HPV
This strain of HPV has the highest carcinogenic potential.
HPV-16
A 27 year old female presents as a new patient. She tell you she has had 1 Guardasil shot from another clinic. She thinks it was the quadrivalent vaccine. You only carry Guardasil-9 at your office. What is your next step?
If the HPV vaccination series already has been initiated in a female patient, the series may be completed with any HPV vaccine product. Give her 2 additional injections with the Guardasil-9 at appropriate intervals.
Rate of cervical cancer in the US as of 2011. Give as number per 100,000 women.
The incidence of cervical cancer in the United States has decreased more than 50% in the past 30 years because of widespread screening. In 1975, the rate was 14.8 per 100,000 women. By 2011, it decreased to 6.7 per 100,000 women.
22 yo G0 presents to establish GYN care. She has never been to a gynecologist before. How do you screen her for cervical cancer?
Women aged 21–29 years should be tested with cervical cytology alone, and screening should be performed every 3 years. Cotesting should not be performed in women younger than 30 years
This country is frequently sited as a leader in HPV vaccination rates and will likely be the first to eradicate HPV.
In Australia, which has a population-based vaccination program with high adherence, a decrease in high-grade cervical abnormalities was noted within 3 years after program implementation
Two risk factors for persistent HPV infection.
cigarette smoking, a compromised immune system, including HIV infection
16 year old female presents to you to establish gyn care. She is a G1P1 and reports 10 sexual partners in the last year. She infrequently uses condoms. She has no medical problems and her HIV test is negative. How should she be screened for cervical cancer?
No screening until age 21.
Percent of cervical cancers caused by HPV-16 and 18.
approximately 75% of all cases of cervical cancer
Your patient is a 39 year old G5P5 with history of in utero exposure to diethylstilbestrol. How should you screen for cervical cancer?
Annual cervical cytology screening is reasonable for women exposed to diethylstilbestrol in utero.
This is the name of the cervical cytologic test result reporting generally accepted in the U.S.
Bethesda System
Average length of time it take to clear HPV infection for young women.
Most young women, especially those younger than 21 years, have an effective immune response that clears the infection in an average of 8 months or decreases the viral load to undetectable levels (in 85–90% of women) in an average of 8–24 months.
A 55 year old woman undergoes a total abdominal hysterectomy. Post-operatively she asks you if she still needs to get Pap smears. She reports a history of CIN2 s/p LEEP and negative follow up screens at age 23. How should she be screened for cervical cancer.
No further screening.
In women who have had a hysterectomy with removal of the cervix (total hysterectomy) and have never had CIN 2 or higher, routine cytology screening and HPV testing should be discontinued and not restarted for any reason.
Women should continue to be screened if they have had a total hysterectomy and have a history of CIN 2 or higher in the past 20 years or cervical cancer at any point. The role of HPV testing has not been clarified in this population. Continued screening for 20 years is recommended in women who still have a cervix and a history of CIN 2 or higher. Therefore, screening with cytology alone every 3 years for 20 years after the initial posttreatment surveillance period seems to be reasonable for these women.
Only 0.1% of cases of cervical cancer occur before age 20 years, which translates to approximately 1–2 cases per year per 1,000,000 females aged 15–19 years
Your patient is a 40 year old G3P0 with history of normal Pap screening by cyt + co-testing 5 years ago. She never had an abnormal Pap. She recently underwent a kidney transplant and is immunosuppressed. How do you screen her for cervical cancer?
No studies or major society recommendations exist to guide cervical cancer screening in women who are immunocompromised because of non-HIV causes. Annual cytology traditionally has been performed in these women, but it is reasonable to extrapolate the recommendations for women with HIV infection to this group.
Yep!
If a water-based lubricant is used, it is important to minimize the amount that comes into contact with the cervix and to choose one that is consistent with the recommendations of the manufacturer of the liquid-based collection kit. A small amount of water-soluble lubricant on the speculum does not decrease the quality of cervical cytology test results
True or false, there is no role for testing for low-risk genotypes, and tests for low-risk HPV should not be performed.
True
33 yo G2P2 presents for annual exam. She does not remember the last time she had a Pap smear and asks what kind of screening she needs. What are her options for screening? Include the test and the interval to next screening.
HPV and cytology every 5 years
cytology alone every 3 years
HPV alone (its complicated, let's discuss.)
The age group is responsible for 19.6% of the new cases of cervical cancer in the U.S.
65 and older
Your patient is a 64 year old G2P2 with a history of CIN2 s/p LEEP at age 54. Her Pap (cytology and co-test) was negative at age 59. She is due for her 5 year cytology and co-testing screening Pap smear. She asks you if she can stop getting Pap smears if this screen is negative.
