Case Study 1. Cervical Cancer Screening and Sexually Transmitted Infections Case Studies

Transcription

1 Case Study 1 Cervical Cancer Screening and Sexually Transmitted Infections Case Studies Joyce, a 32 year old returning veteran, comes in for a Well Woman visit. She has a history of an abnormal Pap before her deployment which was two years ago. Vital signs: 5 feet 6 inches tall, 141 lbs., HR 75, RR 17, temp 97.9 F, BP 122/82, non smoker. 2 Q1: Joyce s Pap smear results come back as ASC- US (atypical squamous cells of undetermined significance). What would you do next? A. If liquid based cytology was used, await reflex HPV testing results. If positive, refer to colposcopy. B. Refer immediately to colposcopy. C. Repeat Pap test in 6 months. Q1: Joyce s Pap smear results come back as ASC- US (atypical squamous cells of undetermined significance). What would you do next? A. If liquid based cytology was used, await reflex HPV testing results. If positive, refer to colposcopy. B. Refer immediately to colposcopy C. Repeat Pap test in 6 months 3 4 Discussion Points Discussion Points Option A: Reflex testing for HPV (if liquid cytology is used, or if a separate sample is collected at time of Pap) is preferred for patient convenience and cost effectiveness Women who test HPV negative: risk of harboring CIN 2/3+ is less than 2%; can perform co testing in 3 years Women who test HPV positive: refer for colposcopy due to 15 27% chance of CIN 2/3+ (unless under the age of 25 where repeat testing in 1 year is suggested) Option B: Proceeding immediately to colposcopy is no longer recommended Option C: If reflex HPV testing is not available, a follow up Pap in 1 year is an option. If one year FU is ASCUS or worse, colposcopy is recommended. The rate of loss to follow up is substantial: 1. Loss of 15 25% in research settings 2. Loss of 54 81% in clinical practice settings 5 6 1

2 Q2: Joyce asks about her chance of having cervical cancer. Based on her ASCUS and HPV neg test results, how will you respond? Q2: Joyce asks about her chance of having cervical cancer. Based on her ASCUS and HPV neg test results, how will you respond? A. <1% B. 1 5% C. 6 10% D. >10% A. <1% B. 1 5% C. 6 10% D. >10% 7 8 Discussion The risk of cancer is very low ( %), and the risk of CIN 2/3+ for any individual patient is also low (2%) Q3: What if Joyce s Pap smear results come back as L-SIL (low-grade squamous intraepithelial lesion)? Co-testing was not performed. What is your next step? Use the table on the next slide to guide your decision. B. Repeat Pap smear in 6 months C. Refer for colposcopy 9 10 Pap result CIN1 CIN2/3 Cancer Normal Pap up to 10% <1% 0.25% ASC US, HPV neg <10% <1.5% <0.01% Normal Pap, HPV+ <1.1% <0.08% ASC US, HPV % 7 18% <0.1% LGSIL 50 60% 2 19% 0.16% HGSIL 20% up to 70% 7% Q3: What if Joyce s Pap smear results come back as L-SIL (low-grade squamous intraepithelial lesion)? Co-testing was not performed. What is your next step? B. Repeat Pap smear in 6 months C. Refer for colposcopy Management options for L SIL result, no co testing: B. Repeat Pap smear in 6 months C. Refer for colposcopy

3 Discussion An L SIL diagnosis is associated with a positive test result for highrisk HPV in most women (83% of the women with L SIL cytology according to the ALTS study*). Therefore, reflex HPV testing is of limited value for triaging colposcopy. There is a high incidence of CIN 2 and 3 in patients with L SIL (15% and 30% respectively). However, for women under the age of 25 with L SIL, regardless of HPV status, immediate colposcopy is not recommended. Q.4: What if Joyce s Pap smear results come back as H-SIL (high-grade squamous intraepithelial lesion)? What is your next step? Use the table on the next slide to guide your decision. B. Repeat Pap smear in 6 12 months C. Refer to Gynecology for colposcopy and/or other procedures *The ASCUS/LSIL Study (ALTS) Group. J Natl Cancer Inst, 2000: 92: Pap result CIN1 CIN2/3 Cancer Normal Pap up to 10% <1% 0.25% ASC US, HPV neg <10% <1.5% <0.01% Normal Pap, HPV+ <1.1% <0.08% ASC US, HPV % 7 18% <0.1% LGSIL 50 60% 2 19% 0.16% HGSIL 20% up to 70% 7% Q.4: What if Joyce s Pap smear results come back as H-SIL (high-grade squamous intraepithelial lesion)? What is your next step? B. Repeat Pap smear in 6 12 months C. Refer to Gynecology for colposcopy and/or other procedures Management options for H SIL result: B. Repeat Pap smear in 6 12 months C. Refer to Gynecology for colposcopy and/or other procedures Discussion Among women with H SIL cytology results, greater than 70% have been reported to have CIN2 or CIN3, and 1 5% harbor invasive cancer. Therefore, a referral to a gynecologist for colposcopy is essential. Joyce, continued Q5. Six months later, Joyce presents with complaints of itching and vaginal discharge. What are possible diagnoses? F. All of the above

