Cervical Cytology and Vulvar Pathology

UCSF Family Medicine Board Review 2013 Quiz: The “Choosing Wisely” Initiative exists for the purpose of… Cervical Cytology and 1. Helping women choose the right method of contraception for their personal circumstances Vulvar Pathology 2. Assisting patients in deciding between medical or surgical treatments for certain conditions Michael Policar, MD, MPH 3. Listing interventions (by specialty society) for which Professor of Ob, Gyn, and Repro Sciences providers and patients should question medical necessity UCSF School of Medicine 4. Advising consumers when a brand name or generic version [email protected] of a drug is preferable based on efficacy No commercial disclosures for this lecture Cervical Cancer Screening ACOG Cervical Cytology Guidelines ACOG Practice Bulletin #109 (2009) • Most successful cancer screening program in the US – 70% reduction in cervical cancer deaths in past 60 years Criteria Recommendation • – 2012 : 12,000 new cervical cancers; 4,200 deaths per year Women under 21 yrs old Avoid screening (regardless of age or other risk factors) • Earlier public health messages have impacted public attitudes • and behaviors...but now they need to evolve! 21-29 years old Screen every 2 years • • Advances in cervical cancer prevention since 1940s 30 to 65 or 70 years old May screen every 3 years • – Liquid-based cytology (LBC)…better test throughput 65 or 70 years old and older May discontinue screening • – hrHPV-DNA testing…co-testing and triage of test results HIV-positive Screen annually • – HPV vaccination…primary prevention of cervical cancer Immunosuppressed • Exposed in utero to DES – Evidence-based cytology screening guidelines Why Start Cervical Cytology at 21? Why Start Cervical Cytology at 21? • Most HPV infections are transient • Invasive cervical cancer is a very rare event in women 15- • When HPV persists, transit to cancer is quite long – 19 years old. In the US from 1998-2006… CIN 3 peaks in the late 20s – – 14 cervical cancers annually Microinvasive cancer does not peak until early 40s – – When CIN 3 persists, >10 years are required for the lesion 1-2 cases per 1 million women • to acquire the capacity to become invasive In teens, screening does not reduce mortality – • Spontaneous regression is common Cervical cancer rates have not changed since 1973- – 65% rate of regression of CIN 2 after 18 months; 75% 1977, before the recommendation to screen at 18 or after 36 months first intercourse ACOG Practice Bulletin No. 109, Dec 2009 ACOG Practice Bulletin No. 109, Dec 2009 Why Start Cervical Cytology at 21? Cervical Cytology in High Risk Women • Consequences of over-screening and over-treatment • Women with reduced immune surveillance have faster – Emotional effect of labeling an adolescent with an STI transit times from pre-invasive to invasive lesions and a pre-cancer may affect self-image and sexuality • Do not increase the screening interval beyond annual – Possibly greater risk of preterm birth if LEEP testing for women who are – Unnecessary morbidity and expense – HIV-positive • Screening women < 21 may be harmful and lacks benefit – Immunosuppressed (transplant with anti-rejection drug) – Don’t begin until 21, regardless of first intercourse – Were exposed in utero to diethylstilbestrol P.S...ACOG Comm on Adolescent Health Care (6/2010) • Follow guidelines for women who have been treated for – If being followed for an abnormal result, continue CIN 2 or 3 or adenocarcinoma in situ ACOG Practice Bulletin No. 109, Dec 2009 ACOG Practice Bulletin No. 109, Dec 2009 USPSTF Cervical Cytology Guidelines: 3/2012 USPSTF Cervical Cytology Guidelines: 3/2012 Moyer VA; Ann Intern Med. 2012; 156(12):880-91 Moyer VA; Ann Intern Med. 2012; 156(12):880-91 Criteria Grade Recommendation Criteria Grade Recommendation • Cytology only, 21 to 65 years old A Every 3 years • Cytology only, 21 to 65 years old A Every 3 years • HPV + cytology co-testing, 30-65 A Every 5 years • HPV + cytology co-testing, 30-65 A Every 5 years years old years old • Women under 21 yrs old D Avoid screening • Age >65 with adequate prior D Avoid screening screening and not high risk • Total hysterectomy; benign disease D Avoid screening • HPV testing, alone or in D Avoid screening combination, < 30 years old Triple A Guideline : ACS, ASCCP, Triple A Guideline : ACS, ASCCP, Am Society for Clinical Pathology Am Society for Clinical Pathology CA CANCER J CLIN March 2012 CA CANCER J CLIN March 2012 Years of Age Screening Years of Age Screening <21 No screening <21 No screening 21-29 Cytology alone every 3 years 21-29 Cytology alone every 3 years 30-65 Preferred: HPV + cytology every 5 years* OR 30-65 Preferred: HPV + cytology every 5 years* OR Acceptable : Cytology alone every 3 years* Acceptable : Cytology alone every 3 years* >65 No screening, following adequate neg prior screens After total No screening, if no history of CIN2+ in the past 20 years hysterectomy or cervical cancer ever *If cytology result is negative or ASCUS + HPV negative *If cytology result is negative or ASCUS + HPV negative Management of Co-Testing Results Other Important Messages • Women at any age should not be screened annually by any Cytology HPV HPV screening method Positive Negative • For women 65 and older – Negative •Co-test in 12 months, or Co-test in 5 “Adequate screening” is defined as… • • Subtype for HPV 16/18 years 3 consecutively negative results in prior 10 years, or • ASC-US Colposcopy Co-test in 5 2 negative co-tests, most recently within 5 years – years If screening stopped, do not restart for any reason • Women treated for CIN 2+ or AIS must be regularly screened for 20 years, even if 65 or older ASC-US/HPV negative is managed as Pap negative/HPV negative – With cytology alone Q 3 years or HPV+ cytology Q5 years ACOG Practice Bulletin #131, Obstet Gynecol 2012;120:1222-38 USPSTF: Co-Testing Caveat Co-testing Strategy as Health Policy • Co-testing is most appropriate for women who want to extend their screening interval to every 5 years Pros Cons But… • Slightly more accurate than • More false positives, esp. if • “Women choosing co-testing … should be aware that cytology alone done too frequently positive screening results are more likely with HPV-based • Higher negative predictive • High cost/ year of life saved strategies… and that some women may require prolonged value than cytology alone if done too frequently surveillance with additional frequent testing if they have • Longer screening interval • Many providers don’t have persistently positive HPV results” available if desired by patient EMRs to prevent overuse Summary of Cervical Cancer Guidelines Summary of Cervical Cancer Guidelines Under 21 21-29 30-65 >65 years old Hyst, Under 21 21-29 30-65 >65 years old Hyst, years old years old Years old benign years old years old Years old benign USPSTF [D] Every 3 y Co-test: Q5 None** [D] USPSTF [D] Every 3 y Co-test: Q5 None** [D] 2012 Cytology: Q3 2012 Cytology: Q3 Triple A None Every 3 y Co-test: Q5* None** None Triple A None Every 3 y Co-test: Q5* None** None 2012 Cytology: Q3 2012 Cytology: Q3 ACOG “Avoid” Every 3 y Co-test: Q5* None** None ACOG “Avoid” Every 3 y Co-test: Q5* None** None 2012 Cytology: Q3 2012 Cytology: Q3 hrHPV Never Reflex Co-test or None None test only reflex * Preferred ** If adequate prior screening with negative results * Preferred ** If adequate prior screening with negative results When Is a Shorter Interval Justified? For women who… • Are in a surveillance pathway – Previously abnormal cytology result – Post-treatment with cryotherapy, LEEP, or a cone biopsy for a pre-invasive cervical lesion • Have had a result of “insufficient specimen adequacy” or an “unsatisfactory” result on her last cytology screen • Have HIV infection, a major organ transplant with the use of an anti-rejection drug, or long term corticosteroid use • Are newly enrolled in a practice and have no documented history of prior cytology results choosingwisely.org Common Questions About Pap Intervals Pelvic Exam at the Well-Woman Visit ACOG Committee opinion #534. Obstet Gynecol. 2012; 120:421-4. • Do virginal women need Pap smears? • • Are the intervals any different for women Women younger than 21 years – – With multiple sexual partners? Pelvic exam only when indicated by medical history – – Using hormonal contraceptives, menopausal hormone Screen for GC, chlamydia with vaginal swab or urine • therapy? Women aged 21 years or older – – Who only have female partners? “ACOG recommends an annual pelvic examination” • No evidence supports or refutes routine exam if low risk – Who are pregnant? – If asymptomatic, pelvic exam should be a “shared decision” • If a cytology is not scheduled or necessary, what about the • Individual risk factors, patient expectations, and medico- need to perform a bimanual pelvic exam? legal concerns may influence these decisions – If TAH-BSO, decision “left to the patient” if asymptomatic The Prostate, Lung, Colorectal and Ovarian (PLCO) Ovarian Cancers: PLCO Cancer Screening RCT Cancer Screening Randomized Controlled Trial Cases Deaths Buys SS, Partridge E, et al. JAMA. 2011;305(22):2295-2303 • Randomized trial of 78,216 women aged 55-74 • Annual screening with CA-125 for 6 years + transvaginal U/S for 4 years (n=39,105) versus usual care (n=39,111) • 10 US screening centers • Followed a median of 12 years • Bimanual examination originally part of the screening procedures but was discontinued JAMA. 2011;305(22):2295-2303 Is The “Screening Pelvic Exam” Outdated? Is The “Screening Pelvic Exam” Outdated? Screen for Preferred test Screen for Preferred test GC, Ct NAAT: vaginal swab or urine sample GC, Ct NAAT: vaginal swab or urine sample Cervical cancer Not recommended until 21 years old Cervical cancer Not recommended until 21 years old Cytology every 3-5 years afterward Cytology every 3-5 years afterward None, if total hyst for benign disease None, if total hyst for benign disease Ovarian cancer USPSTF rec.

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