Dr. Kirtan

Screening may help in early detection of cervical abnormalities

2

Visual Inspection

VIA

VILI

Pap Smear

Conventional

LBC

HPV DNA Testing

Cervicography

Pap Net

Polar Probe

Community low

resource settings

Still Experimental

PAP SMEAR

PAP smear sampling of cervix involves

scraping of cervical surface and a portion of

non visualised cervical canal using various

sampling devices

Cervical cancers and cervical pre-cancers are classified into 2 main types of cervical cancer: squamous cell carcinoma and adenocarcinoma.

About 80% to 90% of cervical cancers are squamous cell carcinomas.

Try not to schedule an appointment for a time during the menses. The best time is at least 5 days after the menses stops.

Don't use tampons, birth-control foams or jellies, other vaginal creams, moisturizers, or lubricants, or vaginal medicines for 2 to 3 days before the test.

Don't douche for 2 to 3 days before the test.

Avoid sexual intercourse for 2 days before the test.

HOW TO TAKE A PAP SMEAR ?

Spatula is rotated through 360

degrees maintaining contact with

ectocervix

Do not use too much force [bleeding

/pain]

Do not use too less force [inadequate

sample]

Sample is smeared evenly on the

slide and fixed immediately

Both sides of spatula are to be

smeared

HOW TO TAKE A PAP SMEAR ?

Endocervical sample is collected

using an endocervical brush

Insert the cytobrush into canal, so

that last bristles of brush are

visible

Rotate the brush through 180

degrees. [more rotations increase

the chance of bleeding]

Sample is rolled on the slide and

fixed.

FIXATION OF SMEAR

Fixation is done immediately with

fixative like 95% alcohol or cytofix

spray to avoid air drying

Spray should be kept at 10 - 12

inches, to avoid destruction of

cells by propellent in the spray

Smear should monolayer for

proper penetration of cell surface

by fixative

Insert the cytobrush into canal, so that last

bristles of brush are visible

Rotate the brush through 180 degrees. [more

rotations increase the chance of bleeding]

Detach the brush and immerse in the

liquid(alcohol)

There is no evidence that LBC improves the accuracy of screening

Advantages of technique

LBC is semi-automated

It creates a uniform spread of epithelial cells that are easier to read by cytotechnicians and cytopathologists

reduces the rate of unsatisfactory samples.

The LBC sample may also be used for reflex testing for HPV DNA and other biomarkers like chlamydia at a later date

Several slides can be prepared from one smear

American cancer society(ACS) American society for colposcopy and cervical pathology (ASCCP) and American society for clinical pathology(ASCP)2012

U.S. Preventive Services Task Force (USPSTF) 2012

American colloege of Ostetricians and Gynacologists (ACOG) 2012

Society of Gynaecological Oncology (SGO)and the American society for colposcopy and cervical pathology (ASCCP) :Interim clinicalguidance for primary hr HPV testing 2015

When to start screening

Age 21 . Women aged < 21 years should not be screened regardless of age of sexual initiation or other risk factors

Age 21(A recommendation) Recommend against screening woman aged < 21years ( D recommendation)

Age 21 regardless of the age of onset of sexual activity .Women aged < 21 years should not be screened regardless of age of sexual initiation and other behaviour relatedrisk factors (

Refer to major guidelines

Statement about annual screening

Women of any age should not be screened annually by any screening method

Individuals and clinicians can use the annual pap test screening visit as a oppurtunity to discuss other health problems and preventive measures . Individuals , clinicians and health systems should seek effective ways to facilitate the receipt of recommended preventive services at intervals that are beneficial to the patient and efforts also should be made to ensure that individuals are able to seek care for additional health concerns as they present.

In women aged 30-65 years , annual cervical cancer screening should not be preformed( Level A evidence).Patients should be counselled that annual well women visits are recommended even if cervical cancer screening is not performed at each visit

Not addressed

Screening method and intervals

Cytology (conventional or liquid based) 21- 29 yrs 30-65yrs

Every 3years Every 3 years

Every 3yrs Every 3 yrs

Every 3years Every 3 years

Not addressed Not addressed

HPV co – test (cytology+ HPV test administered together) 21- 29 yrs 30-65yrs

HPV co testing should not be used for women aged <30 years(D) Every 5 years

HPV co testing should not be usd for women aged <30 years(D) Every 5 years(A)

HPV co testing should not be used for women aged <30 years(A) Every 5 years(A)

Not addressed Not addressed

Primary hr HPV testing( as an alternative to cotesting or cytology alone )

For women aged 30- 65 years , screening by hpv testing alone is not recommended in most clinical settings

HPV co testing should not be used for women aged <30 years(D)

Not addressed Every 3 years . Recommend against primary hr HPV screening in women aged <25 years of age .