Nope!
Adequate negative prior screening test results are defined as three consecutive negative cytology results or two consecutive negative cotest results within the previous 10 years, with the most recent test performed within the past 5 years. Women with a history of CIN 2, CIN 3, or adenocarcinoma in situ should continue screening for a total of 20 years after spontaneous regression or appropriate management of CIN 2, CIN 3, or adenocarcinoma in situ, even if it extends screening past age 65 years.
Why is co-testing q 5 years preferred over cytology alone in the 30-65 age group?
The increased sensitivity of cotesting compared with cytology screening alone allows for greater detection of CIN 3. Cytology alone has been much less effective for the detection of adenocarcinoma of the cervix than for the detection of squamous cancer. Cotesting has the additional advantage of better detection of adenocarcinoma of the cervix and its precursors than cytology screening alone.
In three separate models over a wide range of assumptions, cotesting every 5 years compared with cytology screening alone every 3 years was associated with a similar number of or fewer cases of cancer (6.23–7.39 versus 5.98–8.97 per 1,000 women over a lifetime), number of deaths related to cancer (1.10–1.35 versus 0.95–1.55 per 1,000 women over a lifetime), and number of colposcopy procedures (626–907 versus 416–1,090 per 1,000 women over a lifetime).
This is the number of strains of HPV identified according to CDC.
40
68 year old female G0 presents for her annual exam. She has always had regular interval Pap smears and has never had an abnormal test. She has no significant past medical history. She reports she has two new male sexual partners and has not used condoms. How should you screen her for cervical cancer
Given the low risk of progression to cancer in women in this age group with newly acquired infection, there is no need to resume screening, even if a woman has a new sexual partner.
To further complicate screening in this age group, epithelial atrophy, common after menopause, likely predisposes women to false-positive cytology screening test results. One study noted an extremely low positive predictive value of abnormal cervical cytology test results when performed in postmenopausal women (105). Most positive Pap test results were false positives and likely would be followed with additional procedures, anxiety, and expense
What is risk of invasive disease after a diagnosis of CIN 2 or higher for the next 20 years after diagnosis?
About 3 fold.
Women treated in the past for CIN 2 or higher remain at risk of persistent or recurrent disease for at least 20 years after treatment. A meta-analysis demonstrated that women with a history of treatment for CIN 2 or higher remain at a 2.8-fold increased risk of invasive disease for up to 20 years after treatment. Because of this increased risk, women with a history of CIN 2 or higher should continue to undergo routine age-based screening for 20 years after the initial posttreatment surveillance period, even if it requires that screening continue past age 65.
HIV positive 17 year old female presents for GYN visit. She is sexually active with females only. She does not use barrier protection. Should she be screened for cervical cancer? If so how should you screen her for cervical cancer?
* Initiation of cervical cancer screening with cytology alone should begin within 1 year of onset of sexual activity or, if already sexually active, within the first year after HIV diagnosis but no later than 21 years of age.
Describe the Addressing the Need for Advanced HPV Diagnostics trial.
It is a large U.S.-based study of HPV primary screening which conducted and validated an effective triage algorithm for HPV testing alone in patients older than age 25. In the trial, positive specimens underwent HPV genotyping. If a specimen was positive for HPV-16 or 18, colposcopy was performed. If a specimen was negative for HPV-16 and 18, cytology testing was performed on the specimen, and if the results were abnormal, colposcopy was performed. If negative for HPV 16 and 18 and cytology results were normal, repeat cotesting was performed in 1 year. In 2015, ASCCP and SGO published interim guidance for the use of the FDA-approved HPV test for primary cervical cancer screening (8). The interim guidance panel concluded that because of its equivalent or superior effectiveness, in women 25 years and older, the FDA-approved primary HPV screening test can be considered as an alternative to current cytology-based cervical cancer screening methods. The test should not be used in women younger than 25 years; these women should continue to be screened with cytology alone. Rescreening after a negative primary HPV screening result should occur no sooner than every 3 years. Positive test results should be triaged with genotyping for HPV-16 and HPV-18, and if the genotyping test results are negative, with cytology testing. If genotyping and cytology test results are negative, patients should have follow-up testing in 1 year. The primary HPV screening test should not be used in women who no longer have a cervix. Which test to perform at 1-year follow-up in women with positive HPV primary screening test results and negative genotyping and cytology test results is not stated, but cotesting is reasonable. There is no guidance for use of the test in women with HIV or who are immunocompromised. Only one specific HPV test has FDA approval for primary screening (109). No other tests have undergone validation.