Crevical Ca PGH PDF

CERVICAL CANCER
SCREENING UPDATES
Carolyn R. Zalameda-Castro, MD
INTRODUCTION
• Cervical cancer screening started with the

use of the pap test
Feldman S, Goodman A, Peipert JF. Screening for cervical cancer. UpToDate.

www.uptodate.com. March 15, 2018.
INTRODUCTION

use of the pap test
• HPV testing

INTRODUCTION

use of the pap test
• HPV testing
• Visual inspection with acetic acid (VIA)
especially in low-resource settings where
either pap test or HPV testing are not
available or are too costly
INTRODUCTION
Debate about a lot of issues surrounding cervical
cancer screening
• whom to screen
• how often should screening be done
• which among the available screening modalities
is the best one
• when should screening end
CERVICAL CANCER SCREENING GUIDELINES
A. 2012 ACS-ASCCP-ASCP Screening Guidelines for the

Prevention and Early Detection of Cervical Cancer
B. 2012 PSCPC Clinical Practice Guidelines
C. 2015 SGO and ASCCP Interim Clinical Guidelines on the
Use of Primary HPV Testing
D. 2016 ASCO Resource-Stratified Clinical Practice Guidelines
on Secondary Prevention of Cervical Cancer
E. Philippine Department of Health and Philhealth


E. Philippine Department of Health

2012 ACS-ASCCP-ASCP
Screening Guidelines
Saslo w D , So lo m o n D , Law so n H W , K illacke y M , K u lasin gam SL, C ain J, G arcia FA R , M o riarty A T, W axm an A G , W ilb u r D C , W e n tze n se n N , D o w n s LS
Jr, Sp itze r M , M o scicki A B , Fran co EL, Sto le r M H , Sch iffm an M , C astle PE, M ye rs ER . A m e rican C an ce r So cie ty, A m e rical So cie ty fo r C o lp o sco p y an d
C e rvical Path o lo gy an d A m e rican So cie ty fo r C lin ical Path o lo gy Scre e n in g G u id e lin e s fo r th e Pre ve n tio n an d Early D e te ctio n o f C e rvical C an ce r.
2012 ACS-ASCCP-ASCP
When does screening for cervical cancer start?
At the age of 21 years and not earlier

regardless of age of sexual debut or
presence of risk factors for the disease.
2012 ACS-ASCCP-ASCP
Why?
• Cervical cancer is very rare in women less than 21yo.
• The presence of premalignant diseases of the cervix in

young women have very high probability of spontaneous
resolution.
2012 ACS-ASCCP-ASCP
Focus should be on primary prevention
• Vaccination against HPV
• education
• lifestyle and behavioral modification
2012 ACS-ASCCP-ASCP
Age group Recommendation Comments
2012 ACS-ASCCP-ASCP
No added benefit in screening more
21-29 y.o. Cytology every 3 years
often and in adding HPV testing
2012 ACS-ASCCP-ASCP
Co-testing every 5 years
Addition of HPV DNA testing to
30-65 y.o. cervical cytology increases the
(Acceptable) Cytology alone every 3
detection of prevalent CIN3 & AIS
years
2012 ACS-ASCCP-ASCP
detection of prevalent CIN3 & AIS
years
Discontinued when
• without history of at least a CIN 2 Not be restarted even if a woman
> 65 y.o.
disease has a new sexual partner
• prior negative screening results
2012 ACS-ASCCP-ASCP
detection of prevalent CIN3
years
Discontinued when
• without history of at least a CIN 2 Not be restarted even if a woman
> 65 y.o.
disease has a new sexual partner
• prior negative screening results
No screening needed if
Screening for vaginal cancer is not
Post- hysterectomy done for a benign
cost-effective nor beneficial due to
hysterectomy disease and no history of CIN 2+
the rarity of the disease

disease
2012 ACS-ASCCP-ASCP
When do we NOT stop screening?
üIf with history of CIN 2, CIN 3 or AIS
üContinue “routine screening” for at least 20 years, even if this

extends past age 65 years.
2012 ACS-ASCCP-ASCP
Do we need to screen women who have
already been vaccinated against HPV?
Screening recommendations for vaccinated

women follow the age-specific screening
recommendations


2012 PSCPC Clinical Practice
Guidelines
Philippine Society for Cervical Pathology and Colposcopy Clinical Practice

Guidelines on Cervical Cancer Screening. September 2012.
Guidelines
The Philippine Society of Cervical Pathology and

Colposcopy (PSCPC) advocates initiation of
cervical cancer screening at the age of 21 years.