American cancer society(ACS) American society for colposcopy and cervical pathology (ASCCP) and American society for clinical pathology(ASCP)2012

U.S. Preventive Services Task Force (USPSTF) 2012

American colloege of Ostetricians and Gynacologists (ACOG) 2012

Society of Gynaecological Oncology (SGO)and the American society for colposcopy and cervical pathology (ASCCP) :Interim clinicalguidance for primary hr HPV testing 2015

When to stop screening

Aged >65 years with adequate negative prior screening and no history of CIN 2 or higher within the last 20 years . (Adequate negative prior screening results are defined as 3 consecutive negative cytology prior 2 negative co test within previous 10 years , with the recent test performed within 5 years)

Aged >65 years with adequate screening history and are not otherwise at high risk for cervical cancer(D)

Aged >65years with adequate negative prior screening results and no history of CIN2 or higher(A)

Not addressed

In the UK, the NHS Cervical Screening Programme screens:

women between 25* and 49 years every 3 years

women between 49 and 64 years every 5 years.

Age at initiation – 30 yrs

30 – 49 yrs

Screening even once in a lifetime would be beneficial. Screening intervals may depend on financial, infrastructural, and other resources

3 screening tests – Cytology, HPV , VIA

Three (3) smears per lifetime, with a 10-year interval between each smear, commencing at not earlier than age 30 years.

L SIL and ASCUS: repeat the smear in 12 months’ time

- If the diagnosis remains the same or worsens, refer for colposcopy If negative on the second smear - normal screening cycle.

HSIL and AGUS: refer to a colposcopy. If negative on

colposcopy and cytology, the client can be discharged. If positive, treat.

WHAT IS THE HPV TEST?

The HPV test is a very accurate way to tell if high-risk HPV is present in a woman’s cervix.

This test can use the same sample of cells taken for the Pap test.

A positive test result means a woman has high-risk HPV.

A positive HPV test does not mean that a woman has cancer.

Large RCTs, such as the ARTISTIC in the UK and a recent meta-analysis - HPV-based screening 60-70% better protection against invasive cervical cancer when compared to conventional or liquid based cytology.

It is expected that HPV-based screening will replace cytology-based screening, at least in women aged 30 or older.

Due to the rarity of invasive disease in women below 25.

HPV infection very common in younger age groups; the early identification of clinically insignificant lesions that are likely to regress - increase the risk of over-investigation and over-treatment - adversely impact reproductive outcomes

1.enlarged cells with increased nucleocytoplasmic ratio.

2.Abnormal nucleus –in size,shape and number.

3.Irregularity of nuclear outline.

4.Hyperchromatic nuclei.

5.Condensation of chromatic material.

6.multinucleation.

MILD

-cells are of superficial/intermediate type. -nucleus occupies less than half of total area of cytoplasm

Cells are of superficial,intermediate,

parabasal type.

nucleus-1/2 to 2/3 of cytoplasm.

MODERATE

SEVERE

Cells are of basal type. Round,oval,polygonal or elongated –fibre cells with elongated tail of cytoplasm-tadpole cell

Should be repeated in 2-4 months Papsmears which lack an endocervical component

can be repeated in 1 year If any of the following risk factors present should

be screened every 6 months -high risk HPV positivity -previous glandular abnormality -immunosupression -inability to visualize endocervical canal -non compliance -history of ascus or greater abnormalities in the

past without threeinterval normal pap

POST MENOPAUSAL WOMEN

LSIL POST MENOPAUSAL WOMEN If clinical or cytologic evidence of

Atrophy and no contraindications to

Estrogen therapy

INTRA VAGINAL

ESTROGEN THERAPY

1 week after

therapy

REPEAT CYTOLOGY

HPV DNA

TESTING

12 months after

index Pap

4-6 months

after index

Pap

Negative >ASC HPV + HPV -

REPEAT CYTOLOGY

At 12 months

REPEAT CYTOLOGY at

4-6 months

Negative

Routine screening

>ASC

COLPOSCOPY

PREGNANCY

Routine screening should be deferred

Referred with abnormal cytology - colposcopy in late 1st or early 2nd trimester if no contraindication

Low-grade changes triaged to colposcopy on the basis of a positive HPV test, the woman’s assessment may be delayed until after delivery

If previous colposcopy abnormal, - colposcopy should not be delayed

After treatment colposcopy or cytology after treatment (or follow up of untreated CIN1, - may be delayed until after delivery.

Assessment/ ‘Test of cure’ should not be delayed if the first appointment for follow-up cytology or colposcopy is due following treatment for CGIN, CIN 2, CIN 3 with involved or uncertain margin status unless there is obstetric contraindication.

If repeat cytology is due, and the woman has missed or defaulted her appointment prior to pregnancy, cytology or colposcopy during pregnancy can be considered.