Today, we will be discussing another specific set of screening guidelines, for a type of cancer. A few weeks back we discussed colon cancer screening, today we will talk about cervical cancer screening guidelines.
Just as with colon cancer, cervical cancer screening guidelines aid in the detection of early precancerous or early cancerous changes, before malignancy or more severe malignancy occurs.
Some patients, just like with colon cancer screening, will defer pap smears due to having no complaints of abnormal vaginal bleeding, discharge, pain, or problems.But just like with colon cancer, early pathologic changes often do not present with symptoms.
Benefits Of The PAP Smear
By the time you have symptoms, often malignancy is present.By performing regular pap smear screenings as indicated, we can attempt to catch these cases before cancer is present.
Since guidelines and recommendations were put in place for the screening of cervical cancer, a drastic drop in deaths caused by cervical cancer has been seen.
Annually around 12,000 new cases are found with the mean age being 48 years old.There has been a higher incidence in developing countries, and in the United States, Hispanics have been found to have a higher frequency.Cervical cancer has been found to be the third most common cancer in women.
Cervical Cancer Risks
Risk factors for cervical cancer include early age at first intercourse, smoking, multiple sexual partners, immunocompromised states, non-barrier forms of contraception, multiparity, and infection with high-risk HPV (types 16 and 18).
Infection with high-risk HPV is the most common cause of cervical cancer.Persistent HPV infections cause precancerous changes of the cervix which can lead to cervical cancer.
Both squamous cell and adenocarcinoma of the cervix are associated with HPV infection.More than 30 types of HPV can infect the cervix, but most cases are found to be linked to HPV 16, 18, 45, and 56.
There is some belief that past infection with chlamydia might be associated with a higher risk of cervical cancer, but more research needs to be done on this topic.
Cervical Cancer Presentation
Regarding symptoms and clinical presentation, patients with current cervical cancer might have unusual vaginal bleeding that often is postcoital.Vaginal discharge and odor, or in more advanced cases, a large, bulky lesion that encompasses the vagina, along with lower extremity edema can be present.
Cervical Cancer Screening Guidelines
However, hopefully, as clinicians, we do not run into many cases with those clinical findings, due to the USPSTF Cervical Cancer Screening Guidelines:
- Currently, the recommendations include screening for cervical cancer in women age 21 to 65 years with cytology (Pap smear) every three years.
- Another option for those aged 30 to 65 years is to complete a Pap smear along with human papillomavirus (HPV) cotesting every five years.
- In women younger than 30 years (but older than 21 years), the USPSTF recommends against with HPV cotesting.
- In females 21 years of age and younger, the USPSTF recommends against screening for cervical cancer, no matter the age of first sexual intercourse.
- In women older than 65 years, the USPSTF recommends against screening for cervical cancer who had normal past screening and are not high risk for cervical cancer.
- Screening may be clinically indicated in women over 65 years if the satisfactoriness of prior screening cannot be accessed or documented, or if the patient has had a high-grade precancerous lesion or cervical cancer in the past.Patients with in utero exposure to diethylstilbestrol or those who are immunocompromised may be considered as well.
- Lastly, the USPSTF recommends against screening for cervical cancer in women who have had a hysterectomy with removal of the cervix who do not have a history of cervical intraepithelial neoplasia (CIN) grade 2 or 3, or cervical cancer (Cervical Cancer: Screening, USPSTF, https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/cervical-cancer-screening).
With these current guidelines, our goal is to catch early abnormal cellular changes that could potentially turn into cervical cancer, and treat appropriately.
What To Do With The Results?
The results of the initial pap smear, and HPV cotesting if performed, will dictate when the next test needs to be completed, or if further evaluation or referral for specific testing or procedures need to be done.
There is a multitude of different cytologic or histologic results that can be given on the results of Pap smears and HPV cotesting.I will discuss two of the more common findings and the appropriate algorithms.
The first being a result that reveals normal cytology or an HPV positive testing in patients 30 years and older.
- The first fork in the tree is to determine if the HPV cotesting can be typed, which tells us which HPV virus is present.Most often this will be the case.
- If positive for HPV 16 or 18, referral to OB/GYN needs to be made for further evaluation with colposcopy.