Guidelines

Guidelines
Conventional cytology: annually Due to high burden of cervical CA and
21-29 y.o. Liquid-based cytology (LBC): every 2 low sensitivity of conventional pap
years smear in the local setting

Guidelines
Conventional cytology: annually
21-29 y.o. Liquid-based cytology (LBC): every 2
years Due to high burden of cervical CA and
low sensitivity of conventional pap
Conventional cytology: annually smear in the local setting
30-65 y.o. LBC: every 2 years
Co-testing with HPV every 5 years

Guidelines
Conventional cytology: annually Due to the high rate of cervical cancer
> 65 y.o. LBC: every 2 years in women greater than 65 years old in
Co-testing with HPV every 5 years the country

Guidelines
Conventional cytology: annually Due to the high rate of cervical cancer
> 65 y.o. LBC: every 2 years in women greater than 65 years old in
Co-testing with HPV every 5 years the country
Post- If done for a benign condition and with
No further screening no history of CIN2 or greater lesion
hysterectomy



2015 SGO and ASCCP Interim
Clinical Guidelines on the Use of
Primary HPV Testing
üHPV testing alone as a primary screening
modality for cervical cancer in women 25
years and above.
üThey recommend screening every 3 years if

initial result is negative.
Huh WK, Ault KA, Chelmow D, et al. Use of primary high-risk human papillomavirus testing
for cervical cancer screening: interim clinical guidance. Obstet Gynecol 2015; 125:330.
Primary HPV Testing
üsupported by ACOG with their guidelines released in 2016
üACOG further recommended discontinuation of screening

at age 65 years if previous screening results are all
negative
Huh WK, Ault KA, Chelmow D, et al. Use of primary high-risk human papillomavirus testing
for cervical cancer screening: interim clinical guidance. Obstet Gynecol 2015; 125:330.
Primary HPV Testing
ATHENA (Addressing the Need for Advanced HPV
Diagnostics) Study:
“HPV testing as a primary screening modality was 28.3%

more sensitive in detecting CIN 3+ in women 25-29 years
and 28.3% more in women ≥30 years old compared to
cytology”
Wright TC, Stoler M H, Behrens CM et al. Primary cervical cancer screening with human papillomavirus:
end of study results from the ATHENA study using HPV as the first-line screening test. Gynecol Oncol 2014;
Primary HPV Testing
ATHENA (Addressing the Need for Advanced HPV
Diagnostics) Study:
Limitations:
1. Follow-up of patients is only 3 years with a significant
number of participants getting lost to follow-up
2. The rigorous study design may not really be applicable or
feasible in the clinical setting
Wright TC, Stoler M H, Behrens CM et al. Primary cervical cancer screening with human papillomavirus:
end of study results from the ATHENA study using HPV as the first-line screening test. Gynecol Oncol 2014;

D. 2016 ASCO Resource-Stratified Clinical Practice
Guidelines on Secondary Prevention of Cervical Cancer

2016 ASCO Resource-Stratified Clinical
Practice Guidelines on Secondary
Prevention of Cervical Cancer
Because of the disparity in the

provision of primary prevention
and mass screening both
among and within countries,
ASCO came up with a
resource-stratified CPG.
Jeronimo J, Castle PE, Temin S et al. Secondary prevention of cervical cancer: ASCO resource-stratified
clinical practice guideline. J Glob Oncol 2016; Oct 12, 3(5): 635-57. doi: 10.1200/JGO.2016.006577.
eCollection 2017 Oct.
4-Tiered Resource Settings
for Secondary Prevention Maximal-
Enhanced- resource
resource settings
Limited-
resource settings
Basic-
resource settings
settings
2016 ASCO Resource-StratifiedMass Clinical
screening
Practice Guidelines on Secondary available to the entire
target population,
Most programs in urban
covering ≥80% of
women 25-70 yo
areas of middle-income
Rural areas in countries
middle-income
No mass screening
countries Maximal-
and no culture of
Enhanced- resource
screening
resource settings
Limited-
resource settings
Basic-
resource settings
settings
Maximal-
Enhanced- resource
resource settings
Limited-
resource settings
In the Philippines, screening
Basic- is opportunistic and less
resource settings than 10% only of eligible
women have had at least
settings one pap smear
Recommendation: BASIC-RESOURCE SETTING
Either HPV DNA testing or visual inspection with acetic

acid (VIA) as primary screening modality for women 30 to
49 years old, one to three times per lifetime.


