Current guidelines for Cervical Cancer Screening Rachael Chambers, DO May 29, 2015 Objectives • Review current cervical cancer screening guidelines • Discuss role of HPV testing in cervical cancer screening • Discuss role of primary HPV testing in cervical cancer screening Background • Initial Bethesda system classification – revised in 2001 • ASCCP consensus conference 2006 • Updated guidelines in 2008 – Not from a national consensus conference • 2012 follow up consensus conference – Data from KPNC, NCI, ALTS 2012 Consensus Conference • 47 experts • 23 professional societies • Goal to provide revised evidence-based consensus guidelines for managing women with abnormal cervical cancer screening tests, cervical intraepithelial neoplasia and adenocarcinoma in-situ Major changes 2012 guidelines • ECC showing CIN 1 – manage as CIN 1 • Repeat unsatisfactory cytology – Even when HPV results are known • Negative cytology with absent or insufficient endocervical cells can be managed without early repeat Major changes 2012 guidelines • Genotyping triages HR HPV positive women to colposcopy earlier after negative cytology – Colposcopy indicated for ASCUS +HPV regardless of genotyping • HPV negative ASCUS – Follow up at 3 years with co-testing – Not sufficient for exiting women from screening at age 65 Major changes 2012 guidelines • CIN 2+ follow up is more clearly defined with incorporation of co-testing • Women age 21-24 – Conservative management – Pap only – Co-test in certain circumstances • Incorporate co-testing post colposcopy Guidelines • Available at: • www.asccp.org/Portals/9/docs/ASCCP%20Mana gement%20Guidelines_August%202014.pdf • App available for iPad, iPhone and Android Routine Screening • Cytology every 3 years • Co-testing every 5 years – Women age 30-64 only • Multi-year intervals ok only if risk of developing CIN 3+ is low Case 1 • • • • 55 year old G2P2 Menopause at age 52 No history of abnormal pap testing Pap test with physical shows: – Insufficient cellularity. HPV co-testing is negative. • Now what? Unsatisfactory Cytology • 1% or less across all preparations • Decreased with use of liquid based pap • Most cases now due to insufficient squamous cells Case 2 • Same patient as in Case 1 • Now pap test shows normal results, but no EC/TZ • HPV remains negative • Now what? Cytology NILM but EC/TZ Absent/Insufficient • Suggests squamocolumnar junction may not have been adequately sampled • Reported rates 10-20% • More prevalent in older women • Good specificity and negative predictive value • HPV testing is independent of TZ sampling – Adds margin of safety when co-testing is performed. Management • Age 21-29: routine screening • Age 30-64 – HPV negative: Routine screening – HPV unknown: Test for HPV or repeat cytology in 3 years – HPV positive: Cytology +HPV in 1 year or HPV genotyping Case 3 • • • • 32 year old G1P0 No previous pap testing available Here for initial prenatal care How do we screen her? Case 3 continued • Pap test normal • HPV co-test is positive • Now what? Management Negative Cytology, HPV positive • Due to increased risk for CIN 3+ if hrHPV positive guidelines balance risk of observation vs intervention • Return for earlier retesting • HPV genotyping – Higher risk of CIN 3+ with type 16/18 • Colposcopy if 1 year follow up is ASC or HPV + or immediately if HPV 16/18 are positive Case 4 • 30 year old referred to you for management of ASCUS pap • What else do you want to know? • Was she HPV co-tested? Atypical Squamous Cells of Undetermined Significance • Most common cytologic abnormality • Lowest risk of CIN 3+ – 2/3 are NOT HPV associated • Women >60 years have higher risk for cervical cancer even if HPV negative compared to women with negative co-testing. ASC-US • Reflex HPV testing preferred – Type 16/18 positive women have twice the risk of CIN 3+ compared to other hrHPV positive women • HPV negative – Repeat cotesting in 3 years • HPV positive – Colposcopy – If no CIN co-test at 12 months ASC-US • Cytology only – Repeat cytology in 1 year – Colposcopy if > ASC – Routine screening if normal ASC-US in Special Populations • Postmenopausal – Manage the same as general population • Women age 65 and older – Repeat screening in 1 year when considering exit from screening • Cytology • Co-testing (preferred) ASC-US in Special Populations • Pregnant women – Identical to nonpregnant women – Acceptable to defer colposcopy until 6 weeks postpartum – ECC is unacceptable – If no suspected CIN 2+ at initial colposcopy, follow up postpartum Case 5 • • • • 21 year old, G0 No previous pap test Seen for complete physical Pap test shows LSIL. • What next? Young Women • No screening before age 21 • Routine screening with initial normal pap test is every 3 years – Cervical CA risk is low through age 25 – HPV is common – Most lesions will regress • Less intensive management • Encourage HPV vaccination, smoking cessation Young women • ASCUS/LSIL Cytology every 12 months preferred – HPV reflex is acceptable • Follow up is repeat cytology if positive • Routine screening if negative • Colposcopy only if ASC-H, AGC, HSIL at follow up Low-grade Squamous Intraepithelial Lesions • ALTS Trial showed natural history to be similar to ASC-US HPV+ • Women 21-24 have lower risk CIN 3+ • Estimated 77% of LSIL are HPV positive LSIL Management • Colposcopy (recommended) – Manage based on colposcopic findings • If co-test is negative, repeat co-test in 1 year – If cytology negative and HPV negative • Repeat co-testing in 3 years – If >ASC or HPV positive • Colposcopy LSIL Management • Pregnant women: – Colposcopy preferred • ECC unacceptable • Acceptable to defer until 6 weeks postpartum – If no CIN 2+, follow up post partum LSIL Management • Postmenopausal – – – – Obtain HPV test Repeat cytology at 6 and 12 months Colposcopy Repeat cytology in 12 months if HPV negative or no CIN on colposcopy – If HPV+ or ASC-US or greater on repeat cytology perform colposcopy – Routine screening after 2 negative cytology Atypical Squamous Cells, Cannot Exclude High-Grade Squamous Intraepithelial Lesion • Higher risk of CIN 3+ compared to ASC-US or LSIL – Risk also elevated for women age 21-24, but overall CIN 3+ risk remains lower than older women ASC-H Management • Colposcopy for all women • High rate of HPV + makes reflex testing unsuitable • 5 year cancer risk among ASC-H, HPV negative is 2% High-Grade Squamous Intraepithelial Lesion • CIN 2+ identified in 60% of women at colposcopy • Consider immediate excision of transformation zone • Cervical cancer found in 2% at colposcopy – Risk rises with age – Risk modifies with HPV result • HPV result from co-test may help inform choice Management HSIL • Immediate LEEP • Colposcopy – Diagnostic excisional procedure recommneded for inadequate colposcopy • Except if pregnant HSIL in Young Women • Colposcopy – If no CIN 2+ observe with colposcopy and cytology at 6 month intervals for 24 months. – If CIN 2/3 present manage with colposcopy and biopsy or treat Atypical Glandular Cells • Interpretation is poorly reproducible and uncommon • Associated with – Polyps – Metaplasia – Neoplasia • Adenocarcinomas – Endometrium, cervix, ovary, fallopian tube and other sites AGC • Risk of neoplasia higher if reported as AGC favor neoplasia or AIS • Cancer risk is lower in women <35, but risk of CIN 2+ is higher • Commonly associated with squamous lesions including CIN 1 AGC Management • Colposcopy with ECC • Do not use HPV testing to triage • Endometrial sampling is recommended in women 35+ – Also for women <35 if clinical indictors suggesting risk for endometrial neoplasia. • If no CIN 2+ co-test at 12 and 24 months and routine screening if both are negative. What’s next? PRIMARY HPV SCREENING Primary hrHPV screening • Rate of hrHPV is common in sexually active population • Most infections are transient • FDA previously approved hrHPV testing – For triage of ASCUS – Adjunct to cytology for women age 30+ • April 2014 FDA approved labeling of hrHPV assay to include primary hrHPV screening in women 25+ Primary hrHPV screening • Highly sensitive • Specificity depends on subsequent evaluation strategies and screening frequencies 2011 guidelines • American Cancer Society, American Society for Colposcopy and Cervical Pathology and American Society for Clinical Pathology • “in most clinical settings, women age 30-65 should not be screened with HPV testing alone as an alternative to co-testing at 5 year intervals or cytology alone at 3 year intervals” Consensus panel • Met via conference call and face to face • Invited to scientific summary presentation by Roche Diagnostics of the Addressing the Need for Advanced HPV Diagnostics (ATHENA) trial • MEDLINE database review – 11 papers reviewed in addition to significant papers published prior to November 2011 Consensus panel: Primary question • Is hrHPV testing for primary screening as safe and effective as cytology-based screening? • Negative hrHPV provides greater reassurance of low CIN3+ risk than negative cytology. – Several large trials have evaluated this Consensus panel: Primary question • Can primary hrHPV screening be considered as an alternative to current US cervical cancer screening methods? • hrHPV can be considered as an alternative to current cytology-based screening because of equivalent of superior effectiveness. Additional questions • How Should Positive hrHPV be managed? – Combination of triage of genotyping and reflex cytology appears to be a reasonable approach • Based on data from ATHENA and other studies • What is the Optimal Screening interval? – No sooner than every 3 years • Limited data available Additional questions • At What Age Should One initiate primary HPV screening? – Not before age 25 Additional questions • How does the performance of primary hrHPV screening compare to co-testing? – Most reassurance from co-test comes from the HPV component. – Data shows the 3 year risk following HPV negative test is less than the 5 year risk following co-testing. – Primary hrHPV test every 3 years is at least as effective as 5 year co-testing. • Currently only 1 hrHPV test is FDA-approved for primary screening. • Comparative effectiveness studies are needed • Look for future updates Summary • Cervical cancer screening continues to evolve. • Trend is toward less invasive methods of screening and managing. • hrHPV screening may become the primary screening tool in the future. References • • • • • • • Massad, et al. 2012 Updated Consensus Guidelines for the Management of Abnormal Cervical Cancer Screening Tests and Cancer Precursors. Journal of Lower Genital Tract Disease, Volume 17, Number 5, 2013, S1-S27. Huh , et al. Use of Primary High-Risk Human Papillomavirus Testing for Cervical Cancer Screening: Interim Clinical Guidance. Journal of Lower Genital Tract Disease, Volume 19, Number 2, 2015, 91-96. Partridge et al. Cervical Cancer Screening: Featured Updates. Journal of the National Comprehensive Cancer Network. Volume 12, number 3, march 2014, 333-341. ACOG Practice Bulletin. Management of Abnormal Cervical Cancer Screening Test Results and Cervical Cancer Precursors. Number 140, Volume 122, No. 6, December 2013, 1338-1367 Saraiya, et al. Evolution of cervical cancer screening and prevention in United States and Canada: Implications for public health practitioners and clinicians. Preventive Medicine, Volume 57, 2013, 426-433. Dinkelspiel and Kinney. 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