- If negative for HPV 16 or 18, then repeat cytology and HPV cotesting should be completed in one year.
- If for some reason the initial HPV testing was unable to be typed, then repeat cytology and HPV cotesting should be done in one year.
- If repeat testing shows negative cytology and negative HPV, repeat cotesting should be done in three years.
- If repeat testing reveals atypical squamous cells (ASC) or positive HPV, a referral to OB/GYN for colposcopy is indicated.
The next clinical presentation I will discuss is cases where Atypical Cells of Undetermined Significance (ASC-US) are found on cytology.
- If ASC-US is determined on cytology, the preferred next step is to have HPV cotesting completed.If this reveals HPV negative results, then repeat cytology with HPV cotesting should be completed in three years.
- If the HPV testing reveals positive results, then referral to OB/GYN for colposcopy with endocervical sampling is indicated.
- If HPV testing is unable to be completed, then repeat cytology should be done in one year.At that time, if the cytology is negative for ASC-US, resumption of the routine screening interval is recommended.
- If the repeat cytology remains indicative of ASC-US, the patient should be referred to OB/GYN for colposcopy and endocervical sampling.
Preventing Cervical Cancer
Fortunately, there are now immunizations to help prevent cervical cancers.Initially, there was Cervarix which protected against HPV 16 and 18.Then there was Gardasil which protected against HPV 6, 11, 16, and 18.
Now, since 2015, there is Gardasil 9, which protects from HPV 6, 11, 16, 18, 31, 33, 45, 52, and 58.
Gardasil 9 was shown to reduce the risk of high-grade cervical dysplasia, vulvar, and vaginal disease related to the HPV types as mentioned above by 97% after 40 months following the final vaccination.
Current guidelines from the ACIP recommend giving the Gardasil 9 to males 9 through 21 years of age and females 9 through 26 years of age.
If the vaccine series is started and completed from ages 9 to 14 years, then one vaccine should be given on day zero and the second and final vaccine given on day six months.
If the vaccine series is started after or not completed by age 15 years, the routine vaccine schedule of the first immunization on day zero, second immunization on day two months, and third and final vaccination given on day six months should be applied.
Regarding adverse effects of the vaccine, injection site reactions are common as well as some cases of syncope.It is recommended that patient be seated and monitored for 15 minutes after the vaccine is given.
As great as the Gardasil 9 has been shown to be, there is still a significant amount of pushback from the general public and parents.One conversation that gets brought up to me routinely is, “by giving my child this vaccine, you are telling them that it is safe to go out and have sex.”
The second conversation that occurs is, “if this vaccine helps prevent cervical cancer, why does my son need it then?”
Of course, by giving your child the Gardasil 9 no provider is condoning sexual intercourse.That is not that case whatsoever.I explain to them in simple terms about how this is a vaccination that has been shown to help reduce certain types of cancer.
No other vaccine has statistically shown this.Not only does it reduce the rates of cervical cancer, but also anorectal as well as head and neck cancers.
For the second argument, I typically respond with, “at age 11 years we recommend giving the Tdap booster to your child.When I give that to your child, I do not recommend or condone that he or she go out barefoot, step on rusty nails, and climb on barbwire.”
The same goes for the Gardasil vaccine and the parent’s notion that we are saying that it is okay to have intercourse because it is protecting them from HPV.That is just not the case.
Clay Walker PA-C
Cervical Cancer: Screening, USPSTF. https://www.uspreventiveservicestaskforce.org/Page…. Accessed: 12/16/2017.
Ferri’s Clinical Advisor. Cervical Cancer. 2017.
The Medical Letter. Gardasil 9 – A Broader HPV Vaccine.
AAFP. USPSTF Offers Updated Cervical Cancer Screening Regimen. Accessed: 12/16/2017.
CDC. Inside Knowledge: Get the Facts About Gynecologic Cancer. Accessed: 12/16/2017.
This article, blog, or podcast should not be used in any legal capacity whatsoever, including but not limited to establishing standard of care in a legal sense or as a basis of expert witness testimony.No guarantee is given regarding the accuracy of any statements or opinions made on the article, podcast, or blog.