AMERICAN COLLEGE OF OBSTETRICIANS AND
GYNECOLOGISTS ARMED FORCES DISTRICT
2013 Project J-FIT Proposal
1) TOOLKIT NAME: An Initiative to Educate Primary Care Providers: PAP
Smear Guidelines and Contraception Options at Your Finger Tips
2) PROJECT MANAGER CONTACT INFORMATION:
Name: April McGill
Address: 4789 Sunmore Pkwy, Twentynine Palms, CA 92277
Phone number: (706) 825-6963
Email address: april.mcgill@med.navy.mil
3) TEAM MEMBERS NAMES AND EMAIL ADDRESSES
Kaycee Fiaseu Kaycee.Fiaseu@med.navy.mil
Joshua Combs Joshua.Combs.5@us.af.mil
Erin Keyser Erin.A.Keyser.mil@mail.mil
The Armed Forces District Junior Fellow Officers
4) OBJECTIVES:
To educate primary care providers on important topics in the women’s health care field
including the 2013 ASCCP Pap Smear Guidelines, the appropriate use of HPV Genotype
testing, and basic information about contraceptive options along with their
indications/contraindications. With the PAP smear initiative, we hope to ensure that the
correct frequency and type of tests are performed for all women and that the appropriate
follow-ups are offered to maximize the use of pap smears as screening tests for cervical
cancer. With the contraceptive initiative, we hope to improve the unintended pregnancy
rate in the military population, which currently remains high despite universal access to
healthcare and free contraception. Both of these initiatives will also provide leadership
and teaching opportunities for Junior Fellows.
5) KEY WORDS FOR SEARCHES:
ASCCP Consensus Guidelines, Pap Smear, HPV, Primary Care Physicians,
Contraception, Unintended Pregnancy, Women’s Health Education, Cervical Cancer
Screening
6) TARGET AUDIENCE:
Military primary care providers (including OB/GYN physicians, Family Medicine
physicians, Internal Medicine physicians, Nurse Practitioners, Physician’s Assistants,
Nurse Midwives, General Medical Officers, Flight Surgeons, and Independent Duty
Corpsmen)
7) DATES OF PROJECT / TIMELINE:
The resource cards were developed over 2012 and 2013 after the new ASCCP guidelines
and algorithms were published. The PAP smear cards were published on the ACOG
Junior Fellow AFD website in the summer of 2013 and the badge cards were printed for
distribution at the AFD Annual Clinical Meeting in October.
The study associated with the Contraception Card was submitted for IRB approval in
August 2013 at William Beaumont Army Medical Center, and is currently being
submitted to IRBs at other commands to increase the data included in the study.
Junior Fellow volunteer teachers were identified at the AFD District Meeting in October,
and the educational materials were distributed to them at that time including electronic
versions of both resource cards and badge cards for the PAP smear resource. The
volunteers will plan lectures and distribution of educational material throughout the
upcoming year at their own commands and near-by facilities.
8) VENUE:
Annual Armed Forces District meeting, Individual commands
9) Contact Person email address at venue: N/A
10) NUMBER OF PARTICIPANTS:
1000 PAP badge cards were produced and distributed to attendees of the 2013 Armed
Forces District Meeting to be distributed to medical facilities nationwide in the Navy,
Army and Air Force.
205 charts total were included in the initial Contraceptive Card Study (pre- and postdistribution)
11) LIST OF ALL SUPPLIES NEEDED:
PAP Smear Badge Cards (ordered online)
Contraceptive Information Cards (produced at individual facilities)
Brief Powerpoint Presentation
12) PROJECT PREP TIME: After development of the resources (which are
now available for anyone to use), this project only requires printing of the resources and
distribution to providers with the optional 15-minute PowerPoint presentation.
NUMBER OF VOLUNTEERS NEEDED: Variable on your targeted
distribution. Could be as little as 1 person
2 DELEGATION OF PROJECT RESPONSIBILITIES: Each
volunteer is responsible for producing the resource cards and distributing to primary care
providers at an identified facility
13) ADVERTISEMENT: Recruitment of volunteers to distribute materials was
