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CERVICAL CANCER - PREVENTION & SCREENING
Mortality due to cervical cancer can be reduced by prevention, early detection & treatment.
Vaccination may be started as early as 9 years old.
Vaccination may reduce the incidence of HPV-related disease.
Screening for cervical cancer after vaccination is still recommended because only 70% of the virus types associated w/ invasive cervical cancer consist of HPV 16 & 18 types & women may not be entirely protected if they have been infected w/ other HPV types prior to vaccination.

Classification

The 2014 Bethesda System
Interpretation of Epithelial Cell Abnormalities
Squamous cell
  • Atypical squamous cells (ASC)
    • Of undetermined significance (ASC-US)
    • Cannot exclude high-grade squamous intraepithelial lesion (HSIL) (ASC-H)
  • Low grade squamous intraepithelial lesion (LSIL) encompassing human papilloma virus (HPV)/mild dysplasia/cervical intraepithelial neoplasia (CIN) 1
  • High grade squamous intraepithelial lesion (HSIL) encompassing moderate and severe dysplasia, carcinoma in situ (CIS); CIN 2 and CIN 3
    • With suspicious invasive features (if invasion is suspected)
  • Squamous cell carcinoma
Glandular cell
  • Atypical
    • Endocervical cells (not otherwise specified or specify in comments)
    • Endometrial cells (not otherwise specified or specify in comments)
    • Glandular cells (not otherwise specified or specify in comments)
  • Atypical
    • Endocervical cells, favor neoplastic
    • Glandular cells, favor neoplastic
  • Endocervical adenocarcinoma in situ
  • Adenocarcinoma
    • Endocervical
    • Endometrial
    • Extrauterine
    • Not otherwise specified (NOS)
Adapted from: Nayar R, Wilbur DC. The Pap Test and Bethesda 2014. Acta Cytol. 2015;59(2):121-132.

Evaluation

Contraindications to Use of Human Papilloma Virus (HPV) Vaccine

  • Pregnancy
  • Moderate or severe acute illness
    • Vaccination should be deferred until illness subsides
    • Vaccination may be administered to patients with minor acute illnesses based on clinical judgement
  • Patients with history of immediate sensitivity reaction to yeast or to any vaccine component should not receive quadrivalent or 9-valent HPV vaccine
  •  Patients with anaphylactic latex allergy should not receive bivalent HPV vaccine in prefilled syringes

Screening

Cervical Cancer Screening Recommendations
U.S.1 Hong Kong College of Obstetricians & Gynaecologists2 Malaysia Ministry of Health4 Philippine Cancer Society5 Cervical Screen Singapore6 Taiwan Association of Obstetrics & Gynecology8 Himpunan Onkologi Ginekologi Indonesia9
Start Pap test screening in female patients At 21 years of age 25 years of age or around the 1st vaginal intercourse3 20 years of age if sexually active 21 years of age or within 3 years of onset of sexual activity 25 years of age in sexually active women; women who have never had sexual intercourse need not undergo screening 3 years after 1st vaginal intercourse or ≥30 years of age; women who have never had sexual intercourse need not undergo screening 20 years of age if sexually active
Screening interval for women <30 years old Pap test (conventional and liquid-based): every 3 years Every 3 years after 2 consecutive normal annual cytology tests.
Annually for women at high risk of developing cervical cancer more rapidly 		Every 3 years after 2 consecutive normal annual tests Visual inspection of the cervix aided by acetic acid (VIA) once every 3 years in areas without Pap smear capability; Pap smear in all other areas Every 3 years; may start at an early age and at more frequent intervals if high risk factors7 are present Annual; If 3 consecutive normal tests, consider test every 3 years Every 3-5 years either by Pap smear or VIA
Screening interval for women ≥30 years old Cytology screening for women 30-65 years old: Every 3 years Co-testing (cytology/HPV): every 5 years
Human papilloma virus (HPV) DNA test for screening For women 30-65 years old: Every 5 years along with cytology HPV testing, either as a co-test or stand-alone test, is not used in women <30 years old NA NA NA NA NA
When to stop No screening after adequate screening (3 consecutive negative cytology results or 2 consecutive negative co-tests within past 10 years, with the most recent test within the past 5 years): >65 years old If all screening tests are normal for the past 10 years and not diagnosed to have high-grade squamous intraepithelial lesion (HSIL): ≥65 years old. Women >65 years old who have never had a Pap test and had been sexually active or who request a test should be screened 65 years old 65 years old in women with history of consistently normal screens and not at high risk for cervical cancer 69 years old if smear taken at 69 years old is negative and 2 previous negative tests within last 10 years. Women >69 years old, with history of sexual activity and who have never undergone Pap smear should be screened NA 70 years old in women with history of consistently normal screens
  • NA = No available data
  • 1Saslow D, Solomon D, Lawson HW. Castle PE, Cox JT, et al. American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer. CA Cancer J Clin. 2012;62:147-172.
  • 2Hong Kong College of Obstetricians and Gynaecologists. HKCOG guidelines: guidelines for cervical cancer prevention and screening. Revised Nov 2016; Number 4. http://www.hkcog.org.hk.
  • 3Women <25 years with high-risk profile may be screened.
  • 4Ministry of Health Malaysia, Academy of Medicine. Clinical practice guidelines; management of cervical cancer. http://www.moh.gov.my. Apr 2003. 
  • 5Philippine Cancer Society. Primary prevention of cancer. http://www.philcancer.org.ph. 2011.
  • 6Ministry of Health, Singapore. Cancer screening. http://www.moh.gov.sg. Jan 2010.
  • 7High risk factors: HPV infection, multiple sexual partners, early onset of sexual activity, history of sexually transmitted disease (STD), HIV infection, immunosuppression, cigarette smoking.
  • 82007 recommendations from Taiwan Association of Obstetrics and Gynecology (TAOG).
  • 9Himpunan Onkologi Ginekologi Indonesia (HOGI). Pedoman Pelayanan Medik Kanker Ginekologi. Edisi 2. Jakarta: Badan Penerbit FKUI;2011.
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