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Christine Isaacs, MD Associate Professor, VCU Medical Center

Obstetrics & Gynecology October 26, 2013

1960’s…integration of the “Pap test” into the care of women *HPV role unknown at the time

Preformed ANNUALLY An interval chosen completely arbitrarily

Promoted health care visits for women

Improved women’s health in general through screening, counseling and management of other problems

An effective message….unlinked to research that actually established the best frequency for screening

2003…first recommends lengthening screening intervals

2009…revised screening protocols with new guidelines for initiation, cessation & frequency of screening

2012…Updated Guidelines American Cancer Society (“ASC”) American Society for Colposcopy and Cervical Pathology

(“ASC”) American Society for Clinical Pathology (“ASC”) US Preventive Service Task Force (“USPSTF”) ACOG (November 2012) (“ACOG”) ***cost was never considered in recommendations

Understands that HPV (human papilloma virus) is necessary for the development of squamous cell carcinoma

HPV is incredibly common

Most people infected are:

-unaware of their infection

-do not suffer consequences (let alone cancer)

#1

Transient infection

Cleared by immune system (1-2 years)

No increased risk of cervical cancer

Infections manifested by Low-grade squamous intraepithelial lesion (LSIL) cytology

Cervical intraepithelial neoplasia (CIN 1)

#2 Much smaller group of women

Virus persists

Manifested by High-grade squamous intraepithelial lesions (HSIL) cytology

Cervical intraepithelial neoplasia 2 and 3

**THESE patients DO have an appreciable risk of developing cervical cancer if not detected & treated

~30% will develop cervical cancer over 30 years of follow up

HPV Exposure

CLEARED

(most likely)

PERSISTS & PROGRESSES

(what we want to screen for!)

Most important determinant of persistence & progression

HPV-16 & 18…responsible for 65-75% of cervical cancer cases

~10 other genotypes are associated with the remainder of cervical cancer

COFACTORS that increase the likelihood of persistence: Smoking

Compromised immune system

HIV

Estimated ~4,220 Deaths in the US in 2012

American Cancer Society

KEY CHANGES…

Begin cervical cancer screening at 21 years of age, regardless of risk factors

Allows you to:

Focus on prevention efforts for HPV vaccination

Women 21-30 years should have CYTOLOGY ALONE every 3 years

NO HPV co-testing

-Prevalence of HR HPV infection is high

-Incidence of cervical cancer is extremely low

-Would detect transient HPV infections with little to no clinical significance

Women age 30-65 should be tested with co-testing every 5 years assuming negative results for both tests

IF co-testing is not available…do cytology alone every 3 years

Under usual circumstances…STOP screening at age 65 if…

Adequate negative prior screening

3 consecutive negative cytology results OR 2 negative cotests within the past 10 years

No history of CIN 2 or greater within the last 20 years

Once screening is stopped…do NOT resume!

(Rationale…natural history requires a median of 15 to 25 years after acquisition of HPV to develop cervical cancer)

Balance between BENEFITS & HARMS of screening

HPV Exposure

CLEARED

(most likely)

PERSISTS & PROGRESSES

(what we want to screen for!)

#1…21 and over!

#2…21-30 CYTOLOGY (only) every 3 years!

#3…31-65 cotesting every 5 years! (preferred)

#4…Stop at 65 if you qualify!

http://www.acog.org/For_Patients/Search_FAQs/documents/New_Guidelines_for_Cervical_Cancer_Screening#.UjYv-WZP97c.email