done by word of mouth within the AFD Junior Fellow Leadership. Also, the resource
cards were placed at each of the seats at the AFD Annual Clinical Meeting with several
announcements made that additional cards were available for attendees to take back to
their home facilities.
14) BUDGET:
-
cost of 1000 PAP badge cards to be printed online (double-sided in color with
lanyard hole punch) and delivery costs – $355 on http://4colorprint.com
Powerpoint – Free
Contraceptive Cards were printed for free at local medical facilities
15) FUNDING:
Funding ($1000) was provided by the ACOG Armed Forces District Advisory Council
16) SUMMARY:
PAP Smear Initiative
The PAP Smear resource badge card was developed over several months based on the
article by Saslow et al in 2012 detailing the new screening guidelines, the 2013 ASCCP
Cytology Algorithms, and the ACOG Practice Bulletin #131 published in NOV 2012.
The card was reviewed by several Gynecologic Oncologists for accuracy. The PDF files
were then uploaded to http://4colorprint.com for printing (12mil plastic cards were
chosen because they are both tear and water proof). A copy of the PDF files are included
below and are available for download on the AFD Junior Fellow website. Several Junior
Fellows were also able to print some cards at their home command free of charge. The
cards were then brought to the Armed Forces District Annual Clinical Meeting. A set of
the cards was placed at each seat for attendees of the meeting. Several announcements
were made for people to take cards back with them to their home hospitals. The extra
cards were available at the registration desk. The junior fellow officers were instructed to
take cards back with them for distribution at their home hospitals and were given access
to a power point presentation to give a brief lecture to the primary care providers that
they would be distributing to. A copy of the power point presentation is also included
below as well as available on the AFD Junior Fellow website.
Contraception Initiative
The Contraceptive resource badge was developed from the CDC U.S. Medical Eligibility
Criteria for Contraceptive Use and various textbooks. The card was reviewed by several
3 OB/GYN providers for accuracy. A copy of the PDF is included below and will be
available shortly on the AFD Junior Fellow Website.
An IRB-approved study was conducted at William Beaumont Army Medical Center
using this contraception card. This study was designed to try to assess if women are being asked and offered contraception regularly at well women/routine visits. It is ACOG’s standard of care and belief that every woman should be on contraception if not actively trying to conceive. So, at each visit, every woman should be asked about contraception and offered birth control if interested, hence our slogan, “Every Woman, every time!” This study contained three parts. The first was a chart review of randomly selected charts to see if women are being asked about birth control, and, if not using anything, are being offered contraception during their primary care visits. Six data points were extracted from the charts: 1. Age range (18-­‐25, 26-­‐35, >35) 2. Asked about contraception? Y/N 3. Using contraception? Y/N 4. Trying to conceive? Y/N 5. If not using and not trying to conceive, was she offered contraception? Y/N 6. If yes, was she offered: pills, patch/ring, depo, implant, IUD, permanent? Y/N. And was GYN consult placed? Y/N In the second portion of the study, primary care providers were asked to complete a pre-­‐test on their knowledge about current contraceptives and their uses. Following this test, each provider was given the contraception card that we created. A month later, the providers were given the same test as a post-­‐test (included below). The third part of the study was a chart review of another set of randomly selected charts (for visits that took place one month following the distribution of the “contraception cards”) to see if there has been improvement in their contraceptive counseling. The study has not yet reached statistical significance, but overall the resource card was well received by the primary care providers. The study is currently being expanded for replication at other facilities to determine if it did indeed help improve counseling and provider knowledge. The resource card will be available for distribution from the Junior Fellow Website. 4 17) Photography/Pictures Motivating Junior Fellows to take resources back to their home facilities at the Armed Forces District Meeting 5 PAP Smear Card Abbreviations
