Transcript Screening for Cervical Cancer

Screening for Cervical Cancer
Gina M. Brown, M.D.
U.S. Cases
Cases
2006
2007
Diagnosed 9,710
11,150
Deaths
3,670
3,700
•5 year survival
•Localized lesion
92%
•All stage
73%
Risk Factors
• Early sexual debut
• Multiple partners
• Self or partner
• Smoking
• Uncircumcised partner
What does screening do for cervical
cancer rates?
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Routine screening-1965-1982
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Iceland 80%
Finland 50%
Sweden 40%
decrease
decrease
decrease
US cases
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1973
1994
14.2/100,000
7.4/100,000
Deaths
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1950
1987
1997
11.2/100,000 cases
6.1/100,000
3.7/100,000
Pap test sensitivity/ specificity
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Sensitivity
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Specificity
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ASCUS/
HGSIL HGSIL
Detect disease when LGSIL
present
Sensitivity 83%
58%
No disease when
there is no disease
Specificity 66%
•Thin prep
•Greater sensitivity
•Specificity not better
•More intervention
•? Impact on dx/ death
92%
Pap Equivalency
Pap
CIN
Bethesda
Class I
Normal
Normal
Class 2 mild
atypia
Class 2
moderate
atypia
Class 3
Atypia
ASCUS
CIN I
LGSIL
CIN 2/3, CIS
HGSIL
Role of HPV
• 100 genotypes
• 15 cause cancer
• 16/18  70% cervical cancer
• Others cause benign warts
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• 6/11 90% benign warts
Lifetime risk- 50%
74% new infections are age 15-24
Within 5 years of sexual debut—70%
have HPV
Building a story for current Pap test
guidelines
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80% US women screened in past 3 years
50% Cvx CA in women never or rarely
screened
Adult women
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60-80% LGSIL regresses
Repeat abnormality = persistence = HPV 16/18
Teens age 13-22
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94% LGSIL regresses 1-2 years
Repeat abnormality = new infection
How to do a Pap
Cochcrane Collaborative Martin-Hirsch et al. 2007
Pap adequacy  Endocervical cells Abnormal cells
Ayer spatula
Extended tip
2.25 (2.04-2.42 1.59 (1.19-1.92)
Cytobrush +
spatula
Spatula alone
3.33 (3.05-3.69) 1.59 (1.19-1.92)
When to do Pap screening
USPHSTF
ACOG
ACS
Within 3y onset
sex / Age 21
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+
All age 21
+
Yearly until 2-3
normal then
q 2-3 years
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+
+
Annual screen begin at age
with increased 30
risk
age 65/70
Until age 65
Continue if
Until age 70
sexually active
HPV testing
No
? Teens/
ASCUS
No
No Pap after
TAH for benign
disease
+
+, DES
+, DES
Special Populations--HIV
• Pap q 6 mos until normal X 2
• Pap yearly
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• Until risks change or abnormal Pap
Aggressive follow up for abnormal Pap
• ASCUS goes to Colposcopy
• Reflex HPV not useful
• HPV predictability studied in HIV presumed
negative
Special populations—Teens
SEER study 1985-1991,
• Adolescents rarely have HGSIL/CIS/
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never cancer
*HPV regression 94% within 1-2 years
Recommendations
• Pap within 3 years sexual debut
• ASCUS/ LGSIL
• Repeat Pap every 6 mos (1-2 years?)
• No reflex HPV testing
• HGSIL
• Colposcopy referral
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Bethesda
ASCUS
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Treat and repeat, ?HPV, *Colposcopy with continued
disease
ASC-H
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Colposcopy
AGC
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Colposcopy
LGSIL
• *Colposcopy
HGSIL
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Colposcopy
* Special issues for teens
What’s a provider to do?
• Follow USPSTF guidelines (or ACOG, or ACS)
• Consider special populations
• Teens
• HIV
• Older age
• Post hysterectomy
• Follow up