Pap Smear Guidelines

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					Pap Smear Guidelines
 Baylor College of Medicine
   Anoop Agrawal, M.D.
                       Statistics
• Cervical Cancer was once the #1 Cancer Killer of Women

• Now Cervical Cancer Ranks #13 in the USA
• An estimated 10,370 cases of invasive cervical cancer
  will be diagnosed, and 3,710 women will die from the disease

• With the increase in pap smears, pre-invasive lesions are
  detected much more frequently than invasive cancer.
• Women with pre-invasive lesions have a 5 year survival rate of
  nearly 100%
• Those with cervical cancer detected early have a 5 year
  survival rate of ~92%
         Cervical Cancer and HPV
• Between 93-100% of squamous cell cancer of the cervix
  contains DNA from high risk types of HPV
• HPV is transmitted via sexual activity

• High risk HPV subtypes may lead to either low-grade or
  high-grade intraepithelial lesions
• High-grade lesions may progress to cervical cancer

• However, most lesions are transient—they may result in no
  signs at all or may become low-grade lesions
                   Pap Smears
Purpose:      1) Detect cervical cancer at an early stage

              2) Detect and remove high grade lesions and
                 prevent potential cervical cancer

   Sensitivity for high grade lesions = 70 – 80%
           Limited by:
               • Small lesions
               • Inaccessible location
               • Poor sampling of lesion
               • Few abnormal cells on the slide
               • Small size of abnormal cells
               • Inflammation or Blood obscuring cell
                 visualization
                     Guidelines
• ~50 % of cervical cancer diagnosed in the USA is found in
  women who have never been screened

• Another 10% occur in women who have not been screened for
  5 years

• American Cancer Society and U.S. Preventative Services Task
  Force have issued new guidelines regarding:
        • Timing of Initial Screening
        • Screening Intervals
        • Post-Hysterectomy Patients
        • When to End Screening
Both groups acknowledge that the greatest gains in
reducing morbidity and mortality would likely involve
increasing screening rates among women who are
currently unscreened or screened only infrequently
         When to Start Screening
Both Groups Recommend:
   • Begin Screening 3 years after the onset of sexual activity
   Or
   • At age 21—whichever comes first

Critical that adolescents who may not need yearly Pap smears
obtain other yearly preventative health care
           • Assessment of Health Risks
           • Contraception
           • Prevention Counseling
           • Screening and treatment of STDs
                    Rationale
• Little risk of missing an important cervical lesion until
  3-5 years after the initial exposure to HPV

• Earlier screening may result in over-diagnosis of cervical
  lesions
• These may regress spontaneously, but may lead to inappropriate
  intervention
• Young women who are infected with HIV and/or
  immunocompromised should have Pap smears twice in the
  first year after diagnosis and if normal—annually thereafter
• In women age 13-22 most HPV infections are transient. 70%
  of High-Risk HPV lesions regress in 3 years. 90%
  regression for low-risk types. Regression is more
  common in adolescents.
                Screening Intervals
  • Once screening has begun, test annually until age 30 if using
    conventional cytology or every 2 years if using liquid-based
    cytology (ACS)
 • After age 30, if results are normal and study satisfactory for
   2-3 years in a row AND the patient has no new risk factors
          • OK to screen every 2 – 3 years thereafter
• Studies suggest little added benefit of more frequent screening in
  most women
• Liquid-based cytology offers higher sensitivity than conventional
   Pap smear with comparable specificity.

• Liquid-based cytology costs $45 - $60, compared to $25 - $40
  for conventional Pap smear. If used at 3 year intervals, the
  liquid-based cytology is cost-effective.
             Screening Intervals
• USPSTF recommends screening every 3 years
  based on limited evidence
• ACOG recommends intiating screening with
  annual smears for 2 or 3 years; if these are
  negative, then intervals of up to 3 years.
• ACOG identifies risk factors that might justify
  annual screening:
      •   H/O Cervical Neoplasia
      •   Known infections with HPV
      •   Other STDs and HIV
      •   High risk Sexual behavior
      •   Chronic Corticosteroid Treatment
                    Rationale

• More frequent screening increases sensitivity but also
  increases unnecessary procedures and costs