When to Perform Cervical Cytology
Based on ASCCP 2012 Guidelines
Population
Recommended Screening
<21
None
21-29
PAP every 3 yrs (no HPV)
30-65
PAP & HPV every 5 yrs
(or PAP every 3 yrs)
>65
None (following adequate
negative prior screening*)
After Hysterectomy
NILM
ASCUS
None (without cervix and
without Hx of CIN2 or greater)
LSIL
Low-grade squamous intraepithelial
lesion
HSIL
High-grade squamous intraepithelial
lesion
ASC-H
Atypical squamous cells, cannot rule out
high-grade lesion
HPV
Human papillomavirus
Hx of CIN2
or greater
Routine screening for 20 years
(even after hysterectomy)
EC/TZ
Endocervical/Transformation zone
HIV+
Twice in the first year after
diagnosis, then annually
CIN
Cervical intraepithelial neoplasia
AGC
Atypical glandular cells
ECC
Endocervical curettage
DES
Diethylstilbestrol
EmBx
Endometrial biopsy
Colpo
Colposcopy
Immunosuppressed
Annually
Annually
DES in utero
HPV vaccination
Follow age-specific guidelines
(same as unvaccinated)
*3 consecutive negative cytology results (or 2 consecutive
negative co-tests) within 10 yrs prior to cessation of
screening, with the most recent within 5 yrs
Based on ASCCP 2013 Algorithms
Cytology
Results
Unsatisfactory
Age
Recommendations
Repeat PAP 2-4 months OR
Any
if ≥ 30 and HPV+, may colpo
If HPV-, routine screening
If HPV+, PAP & HPV in 1 yr.
≥30 OR HPV genotype for 16/18
If HPV unk, HPV testing OR
PAP in 3 yrs.
HPV genotype for 16/18 OR
repeat PAP & HPV in 1 yr. If
repeat PAP ≥ASC or HPV+,
colpo
NILM & HPV+
≥30
ASCUS, HPV
unk
HPV testing OR repeat PAP in
1 yr. If repeat PAP is NILM,
Any
routine screening, otherwise
colpo
Recommendations
≥25 PAP & HPV in 3 yrs.
PAP & HPV in 1 yr. (preferred)
If NILM, HPV-, repeat PAP &
HPV in 3 yrs, otherwise colpo
OR immediate colpo
LSIL, HPV-
Any
ASC-H or
HSIL
Colpo OR If HSIL & ≥25 & not
Any pregnant, may do immediate
LEEP
AGC or
Atypical
Endocervical
Cells
Atypical
Endometrial
Cells
21-24 Routine screening
ASCUS, HPV-
Age
PAP in 1 yr. - If NILM, ASC, or
LSIL, repeat PAP again in 1 yr.
21-24 If 2nd repeat PAP is ≥ASC,
then colpo. Return to routine
screening after NILM x 2
ASCUS,HPV+
or LSIL
Colpo
≥25
If pregnant, colpo now
(preferred) or at least 6 wks
postpartum
21-29 Routine screening
NILM, EC/TZ
insufficient
Cytology
Results
Referral Guidelines for Abnormal PAP
Negative for intraepithelial lesion and
malignancy
Atypical squamous cells of undetermined
significance
Colpo, ECC, and EmBx if ≥ 35 Any or chronic anovulation or
unexplained vaginal bleeding
Any
ECC and EmBx. Colpo if both
negative
Saslow D, et al. ACS, ASCCP, and ASCP screening guidelines for the
prevention and early detection of cervical cancer. ©2012
ASCCP Cytology Algorithms ©2013
ACOG Practice Bulletin #131 NOV 2012
6 Pap Smear Power Point Abbreviations
NEW Pap Smear Guidelines
ASCCP 2012 GUIDELINES
AND
ASCCP 2013 ALGORITHMS
ERIN A. KEYSER, MD, FACOG
MAJ, MC, USA
DEPT OF WOMEN’S HEALTH
WILLIAM BEAUMONT ARMY MEDICAL
CENTER
!  NILM: Negative for intraepithelial lesion and
malignancy
!  ASCUS: Atypical squamous cells of undetermined
significance
!  LSIL: Low-grade squamous intraepithelial lesion
!  HSIL: High-grade squamous intraepithelial lesion
!  ASC-H: Atypical squamous cells, cannot rule our
high-grade lesion
!  AGC: Atypical glandular cells
!  Used to be AGUS
Cervical Cancer
!  In US, about 12,000 cases of cervical cancer/year ->
4,000 deaths/year
!
!
!
50% never screened
10%, not screened in last 5 years
Mean age: 48 years
!  Worldwide: major health problem
!
!
530,000 cases per year worldwide -> 230,000 deaths/year
Mortality: 52%
!  On average, severe dysplasia takes 3-7 years to progress
