My Pap Smear is

Abnormal ! Dr. Natalie

Medley
Consultant
Obstetrician/
Gynaecologist
Associate Lecturer
UHWI/UWI
 Quiz
1.A 23 year old presenting with ASC-
US.
2.A 35 year old presenting with AGC
3.A 45 year old presenting with
negative cytology and absent TZ
4.A 32-year-old presenting with LSIL
5.A 29-year old with ASC-H
1. A 23 year old presenting with ASC-
US.
a. Perform colposcopy (5%)
b. Repeat smear in 6 months (63%)
c. Repeat smear in 12 months (11%)
d. Request HPV testing (reflex testing)
(21%)
2. A 35 year old presenting with
atypical glandular cells (AGC)
a. Perform colposcopy, endocervical
curettage (ECC) and endometrial
sampling. (79%)
b. Perform cone biopsy (16%)
c. Repeat smear in 12 months (0%)
d. Request HPV testing (reflex testing)
(5%)
3. A 45-year old presenting with
negative cytology but absent TZ
a. Perform colposcopy (11%)
b. Repeat smear in 6 months (47%)
c. Repeat smear in 12 months (11%)
d. Request HPV testing (co - testing)
(31%)
4. A 24-year-old presenting with LSIL.
a. Perform colposcopy (52%)
b. Repeat smear in 6 months (38%)
c. Repeat smear in 12 months (0%)
d. Request HPV testing (co-testing)
(10%)
5. A 29-year old with ASC-H
a. Perform colposcopy (90%)
b. Repeat smear in 6 months (5%)
c. Repeat smear in 12 months (0%)
d. Request HPV testing (5%)
 Objectives
Cervix
I
Cytologist
I
Counseling the patient
I

Colposcope

Discuss Cancer Risks

George
Papanicolaou
1883 -1962
Aurel Babes
1886-1961

The Babes Smear?

 WHO/Wilsons Screening
Criteria 0 %
10
The condition sought should be an important health problem for the
individual and community
There should be an accepted treatment or useful intervention for
patients with the disease
The natural history of the disease should be adequately understood
There should be a latent or early symptomatic stage
There should be a suitable and acceptable screening test or
examination
Facilities for diagnosis and treatment should be available
There should be an agreed policy on whom to treat as patients
Treatment started at an early stage should be of more benefit than
treatment started later
The cost should be economically balanced in relation to possible
expenditure on medical care as a whole
Case finding should be a continuing process and not a once and for
all project.
 Since its introduction
half the number of cervical cancer cases
estimated to save approximately 4,500
lives per year in England.
50% of cervical cancer cases never
had cervical cytology testing
another 10% had not been screened
within the 5 years before diagnosis
The UHWI Experience

80% of work load at lab is from UHWI

 What the
cytopathologist
sees
 What the patient sees
Satisfactory LSIL
Negative for intra-epithelial lesion or malignancy
Low grade squamous intra-epilthelial lesion (LSIL)
High grade squamous intra-epithelial lesion (HSIL)
Atypical squamous cells undetermined signifance (ASC-US)
Atypical squamous cells high grade (ASC-H)
Atypical glandular cells (AGC)

Shift in flora suggestive of bacterial vaginosis

Candidiasis
Trichomoniasis HSIL
Non specific inflammation

ASC-US
 What the patient feels
Cancer screening itself and abnormal test results have
an impact on patients feelings.
Emotional distress
Shame
Stigma
Anxiety

meaning of an abnormal test result not clearly

explained
Archives of Gynecology and Obstetrics 293 (2),391398
 What the patient feels
Women felt vulnerable when being investigated
for intraepithelial neoplasia
The discovery created unnecessary worry and a
negative experience that may be solved by a
better-developed educational program at the
time of screening.
There were no signs of remaining anxiety 5
years later
8% of women reported a remaining negative
influence on their sexual life.
Acta Obstet Gynecol Scand. 2003 Aug;82(8):756-61.
 What the patient feels
The most important findings in this study were that women
were primarily poorly informed about the aim of cervical
cancer screening and that the information given to them
concerning a mild dysplasia created anxiety, but follow-up
management subsequently enabled most women to recover
confidence
Acta Obstet Gynecol Scand. 2003 Aug;82(8):756-61.