• Many of these lesions will resolve on their own
        Post Hysterectomy Guidelines
• Both sets of guidelines agree:
   • Should not continue to screen women who have had a
      total hysterectomy for benign conditions
   • Presence of CIN 2/3 is not benign
   • Should continue to screen the small number of women who
     retain their cervix
   • Women with h/o CIN 2/3 or whom it is impossible to
     document the absence of CIN 2/3 prior to or as the indication
     for hysterectomy should be screened until 3 documented,
     consecutive, technically satisfactory negative results are
     obtained within a ten year period
   • Women with a h/o DES exposure in utero or a h/o
     cervical cancer should continue screening after
     hysterectomy
                       Rationale
• Pap Smears after hysterectomy screen the vaginal cuff

• Vaginal cancer is uncommon (1 – 2/100,000 per year)

• Abnormal vaginal smears are rarely of clinical significance

• Women with a h/o in utero DES exposure are at increased
  risk for both vaginal and cervical cancer
           When to End Screening
• Both Guidelines recommend against routinely screening
  women after age 65 – 70 if they have received regular screening
  with 3 normal results in a row
        • USPSTF recommends ending at 65
        • ACS recommends ending at 70
        • Both recommendations are arbitrary
• Continue Screening for those women
       • Not previously screened
       • Those with previous screening info unavailable
       • Past screening unlikely
       • H/O cervical cancer
       • in utero DES exposure
       • Immunocompromised
                       Rationale

• Cervical Cancer in older women is almost entirely confined to
  unscreened or underscreened

• Difficult to get satisfactory samples in older women
        • Atrophy
        • Cervical Stenosis

• Screening associated with potential harms:
       • Anxiety
       • Discomfort
       • Increased costs due to false positive results
          Other Recommendations
 • New Technologies:
     • New evidence-based reports (2003) show that both liquid-
     based and conventional cytology are acceptable screening
     tests.
     • USPSTF (2002): Evidence is insufficient to recommend
     for or against routinely using liquid-based cytology
     • ACS: As an alternative to conventional screening, liquid-
     based cytology may be performed every 2 years
• Routine HPV Testing:
    •USPSTF: Evidence is insufficient to recommend for or
                against HPV testing as primary screening
    • ACS: The technology is promising. Once the testing is
             approved by the FDA, it might be appropriate
             screening in addition to Pap testing for
             women 30 and over. Not more frequently
             than every 3 years.
      Recommendations Continued
• It is important to educate women—especially teens—that a pelvic
  exam does not equate with a Pap test
• Women who do not need a Pap test still need regular health care
  visits including gynecologic care and STD screening
• Current guidelines do not address usefulness of pelvic and/or
  rectal exams
• Referrals for patients with low-grade cervical lesions for
  colposcopy may be less necessary for adolescents given the self-
  limited nature of many LSIL lesions at this age group
• Detection and treatment of HSIL should be the goal of adolescent
  screening and referral
• Insurance coverage for new technologies is not uniform—check
  before ordering
          Unique Scenario
• You performed a routine Pap smear on a 24
  yo female. The result is within normal
  limits with a missing endocervical
  component. What are the recommendations
  for this situation?
     Unique Scenario cont…
ASCCP (American Society Colposcopy and Cervical
  Pathology) have published recommendations stating
  Pap can be repeated n 1 year if this was a routine
  screening Pap
Earlier screening at 6 months required if there was a
  previous abnormal Pap without 3 normal f/u Pap
  smears.
  Or patient is immunosupressed; patient has not had
  regular screening; a prior Pap revealed glandular
  abnormalities; a high risk HPV + result was obtained in
  the past year.
                      Summary
• New Guidelines have changed what age to start screening and
  screening intervals

• New recommendations have been developed to address when
  screening may be discontinued, screening of women after
  hysterectomy, and the use of new technologies

• Guidelines emphasize flexibility and the need to discuss
  recommendations, benefits, risks, and limitations with patients

• Individual patients may have different perceptions of risk and
  risk tolerance which may affect their screening choices

• The biggest gains in decreasing morbidity and mortality
  will be by increasing screening rates among women who
  have not been screened
             Further Information

U.S. Preventative Services Task Force Guidelines:

www.ahcpr.gov/clinic/3rduspstf/cervcan/cervcanrr.htm

American Cancer Society:

http://caonline.amcancersoc.org/cgi/reprint/52/6/342.pdf
                 References
• Jemal A, Murray T, Ward E, et al: Cancer
  statistics, 2005. CA Cancer J Clin 55:10, 2005.
• U.S. Preventative Task Force: Screening for
  Cervical Cancer: Guide to Preventative Services.
• ACOG practice bulletin: clinical management
  guidelines for obstetrician-gynecologists. Obstet
  Gynecol 102:417, 2003.

				
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