to invasive cervical cancer
!
Cervical cancer screening effective!
!  Key to getting cancer: persistent HPV (at 1 and 2 years)
!
Increased likelihood of persistent infection:
"  Smoking, compromised immune system, and HIV
Cervical Cancer and HPV
!  Oncogenic HPV causes cervical cancer
!  Among 40 types of HPV, 15 are oncogenic
!  HPV 16 highest carcinogenic potential
!  55-60% of all cases of cervical cancer worldwide
!  HPV infection
!  75-80% of sexually active adults will acquire HPV
"  Most
common in teenagers and women in early 20’s
85-90% will clear infection in an average of 8 months (8-24
months)
!  CIN 1 usually reflects acute HPV and most will regress
!
7 1%
12/1/13%
When to screen
2012 Recommended Screening
!  As of 2012
!
!
!
!
!
Pap smear screening should begin at age 21, regardless of age of
sexual initiation.
Based on low incidence of cancer (0.1% of cases of cervical cancer)
Lack of data that screening is effective in this age group
Overtreatment
"  Increasing rates of PTB
"  Anxiety
Only exception: HIV infected patient
!  Type of pap smear screening
!
Liquid based allows you to concurrently test HPV and other tests
"  Same sensitivity/specificity as conventional cervical cytology
screening
HPV Testing
risk” HPV genotypes
Additional HPV DNA Genotype that can test specifically for 16 or 18
!  Two indications for HPV testing
!
!
!
!
!
!  30-65: PAP and HPV every 5 years (or PAP every 3
years)
!  > 65: None (following adequate negative prior
screening*)
!  After Hysterectomy: None (without cervix and
without Hx of CIN 2 or greater)
* 3 consecutive negative cytology results or 2 consecutive negative co-tests
within 10 years prior to cessation of screening, with the most recent within
5 years.
!  HIV patients: Twice in the first year of diagnosis,
then annually
!  Immunosuppressed: Annually
!  DES in utero: Annually
Reflex Testing – following ASCUS PAP
"  ALTS Trial, 2002
Co-Testing in women 30-65 yrs of age
!  s/p HPV vaccination: No change, follow age based
screening recommendations
!  Co-Testing q 5 years
!
!  21-29: PAP every 3 years (NO HPV)
Special circumstances
!  HPV screening: 15-18 potentially cancer causing “high
!
!  < 21: None
3 RCTs: More effective at detecting high grade dysplasia and
adenocarcinoma which is often missed by cytology alone
Lower cancer rates
Fewer follow up colposcopy
Ordered in CHCS 1 or ahlta:
"  Labs -> HPV -> digene brush
8 2%
What do the results mean?
What to do with the results
!  Risks of cervical neoplasia with abnormal cervical
cytology: Incidence (percent)
Cervical
Cytology
CIN 2+
CIN 3+
Cervical cancer
Negative
0.68
0.26
0.025
ASCUS, HPV pos
18
6.8
0.41
ASCUS, HPV neg
1.1
0.43
0
LSIL
16
5.2
0.16
ASC-H
35
18
2.6
HSIL
69
47
7.3
AGC
13
8.5
2.7
Referral Guidelines for Abnormal Paps
!  Unsatisfactory: Repeat PAP in 2-4 months
!  OR if > 30 and HPV pos may colpo
!  NILM, EC/TZ insufficient:
!  21-29: routine screening, assume negative
!  > 30:
Neg: Routine screening
"  HPV Pos: repeat PAP and HPV in 1 year
"  Or HPV genotype 16/18, and if pos, colpo now
"  HPV ?: HPV testing or repeat PAP in 3 years
!  NILM and HPV Pos: > 30
!  HPV genotype for 16/18 and if pos, colpo now OR
!  Repeat PAP and HPV in 1 year
!  ASCUS, HPV unknown: Any age
!  HPV Testing OR
!  Repeat PAP in 1 year and if NILM, routine screening
!  ASCUS, HPV Neg
!  21-24: Routine screening
!  > 25: PAP and HPV in 3 years
"  HPV
"  If
Referral Guidelines for Abnormal Paps
repeat PAP abnormal or HPV pos, colpo
!  ASCUS, HPV pos or LSIL
!  21-24: PAP in 1 year
"  If
"  If
!
NILM, ASC or LSIL, repeat PAP in 1 year
2nd repeat PAP > ASC, then colpo
> 25: Colpo
3%
9 Referral Guidelines for Abnormal Paps
Treatment
!  LSIL, HPV Neg: ANY age
!
!
PAP and HPV in 1 year
"  If NILM, HPV neg, repeat PAP and HPV in 3 years
"  If abnormal PAP or HPV pos, colpo
OR Colpo
!  ASC-H or HSIL: ANY Age
!
!
Colposcopy
OR if > 25 and not pregnant, immediate LEEP
!  AGC or atypical endocervical cells: ANY age
!
!
Colposcopy and ECC +/- EMBx
EMBx if > 35
"  And < 35 if chronic anovulation or unexplained vaginal bleeding
