely diagnosis?

B. Candidiasis

C. Trichomoniasis

D. Physiologic discharge

E. Atrophic vaginitis

B. Candidiasis

C. Trichomoniasis

D. Physiologic discharge

E. Atrophic vaginitis

Q14. Your exam reveals a frothy, yellow-green discharge with erythematous punctuate lesions on the cervix. Whiff test is negative and pH is normal. What is the most likely diagnosis?

Q15. What treatment would you provide?

A. Metronidazole 2gm oral dose x 1

B. Tinidazole

C. Topical Metronidazole

D. Oral fluconazole

A. Metronidazole 2gm oral dose x1

B. Tinidazole

C. Topical Metronidazole

D. Oral fluconazole

Q15. What treatment would you provide?

Joyce’s partner should also be treated as trichomonas is a sexually transmitted infection

Q16. What would you do if Joyce’s symptoms don’t improve?

• Query about unprotected sex, other partners, and adherence to medication by Joyce and her partner.

• Reassess for other cause of vaginitis after treatment (i.e., candida after exposure to ABX).

Q16. What would you do if Joyce’s symptoms don’t improve?

Q17. Before Joyce leaves your office, what advice might you give her based on the diagnosis of a new STI?

There are three major concerns…1.Discuss her sexual practices:Address the issue of multiple sexual partners in a sensitive fashion. Ensure you understand the following:

• Are all of her sexual encounters consensual? This addresses the possibility of rape or sexual abuse.

• What are Joyce’s motives for having multiple sexual partners? This can reveal possible psychological problems, low self-esteem, substance use, etc.

2.Discuss her high risk of further STI exposure from unprotected sex3.Discuss contraception

Q17. Before Joyce leaves your office, what advice might you give her based on the diagnosis of a new STI?

Cervical Cancer Screening and Sexually Transmitted Infections Case Studies.

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