Philippine Department of Health
Advocate the use of VIA in the Single Visit

Approach (SVA) to women 25-55 years old
especially at the community primary health centers
They advise to continue using pap smear in

facilities and hospitals where these laboratories are
in place and have capabilities for their maintenance.
Banzon EP, Ngelangel CA, Fajutrao LB et al. For an organized cervical cancer screening program in the
Philippines – http://the Health Policy Brief. Healthpolicy-brief-cervical-cancer-screening-philippines
Saslo w D , So lo m o n D , Law so n H W , K illacke y M , K u lasin gam SL, C ain J, G arcia FA R , M o riarty A T, W axm an A G , W ilb u r D C , W e n tze n se n N , D o w n s LS Jr,
Sp itze r M , M o scicki A B , Fran co EL, Sto le r M H , Sch iffm an M , C astle PE, M ye rs ER . A m e rican C an ce r So cie ty, A m e rical So cie ty fo r C o lp o sco p y an d
Jo u rn a l o f Lo w er G en ita l Tra ct D isea se V o l 1 6 N u m b e r 3 , 2 0 1 2 , 1 -2 9 .
MANAGEMENT OF
ABNORMAL SCREENING TESTS
MANAGEMENT OF
ABNORMAL SCREENING TESTS
Based on 2012 ACS-ASCCP-ASCP Screening

Guidelines for the Prevention and Early Detection
of Cervical Cancer
UNSATISFACTORY CYTOLOGY
Photo from WHO International Agency for Research on Cancer

≤ 1% across all types of preparation
Unreliable for detecting epithelial

abnormalities
Most common causes:

• obscuring blood
• inflammation
• presence of mucus or atrophy
Photo from WHO International Agency for Research on Cancer
• insufficient squamous cells (LBC)
Repeat cytology in 2-4 months

Reflex HPV testing is not recommended but if co-testing is done
and HPV test is positive, doing colposcopy is also an acceptable
option.
HPV unknown HPV negative HPV positive
(any age) (age≥30) (age≥30)
either is
acceptable
Repeat cytology
after 2-4 months Colposcopy
Negative Unsatisfactory
Abnormal
Routine screening (HPV-/ unknown) or

Manage per cotesting @ 1year (HPV+)
ASCCP guidelines
Cytology negative for intraepithelial
lesion or malignancy but absent or
insufficient endocervical cells
Cytology negative for intraepithelial
lesion or malignancy but absent or
insufficient endocervical cells
Routine screening
• Occurs in about 10-20% especially in older women
• risk of development of CIN 3+ over time in women with this

result is comparable with those having satisfactory
endocervical cells or transformation zone component.
CYTOLOGY NEGATIVE, HPV POSITIVE
≥ 30 YEARS OLD
≥ 30 YEARS OLD
• Despite negative cytology, women with oncogenic
HPV are at higher risk for later CIN 3+ than women
with negative HPV tests
• Persistent HPV increases risk further
• Most HPV infections are cleared allowing observation

for clearance
≥ 30 YEARS OLD
Repeat co-testing HPV Genotyping
after one year
(-) HPV 16, 18 (+) HPV 16, 18

Negative results ≥ ASC or Co-testing COLPOSCOPY
HPV (+)
Co-testing after after 1 year
3 years COLPOSCOPY
ASCUS
Atypical Squamous Cells of Undetermined Significance
Photo from Blaustein’s Pathology of the Female Genital Tract, 6th ed. (2011)
ASCUS
Atypical Squamous Cells of Undetermined Significance
• Most common cytologic

abnormality
• About 1/3 to 2/3 of cases are not

associated with HPV
• Carries lowest risk of CIN 3+
• reflex HPV testing followed by

colposcopy for HPV-positive
Photo from Blaustein’s Pathology of the Female Genital Tract, 6th ed. (2011) women preferred
ASCUS
HPV Testing Repeat cytology
after 1 year
(-) for High (+) for High