!  Atypical endometrial cells: ANY age
!
!
ECC and EMBx
Colpo also if both negative
Treatment of dysplasia
Adolescents
!  In general:
!
We treat CIN 2+ lesions
"  CIN 3 – need to treat
"  CIN 2 – interobserver variability, mix of CIN 1 and CIN 3
"  Change in path to simply report Low grade or high grade
!  Treatment: Excisional Procedure
!
!
!
LEEP: done in clinic
Cold Knife Cone (CKC): Done in OR
Risks:
"  Pregnancy implications: 1-3% risk
"  Cervical Incompetence
"  Stenosis
"  Bleeding
"  Cure: 95%
!  Ideally pap never done!
!  ASCUS or LSIL
!  Repeat in 1 year
!  HSIL -> colposcopy
!  Surveillance with pap and colpo every 6 months
!  Excisional procedure only if HSIL/CIN3 persists for 1 year
4%
10 Key Points
Questions
!  No PAPS until age 21
!  ASCUS HPV neg = normal PAP
!  AGC = bad!
!  PAPS every 3 years until age 30
!  Over 30, perform concurrent HPV and PAP q 5 years
5%
11 Contraceptive Card Every Woman, Every Time
Contraceptive Options
Method
Implant
(Nexplanon™)
Efficacy*
The Good
>99% 3 years
Safe while breastfeeding
Progesterone only
The Bad
Irregular
bleeding
Irregular
Progestin IUD >99% Mirena™ 5 years, Skyla™ 3 years
Treatment for menorrhagia
bleeding
(Mirena™,
May cause amenorrhea
Skyla™)
Safe while breastfeeding
Progesterone only
Safe in nulliparous and adolescents
Cramping and
Copper IUD >99% Lasts up to 10 years
Safe while breastfeeding
heavier
(Paragard™)
Hormone free
periods
Safe in nulliparous and adolescents
Emergency contraception – place
within 5 days of unprotected sex
Irregular bleeding
Injection 94% Each shot lasts 12 weeks
Safe while breastfeeding
Decreased bone
(Depo-Provera™)
Progesterone only
density
Ring
91% Can make periods more regular
Weight gain
Vaginal discharge
and
Must remember
less painful
monthly
One ring lasts up to 4 weeks
Skin irritation
91% Can make periods more regular
Patch
and
Must remember
(Ortho Evra™)
less painful
weekly
One patch lasts 1 week
Combination Pill 91% Can make periods more regular and Must remember
(Estrogen +
less painful
daily
Progestin)
*Efficacy'Percentages'by'the'CDC'based'on'typical'use'within'the'
first'year'of'use'
(Nuvaring™)
Myth Busters'
•
•
Contra-indications to ESTROGEN containing birth control (OCPs,
Nuvaring and patch). Ok to use progesterone only forms.
–
Smoker > 35 years of age
–
History of VTE
–
Lupus with Antiphospholipid Antibodies
–
Poorly controlled HTN
–
HTN with vascular disease > 35 years of age
–
Diabetes with end organ disease
–
Migraines with aura at any age
–
HPL: TG > 250 or LDL > 160
–
CAD, CHF or cerebrovascular disease
–
May decrease lactation if not well established
Antibiotics, to include Doxycycline, does not effect the efficacy of
birth control
–  Rifampin does decrease the steroid level in women taking
combination oral contraceptives
•  Additional Benefits of combination oral contraceptives:
Decreases blood flow and pain with menses
Improves acne
Decreases hirsutism
Decreases the risk of ovarian cancer (beneficial in BRCA
carriers)
–  Cycle control and uterine protection in PCOS
–
–
–
–
•  IUDs:
–  Can place at time of STI screening, and if positive, treat
infection with IUD in place
–  Do not place if concern for active infection
–  Safe to place in nulliparous and adolescent patients
–  Is NOT associated with infertility or PID
–  Can safely perform colposcopy, LEEP, and endometrial biopsy
with IUD in place
Only condoms protect against sexually transmitted infections
12 Recruitment Flyer for the Contraception Study
28 May 2013
Dear Providers,
In the past few months, the military has received poor publicity due to the
military’s high rate of unintended pregnancies despite a soldier’s free access to
health care. In light of these recent publications and the known 50% rate of
unintended pregnancies in the United States, we, the military gynecologists, are
hoping to improve this with the help of our primary care providers.
We will be conducting a study to try and assess if women are being asked and
offered contraception regularly at visits. It is our belief that every woman should