4 Q5. Six months later, Joyce presents with complaints of itching and vaginal discharge. What are the possible diagnoses? Q6. What components in the history and physical exam might help you distinguish between these diagnostic possibilities? F. All of the above Q6. What components in the history and physical exam might help you distinguish between these diagnostic possibilities? Sexual history to distinguish between infections that are sexually transmitted and other reproductive tract infections Query any recent antibiotic use, diabetes, or immunosuppression (make candida more likely) Inspect the vulva, looking for areas of erythema, edema, ulceration or chronic vulvar skin changes. Palpate with a cottontipped applicator to elicit areas of tenderness. Inspect the vagina and cervix Assess the color, consistency, and odor of discharge Q7. What are the next diagnostic steps? A. Vaginal ph B. Amine (whiff test) C. Potassium hydroxide (KOH) smear D. Normal saline microscopy E. BD Affirm TM point of care testing F. All of the above Q7. What are the next diagnostic steps? A. Vaginal ph B. Amine (whiff test) C. Potassium hydroxide (KOH) smear D. Normal saline microscopy E. BD Affirm TM testing F. All of the above Discussion Obtain specimens from lateral vaginal wall for laboratory evaluation. Evaluations should include vaginal ph, amine (whiff) test, saline and 10% potassium hydroxide (KOH) smears for microscopic examination. Normal ph (< 4.5) rules out bacterial vaginosis, whereas ph > 4.5 has a limited differential diagnosis. Perform whiff test for amines by placing a drop of 10% KOH on vaginal secretions and checking for fishy odor. Saline microscopy permits identification of trichomonads and clue cells. BD Affirm TM can identify candida species, trichomonas vaginalis, and gardnerella vaginalis. Turnaround time may vary by facility

5 Q8. Your exam reveals a positive whiff test and a ph >5. What is the most likely diagnosis? Q8. Your exam reveals a positive whiff test and a ph >5. What is the most likely diagnosis? Q9. What treatment is least effective? Q9. What treatment is least effective? A. Oral Metronidazole B. Topical Metronidazole C. Clindamycin D. Tinidazole E. Triple sulfa A. Oral Metronidazole B. Topical Metronidazole C. Clindamycin D. Tinidazole E. Triple sulfa Q10. Which of the following would you NOT do if Joyce s symptoms don t improve? A. Re evaluate for cure B. Re evaluate for another cause of vaginitis C. Recommend douching D. Query about unprotected sex Q10. Which of the following would you NOT do if Joyce s symptoms don t improve? A. Re evaluate for cure B. Re evaluate for another cause of vaginitis C. Recommend douching D. Query about unprotected sex

6 Q11. Your exam reveals vulvar edema, erythema, and a cheesy white discharge. What is the most likely diagnosis? Q11. Your exam reveals vulvar edema, erythema, and a cheesy white discharge. What is the most likely diagnosis? Q12. Which treatment would you NOT consider? Q12. Which treatment would you NOT consider? A. Topical imidiazole B. Topical metronidazole C. Oral fluconazole A. Topical imidiazole B. Topical metronidazole C. Oral fluconazole Discussion Point Oral fluconazole is good if Joyce has already tried topical imidiazole Also, topical treatment is messy and the oral fluconazole is a one dose pill Q13. Which of the following would you do if Joyce s symptoms don t improve? A. Obtain a culture to confirm type of candida B. Assess for risk factors that potentially promote candida C. Treat the infection for longer period of time

7 Q13. Which of the following would you do if Joyce s symptoms don t improve? A. Obtain a culture to confirm type of candida B. Assess for risk factors that potentially promote candida C. Treat the infection for longer period of time All options are feasible. Discussion Points Option A: May be dealing with another type of candida (candida tropicalis or candida glabrata) which doesn t respond well to fluconazole. Obtain a culture to confirm type of candida. Option B: Many women have risk factors that could promote candida. Assess for antibiotic use (e.g., acne treatment), change to a different/low dose OCP, assess for diabetes mellitus and confirm that she is well controlled. Options C and D: May need to treat infection for a longer period of time (repeat doses of fluconazole on day 4/7). Consider treating Joyce s partner Q14. Your exam reveals a frothy, yellow-green discharge with erythematous punctuate lesions on the cervix. Whiff test is negative and ph is normal. What is the most likely diagnosis? Q14. Your exam reveals a frothy, yellow-green discharge with erythematous punctuate lesions on the cervix. Whiff test is negative and ph is normal. What is the most likely diagnosis? D. Physiologic discharge E. Atrophic vaginitis D. Physiologic discharge E. Atrophic vaginitis Q15. What treatment would you provide? Q15. What treatment would you provide? A. Metronidazole 2gm oral dose x 1 B. Tinidazole C. Topical Metronidazole D. Oral fluconazole A. Metronidazole 2gm oral dose x1 B. Tinidazole C. Topical Metronidazole D. Oral fluconazole Joyce s partner should also be treated as trichomonas is a sexually transmitted infection

8 Q16. What would you do if Joyce s symptoms don t improve? Q16. What would you do if Joyce s symptoms don t improve? Query about unprotected sex, other partners, and adherence to medication by Joyce and her partner. Reassess for other cause of vaginitis after treatment (i.e., candida after exposure to ABX) Q17. Before Joyce leaves your office, what advice might you give her based on the diagnosis of a new STI? Q17. Before Joyce leaves your office, what advice might you give her based on the diagnosis of a new STI? There are three major concerns 1. Discuss her sexual practices: Address the issue of multiple sexual partners in a sensitive fashion. Ensure you understand the following: Are all of her sexual encounters consensual? This addresses the possibility of rape or sexual abuse. What are Joyce s motives for having multiple sexual partners? This can reveal possible psychological problems, low selfesteem, substance use, etc. 2. Discuss her high risk of further STI exposure from unprotected sex 3. Discuss contraception