Cervical cancer screening

Dr. Atul Verma

Cancer Screening
 Cancer screening is synonymous with secondary
prevention, in which earlier therapeutic intervention is
possible through screening an asymptomatic population to
identify cancer at an earlier stage than it would have been
diagnosed in the absence of screening.

 Screening is generally not diagnostic. It is the application

of a test to an asymptomatic population to determine who
is likely to have the disease and who is not likely to have
the disease.
history

 Screening for cancer began with the Pap smear, a test

developed by George Papanicolaou in 1928 & in 1941
published his paper The diagnostic value of vaginal
smears in carcinoma of the uterus in the American
Journal of Obstetrics and Gynecology.
 The first widespread use of this technology may have
been as early as 1937 when Dr. Elise L'Esperance
established a cancer detection center in New York.
 1960 Breast Cancer Screening. mammography
 1970 lung cancer screening-cxr, sputum cytology.
 1975 colorectal cancer
 Cervical cancer screening policies follow a triage
system for
 1. detection,
 2. treatment, and
 3.follow-up.
 The principal screening test for cervical cancer in
developed countries is the Pap smear, in which a
cellular specimen from the cervix is fixed and
stained on a slide for visual interpretation.
IARC’s CERVICAL CANCER SCREENING PROGRAMME
SCREENING TESTS EVALUATED

 Conventional cervical cytology

 Unaided visual inspection (“downstaging”)
 Naked eye visual inspection with 3-5% acetic
acid (VIA)
 Visual inspection with acetic acid using low-level
(2-4X) magnification (VIAM)
 Visual inspection with Lugol’s iodine (VILI)
 HPV testing
 Current recommendations favour initiation of
screening by the age of 21 years or within 3 years of
first sexual intercourse, whichever comes first.

 Upto 30yrs 1-3yrs intervals.

 After 30 2-3yrs intervals in low risk

 Stop after 65-70yrs or after hystrectomy

The American Cancer Society regularly reviews the science and
updates screening recommendations when new evidence suggests that a
change may be needed. The latest recommendations are:
All women should begin cervical cancer screening at age 21.

Women between the ages of 21 and 29 should have a Pap test every 3
years. They should not be tested for HPV unless it is needed after an
abnormal Pap test result.

Women between the ages of 30 and 65 should have both a Pap test and
an HPV test every 5 years. This is the preferred approach, but it is also
OK to have a Pap test alone every 3 years.

Women over age 65 who have had regular screenings with normal
results should not be screened for cervical cancer. Women who have
been diagnosed with cervical pre-cancer should continue to be
screened.
 Women who have had their uterus and cervix removed in
a hysterectomy and have no history of cervical cancer or
pre-cancer should not be screened.

 Women who have had the HPV vaccine should still

follow the screening recommendations for their age
group.

 Women who are at high risk for cervical cancer may need
to be screened more often. Women at high risk might
include those with HIV infection, organ transplant, or
exposure to the drug DES. They should talk with their
doctor or nurse
 When obtaining the Pap smear, special attention
should be directed to not using a lubricating agent
(warm water on the speculum will suffice), to
obtaining good scrapings from the cervix and vaginal
posterior fornix (without blood), and to using a small
brush to obtain an endocervical sample.

 If the cytologic smear shows atypia or mild dysplasia

(class II), the smear should be repeated no sooner than
after 2 weeks, to allow representative cellular
exfoliation
Pap classifiction
I normal

 II inflammatory –rpt smear

 III more serious abnormality –need bx

 IV distinctly abnormal definitely bx

V malignant cell present

HPV and Cervical Cancer

About 80% of Women

will be infected with
HPV in their lifetime

Source: Gynecologic Cancer Foundation

HPV and Cervical Cancer

About 7% of
Women have
an abnormal
smear test
 How cervical smear tests help
prevent cervical cancer
•Routine cervical screening (smear tests) detects abnormal
cervical cells before they have a chance to turn into cancer.
•Cervical cancer is a disease that develops quite slowly and
begins with a pre-cancerous condition known as dysplasia.
•Dysplasia is easily detected in a routine smear and is
completely treatable.
•Cervical cancer is a malignant tumour deriving from cells of
the cervix.
•Detecting and treating abnormal cervical cells early can
almost always prevent cervical cancer from developing.