Despite increasing public awareness of HPV and cervical

cancer, the results from our survey of nearly 1500 women in
France, Spain and Portugal show that the current profile of
feelings (predominantly anxiety, panic and stress) in
response to being informed of an abnormal Pap result
Being well informed is critical for lowering anxiety over
abnormal results.
BMC Womens Health. 2011; 11: 18.
What about the partners
 PATIENT
INFORMATI
ON
RESOURCES
 What does it really mean?
Negative cytology:

61 to 84% reduction in the risk of

developing cervical cancer over the
three to five year interval following
negative cervical cytology
British Journal of Cancer, 2003, 89(1): 88-93
 What does it really mean?
Unsatisfactory
unreliable for detecting epithelial
abnormalities.
use of liquid-based media that minimize
obscuring blood and inflammation in
processing
unsatisfactory specimens are usually the
result of insufficient squamous cells
HPV test result may be falsely negative
because of an insufficient sample
 What does it really mean?
Absent EC/TZ
Incidence 10-20% (higher in older women)
Has sufficient cellularity
No metaplastic cells seen
Raises concerns about missed disease

Negative cytology has good specificity and

NPV despite absent/ insufficient EC/TZ
Elumir-Tanner L, CMAJ 2011; 183:563Y8.
 What does it really mean?
Negative cytology/ Positive HPV
Despite negative cytology, positive
HPV are at higher risk for later CIN3+
normal cervical cytology test results
and a single positive HPV test result
have a 2.26.1% risk of CIN 2+
HPV-18 is associated with
adenocarcinoma which is less
efficiently detected on cytology
 What does it really mean?
ASC-US
The most common abnormality
Lowest risk of CIN3+
One to two-third not associated with
HPV
ALTS (ASC-US/LSIL Triage study)
reflex testing identified HPV positive
women at higher risk of CIN3
5-year risk of CIN3+ is 3%
 What does it really mean?
LSIL
Progression similar to HPV-positive
ASC-US
Highly associated with HPV infection
(77%)
Hence reflex testing is not justified
Women age 21-24 carry a lower risk
of CIN3+ than older women
 What does it really mean?
ASC-H
Higher risk of CIN3+ than ASC-US
and LSIL
Lower risk than HSIL
High risk of HPV detection makes
reflex testing unacceptable
The 5-year cancer risk with ASC-H
with negative HPV is 2%
Too high to justify observation
 What does it really mean?
HSIL
Confers substantial risk
CIN2+ is found in 60% at colposcopy
Cervical cancer found in 2%
5-year cervical cancer risk is 8%
in 30+ yrs old
HPV- negative, uncommon
 What does it really mean?
AGC
Poorly reproducible
Polyps, metaplasia, neoplasia
Adenocarcinomas of endometrium, cervix,
ovary, tube
Higher risk of CIN2+ in women older than
35yr
CIN3+ found in 9% women older than 30yrs
Cancer found in 3%
 What is the next step?
ACOG
ASCCP American Society for Colposcopy and
Cervical Pathology
CAP College of American Pathologists
LAST project Lower Anogenital Squamous Terminology
ALTS ASCUS/LSIL Triage Study

NHS Cervical Screening Programme - UK

(Caribbean Gynae-oncology Society ? coming soon)

 First, do no harm
Preventing cervical cancer has benefits and harms
Risk of cervical cancer cannot be completely reduced
to zero
HARMS
Attempts achieve zero risk may result in unbalanced
harms from overtreatment BENEFITS
Optimal prevention strategies
detect abnormalities likely to progress to invasive
cancer
Avoiding destructive treatment not likely to become
cancerous
 First, do no harm
Studies of effect on future pregnancy
are conflicting
Some indicate a two-fold preterm
delivery risk
JAMA 2004;29:2100Y
Obstet Gynecol 2009;114:504Y10.
BJOG 2011;118:1031-41.

Interestingly, women with CIN may

be at risk of preterm delivery even if
untreated
 Rationale for management
Immediate colposcopy recommended when
the 5 year risk of CIN3+ exceeded 5%
A 6-month to 12-month return risk of 2-5%
A 3-year return risk of 0.1 to 2%
A 5 year return for risk of 0.1%