be on contraception if not actively trying to conceive. So, at each visit, every
woman should be asked about contraception and offered birth control if
interested, hence our slogan, “Every Woman, every time!.” I will be performing a
random chart review to see if women are being asked about birth control and if
not using anything, offered. I will then be asking you, our primary care providers,
to complete a pre-test on your knowledge about current contraceptives and their
uses. Following this test, each provider will be given a “contraception card” with
basic information about contraceptive options along with their
indications/contraindications. A month later we will conduct a post-test followed
by a repeat chart review to see if there has been improvement in our
contraceptive counseling.
Your participation will be completely voluntary and anonymous. Regardless of
your choice to participate in the pre and post-test, we will share our cards and
information. This is not a test of your knowledge, rather a conglomerate
assessment of how well our primary care providers are trained in contraceptive
counseling. I do hope you will be honest in your answers.
I do believe that military women have access to great medical care. Military
providers are the leaders in trauma and battle-field medicine. We want to do our
part to assure that women’s health issues are being addressed as well.
Please do not hesitate to contact me if you have any questions or concerns.
Sincerely,
Erin A. Keyser, MD, FACOG
MAJ, MC, USA
Staff OB/GYN
Department of Women’s Health
William Beaumont Army Medical Center
13 Post-Test Script for Recruitment
Thank you to all of those that participated in the pre-test of my contraception
study.
Today I am recruiting you to participate in the post-test. I want to again reiterate
that your participation will be completely voluntary and anonymous. There will be
no identifiable data collected. This is not a test of your knowledge, rather a
conglomerate assessment of how well our primary care providers are trained in
contraceptive counseling. I do hope you will be honest in your answers.
Thank you again for your help.
14 The Pre/Post Test that was Given to Providers
1. The rate of unintended pregnancies in the US is:
a. 10%
b. 25%
c. 50%
d. 75%
2. Typical use of birth control pills make the pills effective
a. 80% of the time
b. 90% of the time
c. 95% of the time
d. 99% of the time
3. True or False: IUDs are as effective as permanent sterilization at preventing pregnancy
4. True or False: Nulliparous and adolescent women can be offered IUDs
5. True or False: There is evidence to suggest that IUDs are associated with higher rates of
PID and infertility.
6. True or False: Colposcopy, LEEP and endometrial biopsies cannot be performed with
IUDs in place
7. True or False: Routine screening for gonorrhea and Chlamydia is required prior to
placement of IUD
8. True or False: An IUD must be removed if there is a positive Gonorrhea or Chlamydia
test
9. True or False: The copper IUD can be used as post-coital contraception up to 5 days after
unprotected intercourse
10. True or False: Long acting reversible contraceptive methods have few contraindications
and almost all women are eligible for Implants or IUDs
11. Circle the absolute contraindications to estrogen containing contraceptives: circle all that
apply
a. Smoking > 35 yrs of age
b. Smoking > 1ppd at any age
c. History of venous thromboembolism
d. Lupus
e. Lupus with antiphospholipid antibodies
f. Well established breastfeeding mothers
g. Well controlled hypertension
h. Poorly controlled hypertension
i. Diabetes < age 35
j. Diabetes with retinopathy or end organ disease
k. Migraine headaches
l. Migraine headaches with aura
m. TG > 250 or LDL > 160
n. Women with CAD, CHF or Cerebrovascular disease
12. True or False: Doxycycline effects the efficacy of birth control pills
15 NEW Pap Smear Guidelines
ASCCP 2012 GUIDELINES
AND
ASCCP 2013 ALGORITHMS
ERIN A. KEYSER, MD, FACOG
MAJ, MC, USA
DEPT OF WOMEN’S HEALTH
WILLIAM BEAUMONT ARMY MEDICAL
CENTER
Abbreviations
 NILM: Negative for intraepithelial lesion and





