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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