Guidelines cannot be developed for all

situations
Clinical judgment
Individualized care
 Rationale for management
ALTS
For ASC-US
repeat cytology at 6 months and 12 months
with colposcopy for abnormal results
reflex HPV testing with colposcopy for women
with positive results
immediate colposcopy.
Reflex HPV testing was the preferred option
it identifies more CIN 3+ lesions
fewer referrals to colposcopy
ASCCP Recommended Screening Schedule
 Unsatisfactory smear
Less than 1% of all smears
Conventional > liquid based
Repeat cytology in 2 to 4 months
Two consecutive unsatisfactory
smears -> colposcopy
 Absent EC/TZ
Recommendation
21-29 yrs:
continue regular screening pattern
30+ years:
HPV testing is preferable
repeat cytology in three years is
acceptable
 Cytology negative/HPV
positive
repeat co-testing at 1 year is acceptable
If at one year:
the HPV test result is positive or cytology is
ASC-US or worse -> colposcopy
HPV-negative and cytology negative -> co-
testing in 3 years is recommended.
HPV genotyping is also acceptable.
HPV 16 and HPV 18 positive -> colposcopy
 ASC-US
25 yrs and older :
reflex HPV testing is preferred.
HPV-negative -> repeat co-testing in 3 yrs
HPV-positive -> colposcopy
HPV not available -> repeat cytology in 1 year
21-24yrs:
Repeat cytology in 12-month intervals is preferred
reflex HPV testing is acceptable.
HPV positive - > repeat cytology in 12 months (up to 24)
Immediate colposcopy or repeat HPV testing is not
recommended.
 LSIL
25 yrs and older :
no HPV test or a positive HPV test
-> colposcopy
(If co-testing shows HPV-negative LSIL, repeat co-
testing at 1 year is preferred, colposcopy is
acceptable)
21-24 yrs:
follow-up with cytology testing at 12-month
intervals is recommended (up to 24 months)
Colposcopy is not recommended.
 ASC-H
25 yrs and older :
Colposcopy

21-24 yrs :
Colposcopy
 HSIL
25 yrs and older:
immediate loop electrosurgical
excision or colposcopy

21 24 yrs:
colposcopy is recommended.
Immediate treatment (ie, see-and-
treat) is unacceptable.
 AGC, AIS
All subcategories of AGC and AIS except
atypical endometrial cells
-> colposcopy with endocervical
sampling (ECC) is recommended
regardless of HPV result
In addition -> Endometrial sampling
if 35 yrs or older or
Younger than 35 yrs with increased risk for
endometrial neoplasia eg. chronic anovulation
 Special considerations
Immunocompromised
Managed the same way
Pregnant women
Colposcopy is preferred if indicated
Deferring colposcopy until six weeks
post partum is acceptable
ECC is unacceptable
 Adjuncts
Endocervical Sampling (Endocervical
Curettage, ECC)
ASC-US or LSIL when no lesion is see on
colposcopy,
Colposcopy is unsatisfactory
Previous excision or ablation of the
transformation zone
if ablative treatment such as cryotherapy
or laser ablation is contemplated
(ASC-H), HSIL, AGC, or AIS, ECC should be
considered as part of the initial
colposcopic evaluation unless excision is
planned.
 Alternatives
Primary HPV testing
Approved 2014
Age 25 years and over
50% reduction in cervical Ca from single lifetime test
N Engl J Med 2009;360:138594
Detects more than 90% CIN2+, 25% more sensitive
than LBC, 6% less specific
VIA
NPV 99%,
sensitivity similar to that of cytology
See and treat/ screen and treat
WHO 2013
 77% less 38% less
CIN3 CIN 3

World Health Organization. WHO guidelines for screening and treatment of

 Future
P16
LAST Project
Our Wages of CIN: Obst Gyn VOL. 120, NO. 6, DEC 2012
Over Treatment of CIN2, role of P16
Pap score
Patient factors
Previous smears
Protocols for follow-up after CIN
not been evaluated in randomized trials
Jamaican cohort
Similar to the KPNC cohort in ASCCP recommendation
 Quiz
1.A 23 year old presenting with ASC-
US.
2.A 35 year old presenting with AGC
3.A 45 year old presenting with
negative cytology and absent TZ
4.A 32-year-old presenting with LSIL
5.A 29-year old with ASC-H
Than
k you
 References
2012 Updated ASCCP Consensus Guidelines for the
Management of Abnormal Cervical Cancer Screening Tests
and Cancer Precursors
Cervical cancer screeening and prevention, Practice
Bulletin, Jan 2016
Management of Abnormal Cervical Cancer Screening Test
Results and Cervical Cancer Precursors, Practice Bulletin,
Dec 2013
ACOG Cervical Cancer Screening in low resource setting,
committee Opinion, February 2015
WHOguidelinesforscreening and treatment of precancerous
lesions for cervical cancer prevention. Geneva: WHO; 2013
NHS cercical Screening programme, March 2016