Between 60% and 80% of women diagnosed with cervical cancer had not had a smear
test within 5 years of their diagnosis.
What does the biopsy result mean?
 Mild dysplasia (CIN I)-undifferentiated cells confined to the lower
third of the epithelial layer
Usually you will be watched closely to see if your body can
fight the infection
 Moderate dysplasia (CIN II)-lower50-70 percent of
epitheliallayer is undifferentiated
 Usually you will be scheduled for treatment or watched
closely
 Precancer (CIN III)
 Usually requires office or outpatient treatment
 Cancer
 Usually followed by a consultation with a gynecologic
oncologist
 Treatment options for CIN

Treatments include:
 LEEP
 Laser
 Cryotherapy
 Cone Biopsy
 Hysterectomy may be
recommended (rarely)
SURGICAL MANAGEMENT
 Laser surgery - a narrow beam of intense
light destroys cancerous and precancerous
cells.
 LEEP (loop electrosurgical excision
procedure) - a wire loop which has an
electric current cuts through tissue
removing cells from the mouth of the
cervix.
 Bethesda System 2001 for Cervicovaginal Cytology
reporting-

 Specimen type
 Specimen adequacy-:Assessment of specimen adequacy (satisfactory and
unsatisfactory):
1 - Adequate number of squamous cells (conventional smear should have
8,000-12,000 cells, liquid-based preparation should have 5,000 cells)
2 -The presence or absence of endocervical cells should be reported; an
adequate number of endocervical cells (at least 10 well-preserved endocervical
or metaplastic cells, singly or in clusters) confirms sampling of transition zone
3 - Specimen with more than 75% of cells obscured by inflammation and
bacteria is unsatisfactory (assuming that no abnormal cells are present)

- Unsatisfactory for evaluation

- Specimen rejected/not processed
- Specimen processed and examined, but unsatisfactory for evaluation of
epithelial abnormality
 Interpretation/result
Negative for Intraepithelial Lesion or Malignancy (NILM)
- Organisms
● Trichomonas vaginalis
● Fungal organisms morphologically consistent with Candida species
● Shift in flora suggestive of bacterial vaginosis
● Bacteria morphologically consistent with Actinomyces species
● Cellular changes associated with Herpes simplex virus

- Other non-neoplastic findings (optional to report, list is not

inclusive)
● Reactive cellular changes associated with:
- inflammation (includes typical repair)
- radiation
- Intrauterine contraceptive device (IUD)
● Glandular cells status post hysterectomy
● Atrophy
 ● Epithelial Cell Abnormalities
SQUAMOUS CELL
● Atypical squamous cells
- of undetermined significance (ASC-US)
- cannot exclude HSIL (ASC-H)
● Low grade squamous intraepithelial lesion (LSIL)
- encompassing HPV/mild dysplasia/CIN I
● High grade squamous intraepithelial lesion (HSIL)
- encompassing: moderate and severe
dysplasia/CIN2/CIN3/CIS
- with features suspicious for invasion (if invasion
suspected)
● Squamous cell carcinoma
 GLANDULAR CELL
● Atypical
- endocervical cells (NOS or specify in comment)
- endometrial cells (NOS or specify in comment)
- glandular cells (NOS or specify in comment)
● Atypical
- endocervical cells, favor neoplastic
- glandular cells, favor neoplastic
● Endocervical Adenocarcinoma in situ
● Adenocarcinoma
- endocervical
- endometrial
- extrauterine
Accuracy of screening tests in developing countries:
range in sensitivity and specificity

Test Sensitivity Specificity

Cytology 31-78% 91-99%

HPV testing 61-90% 62-94%

VIA 50-96% 44-97%

VILI 44-93% 75-85%

OSMANABAD RCT OF CERVICAL SCREENING, INDIA Study

RESULTS OF TREATMENT OF CIN

Treatment Total number Cured (%)

Cryotherapy 562 477 (85%)

LEEP 422 357 (85%)

Abnormal Pap test – How common is it?

10,000
cancers

300,000 HSIL (High-Grade

precancerous lesions

1.25 million LSIL (Low-Grade precancerous lesions)

2-3 million ASC (Atypical Squamous Lesions

50-60 million women screened

Cervical cancer: What is the chance of
survival after treatment?
FIGO Stage 5-Year Survival

Stage I 81-96%

Stage II 65-87%

Stage III 35-50%

Stage IVA 15-20%

Clinical staging of cervical cancer

Source: “FIGO Annual Report on The Results of Treatment in

Gynaecological Cancer” Journal of Epidemiology and Biostatistics, (2001)
vol. 6 no. 1, page 14.