Risk Types Risk Types Negative result ≥ ASC
Co-testing COLPOSCOPY Routine COLPOSCOPY
after 3 years screening
LSIL
Low-grade Squamous Intraepithelial Lesion
Photo from Blaustein’s Pathology of the Female Genital Tract, 6th ed. (2011)
LSIL
No HPV test Positive HPV test Negative HPV test
Repeat co-testing
COLPOSCOPY after 1 year
(PREFERRED)
Negative results
Routine
screening
ASCUS or LSIL
in women 21-24 years
ASCUS: Reflex
REPEAT HPV testing
CYTOLOGY
AFTER 1 YEAR
Negative result Positive result
Routine Repeat cytology
screening after 1 year
LSIL
in pregnant women
Postponing
COLPOSCOPY colposcopy 6
weeks postpartum
*Endocervical (ACCEPTABLE)
curettage is totally
unacceptable
ASC-H
Atypical Squamous Cells: Cannot Exclude High-Grade SIL
• ASC-H confers higher risk for CIN 3+ over time than ASC-US or
LSIL, although lower than that following HSIL.
• There is high rate of HPV detection in women with ASC-H making

reflex HPV testing unsuitable.
ASC-H
Atypical Squamous Cells: Cannot Exclude High-Grade SIL
COLPOSCOPY
*Regardless of age/HPV status
HSIL
High-grade Squamous Intraepithelial Lesion
Photo from Blaustein’s Pathology of the Female Genital Tract, 6th ed.
(2011)
HSIL
High-grade Squamous Intraepithelial Lesion
Risk for CIN 3 is from 29-50%

depending on the HPV status,
while that of cervical cancer is 7%
regardless of the HPV status
(2011)
HSIL
Colposcopy with Immediate loop

endocervical electrosurgical
assessment excision procedure
(LEEP)*
*not acceptable in 21-24 years
and in pregnant women
AGC
Atypical Glandular Cells
(2011)
AGC
Atypical Glandular Cells
Associated with polyps, metaplasia,

adenocarcinoma of the
endometrium, ovary, fallopian tube
and other sites
The risk of CIN 3+ is about 9% in

women at least 30 years old while
the risk of cancer is 3%.
(2011)
AGC
All subcategories Atypical
except Atypical endometrial cells
endometrial cells
Endometrial and
Colposcopy with endocervical endocervical
sampling + endometrial sampling
sampling if ≥35yo or if with
risk factors for EM neoplasia No endometrial pathology
COLPOSCOPY
Primary HPV testing
COLPOSCOPY
Abnormal HPV if abnormal pap
test Pap test
test

Primary HPV testing
High risk HPV Non-high risk HPV

types types
OUTRIGHT Pap Test

COLPOSCOPY

HPV DNA IF POSITIVE
VIA
Testing
Negative result Positive
Cryotherapy
or LEEP
Follow up in 12 mos
VIA
Positive
Cryotherapy
or LEEP
Follow up in 12 mos
CERVICAL CANCER
SCREENING UPDATES


REFERENCES
5. Committee on Practice Bulletins—Gynecology. Practice Bulletin No. 168: Cervical Cancer

