The Latest and Greatest on Pap Smear ScreeningSUSAN M. SHERIDAN, M.D., F.A.C.O.G

CASPER OBSTETRICAL AND GYNECOLOGIC ASSOCIATES, CASPER, WY

No conflicts to disclose

Developments Affecting Screening Guidelines� Persistent infection with HIGH RISK HPV is necessary for

development of cervical cancer

� HPV 16: most carcinogenic, accounts for 55-60% of all cervical cancer

� HPV 18 accounts for 10-15% of cervical cancers

� Greater proportion of glandular cancer, adenocarcinoma, adenosquamouscarcinoma

� 10 other HPV genotypes account for remaining 25-35%

� Approximately 90% of HPV infections are TRANSIENT

� Undetectable within 1-2 years

� Persistence of HPV 16 over 1-2 years:

� 20-30% risk of CIN 3 over 5 years

� Untreated CIN 3 has 30% probability of becoming cancer over 30 years, treated CIN 3 has 1% probability of becoming invasive

Objectives of Screening for Cervical Cancer

� Prevention of morbidity and mortality from cervical cancer

� Avoid detection and unnecessary treatment of

� Transient HPV infections

� Benign lesions likely to regress spontaneously

� Minimize harms associated with false positive tests and overtreatment

� Increased risks after LEEP

� Preterm birth (OR 1.7)

� Low birth weight (OR 1.8)

� PPROM (OR 2.7)

Enhancing Pap smear screening with HPV testing

� HPV testing has increased sensitivity compared to cytology

� Lower specificity

� Better reproducibility

� May better predict development of CIN 3+ over the next 5-15 years than cytology

� Incorporation of HPV into screening allows:

� Increased disease detection � improving benefits of screening

� Increased length of screening � decreasing harms

Obstacles to prevention of cervical cancer� Invasive cervical cancer rates are 7x higher

in low-resource, medically underserved regions

� Disease linked to socioeconomic, geographic, and racial disparities

� 50% of all cervical cancers diagnosed in women who have NEVER BEEN SCREENED

� Additional 10% occur in women not screened within the past 5 years

Cervical Cancer Screening by Age

� Women under age 21 SHOULD NOT BE SCREENED

� Regardless of age of sexual initiation or other risk factors

� Incidence of cervical cancer is rare and has not changed with increased screening over the past 4 decades

� Screening not associated with cancer prevention in this age group

� Women ages 21-29 screen with CYTOLOGY ALONE every 3 years

� HPV testing should not be used for screening

� Annual screening TRIPLES the number of colposcopies

� Minimal cancer risk reduction (3/1000 versus 5/1000)

� Reflex HPV can be added to ASCUS cytology for triage

Cervical Cancer Screening Women Aged 30-65

� Cotesting EVERY 5 YEARS with cytology and HPV �PREFERRED

� Increased detection of prevalent CIN 3+ in subsequent screening

� Enhances identification of adenocarcinoma and its precursors

� 3 year to 5 year intervals minimal change in lifetime cervical cancer risk (0.39% vs. 0.61%) with significant reduction in colposcopies

� 3 year cytology to 5 year cotesting is comparable (0.69% vs. 0.61%)

� Cytology alone EVERY 3 YEARS �ACCEPTABLE

Management of HPV Positive, Cytology Negative cotests

� Option 1: Repeat contesting in 12 months

� HPV positive at 12 months COLPOSCOPY

� Option 2: Immediate HPV genotype-specific testing for HPV 16/18 or HPV 16 alone

� HPV 16 or HPV 16/18 positive directly to COLPOSCOPY

Women Older than age 65

� 1) Evidence of adequate negative prior screening

� 2) No history of CIN 2+ in the last 20 years

�Should NOT BE SCREENED

�Screening should not resume for any reason, including new sexual partner

� Based upon extended natural history of disease, new HPV infections and newly detected CIN 3 will have insufficient time to progress to invasive cancer in the woman’s lifetime (cancer develops median of 20-25 years after infection)

Tools for following new screening guidelines and management of abnormal

tests

• asccp.org• Screening guidelines• Management guidelines

• ASCCP Mobile Consensus Guidelines for Smartphone/iPad $9.99