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HPV and cervical cancer screening
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HPV infection and cervical atypia epidemiology
Accounts for 80%+ of CIN
Accounts for 99.7% invasive cervical cancer
HPV infection rates
Highest among those 20-29 years old
-Condoms provide protection against transmission of them 60%
Types of HPV
130 total
30-40 types infect the anus and vagina
Low risk: condylomata/CIN 1 (HPV types 6 and 11)
High risk: CIN 2, 3, and cancer
-HPV type 16 (most cancer)
-HPV type 18 (less cancer)
Natural history of HPV
Most genital HPV infections are transient, asymptomatic and have no clinical consequences in immunocompetent individuals
-Time and development of clinical manifestations vary
-Median duration of new cervical infections is 8 months, but varies
(90% of infections clear within 2 years)
-Persistent HPV infection is not cleared by the immune system
-Characterized by persistently detectible type specific HPV DNA
-Persistent oncogenic HPV infection is most important risk factor for precancerous cervical cellular changes and cervical cancer
Risk factors for cervical intraepithelial neoplasia (CIN)
HPV infection +
Multiple sex partners, early onset sex, high risk partner, STI history, cigarette smoking*, HIV/AIDs or other immunosuppression, long term OCP use, multiparity
HPV infection and smoking
Synergistic effect
-Greatly increases risk of atypia and cancer
-Carcinogens accumulate in cervical mucus
-More packyears=increased risk
Why not just check for hPV?
90% immunocompetent have spontaneous resolution in a 2 year period
HPV transmission
Usually sexually transmitted (condoms prevent this 60% of the time)
-Infection is often shared between partners
-Determining source is difficult, varying incubation times
-Recurrences are usually not reinfection
-Transmission risk to current and future partners after treatment is unclear
-Likelihood of transmission and duration of infectivity with or without treatment are unknown
Preventing HPV
Gardasil: quadrivalent (16, 18, 11, 6)
Cervarix: bivalent (16, 18)
3 dose series given over 6 months
Approved in boys (11-21) and girls (9-26), most effective if started before sexual debut
-May give even if positive for HPV
-Adverse effects: fainting
Success story
Cervical cancer rates have fallen 75% since pap testing
Starting screening
-Age 21
Adverse effects of starting earlier: anxiety, cost, morbidity, long term consequences of follow up procedures
Continue screening if cytology is normal...
Age 21-29: every 3 years
Age 30+: cytology and HPV co-testing every 5 years, or cytology alone every 3 years
Stopping testing
After total hysterectomy
After 65 years old, negative screening over the past 10 years and 2 consecutive negative co-test results or 3 consecutive cytology results within the past 10 years
Pap cytology
Visualize cervix, obtain specimen from squamocolumnar junction
-Use 2 methods for sampling: spatula at ectocervix and cytobrush/broom for endocervix
Rinse instrument in thinprep ASAP
Special populations
History of CIN 2,3 or higher in the past 20 years should continue screening per age based guidelines, and may extend beyond age 65
History of hysterectomy from cervical cancer should continue screening with cytology alone every 3 years for 20 years post op
HIV+ immunocompromised: no consensus, annual screening after age 21
Bethesda system: cytology
Normal: negative
Atypical squamous cells of undetermined significance (ASCUS)
- most common result of abnormal paps, atypical cells
LSIL: low grade squamous intraepithelial cells
-mild/moderate dysplasia, usually resolves spontaneously
HSIL: high grade squamous intraepithelial cells: severe dysplasia or carcinoma
Biopsy results
CIN 1: mild, spontaneous resolution in many
CIN 2: moderate, okay to follow in adolescence and pregnancy, will likely need further care
CIN 3: severe
Carcinoma in situ: full thickness epithelial lesion
Comparing Bethesda and CIN system
ASCUS (+/- HPV)
CIN 1, LSIL, spontaneous resolution in many
CIN 2 (moderate), HSIL
CIN 3 (severe), HSIL
CIS: full thickness
Natural history of cervical cancer
Persistent HPV infection can turn to CIN 2,3 in 3-5 years, which can turn into invasive cancer in 10-20 years
ASCUS or postmenopausal LSIL treatment
1. Serial cytology every 6 months until 2 consecutive normals
If abnormal again, colposcopy
2. +HPV: colposcopy
-HPV: repeat cytology in 1 year
3. Immediate colposcopy
Colposcopy
Vinegar and/or iodine is brushed on the cervix
Low power magnification inspects epithelium (cervix, vagina, vulva, anus)
-Biopsy accomplished at abnormal sites, in office
Procedures for CIN 2 and 3
Ablation
-Cryotherapy: no biopsy
CO2 laser: no biopsy
Excision: LEEP
Cone biopsy
Cone biopsy
-Done if colposcopy is unsatisfactory, if lesion extends into the os beyond the view of colposcope, if dysplasia is visualized on colposcopy, if cancer or ACIS is suspected (OR)
Treatment for cervical cancer
Surgical: hysterectomy
Chemotherapy
Radiation
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