Update on Cervical and HPV Screening Guidelines: To pap or not to pap? Marina Delazari Miller MD Clinical Assistant Professor Department of Obstetrics & Gynecology University of Iowa Hospitals and Clinics October 4th, 2016 Objectives»» Epidemiology» 2012 guidelines and their rationale» 2016 update» Cases» Cervical cancer» Worldwide - estimated 527,624 new cases of the disease and 265,672 resultant deaths each year» US - 50% decrease in incidence in past 30 years» Cervical cancer» 50% of the women in whom cervical cancer is diagnosed never had cervical cytology testing» 10% had not been screened within the 5 years before diagnosis» Human papilloma virus (HPV) Most common sexually transmitted infection 80% risk of acquiring the virus by age 50 most infections spontaneously regress approximately 130 genetically distinct types have been identified» Human Papilloma Virus (HPV)» Non-oncogenic» Oncogenic» Transient infection» Persistent infection» strong indicator of development of severe dysplasia/cancer 1
» What causes persistent infection?» Genotype» 16 is most carcinogenic (50-60%)» 18 second most carcinogenic (10-15%)» 12 others» What causes persistent infection?» Risk factors» Immunosuppression» Tobacco» Age» 30» Pap smear short for Papanikolaou introduced in 1950s significantly reduced incidence AND mortality from cervical cancer Guideline Update Resources Resources 2
2012 Guidelines Annual Screening» Why are we abandoning the yearly screening?» The test got better - added HPV» Relatively indolent disease» Even when CIN3 is diagnosed, it takes ~10 years for it to progress to cancer Annual Screening» Why are we abandoning the yearly screening?» effects of work up: overtreatment of disease likely to regress, cost, potential impact on reproduction» Anxiety and stigma associated with HPV infection To lube or not to lube?» How to collect pap» Liquid based vs. conventional» Lubricant or no lubricant» small amount is ok - minimize contact with the cervix» water based HPV Screening» FDA approved tests for high risk HPV (~ 15 strains)» HPV screening (w/o cytology): in women 25 years and older, the FDA-approved primary HPV screening test can be considered as an alternative to current cytology-based cervical cancer screening methods» Genotyping is available for 16/18» No role for low risk HPV screening» Sally is 16 years old and her mother is the sex ed teacher at her school. Her mother discovers that Sally has become sexually active and has had two partners, so she bring her in to begin her annual paps. 3
» To pap or not to pap? Do NOT pap < 21 years of age despite early onset of sexual activity Only 0.1% of cases of cervical cancer occur before age 20 years screening younger women has not decreased their rate of cervical cancer» Nearly all cases of HPV infection in this age group are cleared at 1-2 years after infection without development of any neoplastic changes» Most cervical neoplasia also will resolve spontaneously in this population Plug in» HPV vaccination» 3 FDA approved vaccines» bivalent, quadrivalent, 9-valent» Recommended for females 9-26» 9-valent vaccine approved for males HPV Vaccination» HPV vaccination» Significant reduction in cancer cases - 20 years of widespread use» 50% of girls aged 13-17 have received at least one dose» 33% have received all three doses VACCINATE VACCINATE VACCINATE 4
» You did perform an STD screening panel and Sally tested positive for HIV.» HIV - to pap or not to pap? Pap at diagnosis Pap at 6 and 12 months after diagnosis Yearly pap (can change to every 3 years if 3 consecutive negative tests) Don t stop at age 65 Case 2 Case 2» Sandy (24yo) comes to you for a pap, which you performed and ordered cytology alone as indicated. She has never had an abnormal pap.» Her pap cytology comes back with ASCUS.» Now what? Case 2 Case 2» Should you have ordered co-testing? No Use of cotesting in women younger than 30 years largely would detect transient HPV infection without carcinogenic potential 5
Case 3» Susan (45yo) had a negative pap with cotesting a year ago. She returns for her annual exam and requests her yearly pap. Case 3» To pap or not to pap?» In the Kaiser Permanente Northern California cohort the 3-year risk of CIN 3+ was 0.16 in women with a negative cytology the 5-year risk was 0.08 in women with a negative co-test result Case 3» Samantha (72yo) sees you for her annual exam and requests a pap smear.» To pap or not to pap? NO more paps after age 65 in adequately screened patients 6
» What does adequately screened mean? three consecutive negative cytology results OR two consecutive negative co-test results within the previous 10 years most recent test performed within the past 5 years» Because cervical cancer occurs a median of 15 25 years after HPV infection, screening women in this age group would prevent very few cases of cancer» No need to screen even if the woman has a new sexual partner» Atrophy can lead to false positive results» Samantha s daughter calls to inform you that she forgot to tell you during her visit that she had a hysterectomy 15 years ago and final pathology came back with CIN2.» To pap or not to pap? What to do with abnormal results? 7
What to do with abnormal results? References 1. ACOG. Practice Bulletin Number 157: Cervical cancer screening and prevention. January 2016. 2. ACOG. Committee Opinion Number 641: Human Papillomavirus Vaccination. September 2015. 3. Hoffman, B. L. (2012) Preinvasive lesions of the lower genital tract. Williams Gynecology. Second edition. Dallas, TX: McGraw Hill Medical. Questions? 8