malignancy
ASCUS: Atypical squamous cells of undetermined
significance
LSIL: Low-grade squamous intraepithelial lesion
HSIL: High-grade squamous intraepithelial lesion
ASC-H: Atypical squamous cells, cannot rule our
high-grade lesion
AGC: Atypical glandular cells

Used to be AGUS
Cervical Cancer
 In US, about 12,000 cases of cervical cancer/year ->
4,000 deaths/year



50% never screened
10%, not screened in last 5 years
Mean age: 48 years
 Worldwide: major health problem


530,000 cases per year worldwide -> 230,000 deaths/year
Mortality: 52%
 On average, severe dysplasia takes 3-7 years to progress
to invasive cervical cancer

Cervical cancer screening effective!
 Key to getting cancer: persistent HPV (at 1 and 2 years)

Increased likelihood of persistent infection:
 Smoking, compromised immune system, and HIV
Cervical Cancer and HPV
 Oncogenic HPV causes cervical cancer
 Among 40 types of HPV, 15 are oncogenic
 HPV 16 highest carcinogenic potential
 55-60% of all cases of cervical cancer worldwide
 HPV infection
 75-80% of sexually active adults will acquire HPV



Most common in teenagers and women in early 20’s
85-90% will clear infection in an average of 8 months (8-24
months)
CIN 1 usually reflects acute HPV and most will regress
When to screen
 As of 2012





Pap smear screening should begin at age 21, regardless of age of
sexual initiation.
Based on low incidence of cancer (0.1% of cases of cervical cancer)
Lack of data that screening is effective in this age group
Overtreatment
 Increasing rates of PTB
 Anxiety
Only exception: HIV infected patient
 Type of pap smear screening

Liquid based allows you to concurrently test HPV and other tests
 Same sensitivity/specificity as conventional cervical cytology
screening
2012 Recommended Screening
 < 21: None
 21-29: PAP every 3 years (NO HPV)
 30-65: PAP and HPV every 5 years (or PAP every 3
years)
 > 65: None (following adequate negative prior
screening*)
 After Hysterectomy: None (without cervix and
without Hx of CIN 2 or greater)
* 3 consecutive negative cytology results or 2 consecutive negative co-tests
within 10 years prior to cessation of screening, with the most recent within
5 years.
HPV Testing
 HPV screening: 15-18 potentially cancer causing “high
risk” HPV genotypes