Screening and Prevention. Obstet Gynecol 2016; 128:e111.
6. Wright TC, Stoler MH, Behrens CM et al. Primary cervical cancer screening with human
papillomavirus: end of study results from the ATHENA study using HPV as the first-line screening
test. Gynecol Oncol 2014; http://dx.doi.org/10.1016/j.ygyno.2014.11.076.
7. Jeronimo J, Castle PE, Temin S et al. Secondary prevention of cervical cancer: ASCO resource-
stratified clinical practice guideline. J Glob Oncol 2016; Oct 12, 3(5): 635-57. doi:
10.1200/JGO.2016.006577. eCollection 2017 Oct.
8. Banzon EP, Ngelangel CA, Fajutrao LB et al. For an organized cervical cancer screening
program in the Philippines – http://the Health Policy Brief. Healthpolicy-brief-cervical-cancer-
screening-philippines
Thank you very much! J
Interactive Questions
1. Which statement is true based on the recommendations of
the Philippine Society of Cervical Pathology and Colposcopy
(PSCPC) for cervical cancer screening for Filipino women?
1. For women 21 years old and above, annual screening using conventional
cytology or every 3 years with liquid-based cytology is advised.
2. Screening is discontinued at the age of 65 years if there are three prior
normal Pap smear results.
3. Screening for vaginal cancer in women who had total hysterectomy for
benign conditions, except premalignant cervical lesions, is not
recommended.
4. Screening for women below 21 years is recommended if there is first coitus
within two years from menarche or if with one pregnancy prior to age 17.
1. Which statement is true based on the recommendations of
the Philippine Society of Cervical Pathology and Colposcopy
(PSCPC) for cervical cancer screening for Filipino women?
1. For women 21 years old and above, annual screening using conventional
cytology or every 3 years with liquid-based cytology is advised.
2. Screening is discontinued at the age of 65 years if there are three prior
normal Pap smear results.
3. Screening for vaginal cancer in women who had total hysterectomy for
benign conditions, except premalignant cervical lesions, is not
recommended.
4. Screening for women below 21 years is recommended if there is first coitus
within two years from menarche or if with one pregnancy prior to age 17.
2. A 32-year old G1P1(1001) comes in with an
unsatisfactory Pap smear result due to
obscuring blood. What will be the next step?
1. Repeat cytology
Interactive in 2-4 months
Questions
2. Do reflex HPV testing
3. Repeat cytology in 12 months
4. Proceed to colposcopy
2. A 32-year old G1P1(1001) comes in with an
unsatisfactory Pap smear result due to
obscuring blood. What will be the next step?
1. Repeat cytology
Interactive in 2-4 months
Questions
2. Do reflex HPV testing
3. Repeat cytology in 12 months
4. Proceed to colposcopy
3. On repeat cytology, the result turned out to
be ASCUS. What will be the preferred
management?
1. Repeat cytology
Interactive after 6 months
Questions
2. Repeat cytology after 12 months
3. Colposcopy
4. HPV DNA testing
3. On repeat cytology, the result turned out to
be ASCUS. What will be the preferred
management?
1. Repeat cytology
Interactive after 6 months
Questions
2. Repeat cytology after 12 months
3. Colposcopy
4. HPV DNA testing
4. A 51-year old G5P5 (5005) was referred to
your clinic due to a Pap smear result of HSIL.
What will you do next?
1. Immediate
Interactiveloop electrosurgical
Questions excision
(LEEP)
2. Colposcopy with endocervical assessment
3. HPV DNA testing
4. Either A or B
4. A 51-year old G5P5 (5005) was referred to
your clinic due to a Pap smear result of HSIL.
What will you do next?
1. Immediate
Interactiveloop electrosurgical
Questions excision
(LEEP)
2. Colposcopy with endocervical assessment
3. HPV DNA testing
4. Either A or B
5. Based on the 2016 ASCO Resource-Stratified Clinical
Practice Guidelines on Secondary Prevention of Cervical
Cancer, which among the following are appropriate
screening and treatment methods in our local setting?
1. Primary screening recommended is HPV DNA testing or VIA.
2. If VIA was the primary screening done and turned out positive,
outright treatment with either cryotherapy or LEEP is
advocated.
3. Women with negative triage result should be followed up in 12
months while those with positive result should receive
treatment then followed up after 1 year.
4. All of the above.
5. Based on the 2016 ASCO Resource-Stratified Clinical
Practice Guidelines on Secondary Prevention of Cervical
Cancer, which among the following are appropriate
screening and treatment methods in our local setting?
1. Primary screening recommended is HPV DNA testing or VIA.
2. If VIA was the primary screening done and turned out positive,
outright treatment with either cryotherapy or LEEP is
advocated.
3. Women with negative triage result should be followed up in 12
months while those with positive result should receive
treatment then followed up after 1 year.
4. All of the above.
THANK YOU!
REFERENCES
1. Feldman S, Goodman A, Peipert JF. Screening for cervical cancer. UpToDate.

