In the Name of GodIn the Name of God

Screening of CervicScreening of Cervicalal CancerCancer

Pap smear and colposcopyPap smear and colposcopy

F.BehnamfarF.Behnamfar

Gynecology Oncology FellowshipGynecology Oncology Fellowship

Associate ProfessorAssociate Professor

Isfahan University of medical SciencesIsfahan University of medical Sciences

Epidemiology and Risk FactorsEpidemiology and Risk Factors

Second most common cancer among Second most common cancer among women worldwidewomen worldwide83% of cases in developing countries83% of cases in developing countries

12,200 new cases and 4210 cancer 12,200 new cases and 4210 cancer related deaths in USA,2010related deaths in USA,201050-60 million pap tests are performed in 50-60 million pap tests are performed in the US each year,3.5 million abnormal and the US each year,3.5 million abnormal and 2.5 million colposcopy each year 2.5 million colposcopy each year

Natural HistoryNatural History

External genital warts ,1%External genital warts ,1%

Cervical intraepithelial neoplasia (CIN)Cervical intraepithelial neoplasia (CIN)

Slow malignant transformationSlow malignant transformation long latency period for cervical cancerlong latency period for cervical cancer CIN I,II,IICIN I,II,II

Papanicolaou SmearPapanicolaou Smear

ConventionalConventional

Thin layer,liquid basedThin layer,liquid based

Cytology report includesCytology report includesAdequacyAdequacy

General categorizationGeneral categorization

Epithelial cell abnormalityEpithelial cell abnormality

Glandular cell abnormalityGlandular cell abnormality

Bethesda SystemBethesda SystemWithin normal limitsInfection (organism should be specified)Reactive and reparative changesSquamouscell abnormalities

Atypical squamouscells(0)of undetermined significance

(ASC-US)(1)exclude high-grade lesions

(ASC-H)

Low-grade squamousintraepithelial lesion(LSIL)

High-grade squamousintaepithelial lesion(HSIL)

squamouscell carcinoma

Abnormal pap smearAbnormal pap smear

ASCUS LSIL ASCUS LSIL

HSIL

Cytologic diagnosisCytologic diagnosis

Pap test yeilds cytologic diagnosisPap test yeilds cytologic diagnosis

Diagnosis of CIN or cervical cancer Diagnosis of CIN or cervical cancer requiers a requiers a tissue sampletissue sample for histologic for histologic diagnosisdiagnosis

Pap TestPap Test

Screening test rather than diagnostic testScreening test rather than diagnostic test

Sensitivity and specificitySensitivity and specificity

Liquid based/ conventional pap smearLiquid based/ conventional pap smear

EffectivenessEffectivenessNo pap in last five years, No pap in last five years, risk of cervical cancer risk of cervical cancer

is threefoldis threefold

90% risk reduction 90% risk reduction

Follow up of abnormal cytologyFollow up of abnormal cytology

ASCUSASCUS

ASC-HASC-H

AGC AGC Risk for CIN 2-3 and AIS ,serious Risk for CIN 2-3 and AIS ,serious precursor of adenocarcinomaprecursor of adenocarcinoma

LSIL(CIN I- HPV infection)LSIL(CIN I- HPV infection)

HSILHSIL

HPV testHPV test

High risk HPV,16-18…High risk HPV,16-18…

Transient InfectionTransient Infection

ScreeningScreening

triagetriage

Screening ParametersScreening Parameters

Initial screeningInitial screening

Discontinuing screeningDiscontinuing screening

Frequency of screeningFrequency of screening

Perior hysterectomyPerior hysterectomy

HPV VaccinationHPV Vaccination

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THANKS

ManagementManagement

HPV and CIN 1:Follow up(60-85% regress HPV and CIN 1:Follow up(60-85% regress spontaneously in 2 years)spontaneously in 2 years)

CIN 2-3: LEEP (loop electro surgical CIN 2-3: LEEP (loop electro surgical exision of T zone)exision of T zone)

Cryo ,Laser,Hysterectomy Cryo ,Laser,Hysterectomy

Pap smearPap smear

79% reduction in cervical cancer79% reduction in cervical cancer47-62%sensitivity(30% of cervical cancers…)47-62%sensitivity(30% of cervical cancers…)Liquid based,80% sensitiveLiquid based,80% sensitiveAuto prepAuto prep

Inadequacy,repeat in 6-12 monthsInadequacy,repeat in 6-12 monthsGenerally:Generally:negative for intraepithelial lesionnegative for intraepithelial lesionEpithelial cell abnormalityEpithelial cell abnormalityOther:glandular cell abnormalitiesOther:glandular cell abnormalities

ScreeningScreening

Beginning at 21y,or 3y after onset of Beginning at 21y,or 3y after onset of sexual activitysexual activity

Can stop at 70Can stop at 70

Yearly<30 Yearly<30

2-3 years>30(if pap&HPV neg) 2-3 years>30(if pap&HPV neg) HPV>99%sensitiveHPV>99%sensitive

Cervical CancerCervical Cancer

33rdrd most common gyn cancer in USA most common gyn cancer in USASquamous most commonSquamous most commonAdenocarcinoma increasingAdenocarcinoma increasingClinically stagedClinically stagedRisk factorsRisk factorsEvaluation(vaginal bleeding,post coital,irregular, Evaluation(vaginal bleeding,post coital,irregular, post menopausal)post menopausal)DischargeDischargeObvious tumorObvious tumorSuspicious ,colposcoy biopsy,conizationSuspicious ,colposcoy biopsy,conization

StagingStagingStage I(1a1, 1a2 ,1b1, 1b2)Stage I(1a1, 1a2 ,1b1, 1b2)StageIIStageIIStageIIIStageIIIStageIVStageIV