Additional HPV DNA Genotype that can test specifically for 16 or 18
 Two indications for HPV testing


Reflex Testing – following ASCUS PAP
 ALTS Trial, 2002
Co-Testing in women 30-65 yrs of age
 Co-Testing q 5 years




3 RCTs: More effective at detecting high grade dysplasia and
adenocarcinoma which is often missed by cytology alone
Lower cancer rates
Fewer follow up colposcopy
Ordered in CHCS 1 or ahlta:
 Labs -> HPV -> digene brush
Special circumstances
 HIV patients: Twice in the first year of diagnosis,
then annually
 Immunosuppressed: Annually
 DES in utero: Annually
 s/p HPV vaccination: No change, follow age based
screening recommendations
What do the results mean?
 Risks of cervical neoplasia with abnormal cervical
cytology: Incidence (percent)
Cervical
Cytology
CIN 2+
CIN 3+
Cervical cancer
Negative
0.68
0.26
0.025
ASCUS, HPV pos
18
6.8
0.41
ASCUS, HPV neg
1.1
0.43
0
LSIL
16
5.2
0.16
ASC-H
35
18
2.6
HSIL
69
47
7.3
AGC
13
8.5
2.7
What to do with the results
Referral Guidelines for Abnormal Paps
 Unsatisfactory: Repeat PAP in 2-4 months
 OR if > 30 and HPV pos may colpo
 NILM, EC/TZ insufficient:
 21-29: routine screening, assume negative
 > 30:
HPV Neg: Routine screening
 HPV Pos: repeat PAP and HPV in 1 year
 Or HPV genotype 16/18, and if pos, colpo now
 HPV ?: HPV testing or repeat PAP in 3 years

 NILM and HPV Pos: > 30
 HPV genotype for 16/18 and if pos, colpo now OR
 Repeat PAP and HPV in 1 year

If repeat PAP abnormal or HPV pos, colpo
Referral Guidelines for Abnormal Paps
 ASCUS, HPV unknown: Any age
 HPV Testing OR
 Repeat PAP in 1 year and if NILM, routine screening
 ASCUS, HPV Neg
 21-24: Routine screening
 > 25: PAP and HPV in 3 years
 ASCUS, HPV pos or LSIL
 21-24: PAP in 1 year
If NILM, ASC or LSIL, repeat PAP in 1 year
 If 2nd repeat PAP > ASC, then colpo


> 25: Colpo
Referral Guidelines for Abnormal Paps
 LSIL, HPV Neg: ANY age


PAP and HPV in 1 year
 If NILM, HPV neg, repeat PAP and HPV in 3 years
 If abnormal PAP or HPV pos, colpo
OR Colpo
 ASC-H or HSIL: ANY Age


Colposcopy
OR if > 25 and not pregnant, immediate LEEP
 AGC or atypical endocervical cells: ANY age


Colposcopy and ECC +/- EMBx
EMBx if > 35
 And < 35 if chronic anovulation or unexplained vaginal bleeding
 Atypical endometrial cells: ANY age


ECC and EMBx
Colpo also if both negative
Treatment
Treatment of dysplasia
 In general:

We treat CIN 2+ lesions
 CIN 3 – need to treat
 CIN 2 – interobserver variability, mix of CIN 1 and CIN 3
 Change in path to simply report Low grade or high grade
 Treatment: Excisional Procedure



LEEP: done in clinic
Cold Knife Cone (CKC): Done in OR
Risks:
 Pregnancy implications: 1-3% risk
 Cervical Incompetence
 Stenosis
 Bleeding
 Cure: 95%
Adolescents
 Ideally pap never done!
 ASCUS or LSIL
 Repeat in 1 year
 HSIL -> colposcopy
 Surveillance with pap and colpo every 6 months
 Excisional procedure only if HSIL/CIN3 persists for 1 year
Key Points
 No PAPS until age 21
 ASCUS HPV neg = normal PAP
 AGC = bad!
 PAPS every 3 years until age 30
 Over 30, perform concurrent HPV and PAP q 5 years
Questions