2. Saslow D, Solomon D, Lawson HW, Killackey M, Kulasingam SL, Cain J, Garcia FAR, Moriarty
AT, Waxman AG, Wilbur DC, Wentzensen N, Downs LS Jr, Spitzer M, Moscicki AB, Franco EL,
Stoler MH, Schiffman M, Castle PE, Myers ER. American Cancer Society, Americal Society for
Colposcopy and Cervical Pathology and American Society for Clinical Pathology Screening
Guidelines for the Prevention and Early Detection of Cervical Cancer. Journal of Lower Genital
Tract Disease Vol 16 Number 3, 2012, 1-29.
3. Philippine Society for Cervical Pathology and Colposcopy Clinical Practice Guidelines on
Cervical Cancer Screening. September 2012.
4. Huh WK, Ault KA, Chelmow D, et al. Use of primary high-risk human papillomavirus testing for
cervical cancer screening: interim clinical guidance. Obstet Gynecol 2015; 125:330.

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CERVICAL CANCER

• Cervical cancer screening started with the

Feldman S, Goodman A, Peipert JF. Screening for cervical cancer. UpToDate.

• Cervical cancer screening started with the

Feldman S, Goodman A, Peipert JF. Screening for cervical cancer. UpToDate.

• Cervical cancer screening started with the

A. 2012 ACS-ASCCP-ASCP Screening Guidelines for the

E. Philippine Department of Health and Philhealth

A. 2012 ACS-ASCCP-ASCP Screening Guidelines for the

E. Philippine Department of Health

At the age of 21 years and not earlier

• Cervical cancer is very rare in women less than 21yo.

• The presence of premalignant diseases of the cervix in

the rarity of the disease

üIf with history of CIN 2, CIN 3 or AIS

üContinue “routine screening” for at least 20 years, even if this

Screening recommendations for vaccinated

A. 2012 ACS-ASCCP-ASCP Screening Guidelines for the

E. Philippine Department of Health

Philippine Society for Cervical Pathology and Colposcopy Clinical Practice

The Philippine Society of Cervical Pathology and

Philippine Society for Cervical Pathology and Colposcopy Clinical Practice

Philippine Society for Cervical Pathology and Colposcopy Clinical Practice

Philippine Society for Cervical Pathology and Colposcopy Clinical Practice

Philippine Society for Cervical Pathology and Colposcopy Clinical Practice

Philippine Society for Cervical Pathology and Colposcopy Clinical Practice

Philippine Society for Cervical Pathology and Colposcopy Clinical Practice

A. 2012 ACS-ASCCP-ASCP Screening Guidelines for the

E. Philippine Department of Health and Philhealth

üThey recommend screening every 3 years if

üsupported by ACOG with their guidelines released in 2016

üACOG further recommended discontinuation of screening

“HPV testing as a primary screening modality was 28.3%

A. 2012 ACS-ASCCP-ASCP Screening Guidelines for the

E. Philippine Department of Health

Because of the disparity in the

Either HPV DNA testing or visual inspection with acetic

A. 2012 ACS-ASCCP-ASCP Screening Guidelines for the

E. Philippine Department of Health

Advocate the use of VIA in the Single Visit

They advise to continue using pap smear in

Based on 2012 ACS-ASCCP-ASCP Screening

Photo from WHO International Agency for Research on Cancer

≤ 1% across all types of preparation

Unreliable for detecting epithelial

Most common causes:

Repeat cytology in 2-4 months

Routine screening (HPV-/ unknown) or

• risk of development of CIN 3+ over time in women with this

• Persistent HPV increases risk further

• Most HPV infections are cleared allowing observation

(-) HPV 16, 18 (+) HPV 16, 18

• Most common cytologic

• About 1/3 to 2/3 of cases are not

• reflex HPV testing followed by

(-) for High (+) for High

• There is high rate of HPV detection in women with ASC-H making

Risk for CIN 3 is from 29-50%

Colposcopy with Immediate loop

Associated with polyps, metaplasia,

The risk of CIN 3+ is about 9% in

Feldman S, Goodman A, Peipert JF. Screening for cervical cancer. UpToDate.