American Academy of Family Physicians

Transcription

1 American Academy of Family Physicians Barbara E. Stanford MD Grand Rapids Family Medicine Residency Wege Family Medicine

2 HPV is transient in most women HPV-75% Normal ASCUS LSIL HSIL Cancer 80-90% 75%??? 25% Years

3 All HPV does not cause cancer 3

4 Some HPV may cause cancer 4

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6 Don t perform routine screening Pap smears on women younger than 21 Overall risk of cervical cancer in this age group is about 1% ( : pre-vaccine) data per year rate of 0.15 per 100,000 females < 21years DES exposed individuals no longer exist Last use 1971 these individuals are now 43 years old HPV infection clears, in most women, within 3 years HPV vaccine is a covered benefit for both males and females < 26 years on Medicaid and other plans STI testing is recommended annually, or for exposure, or symptomatic concerns 6

7 HPV vaccine may further change how and when we screen 108,353 young women in Queensland, Australia, who were fully vaccinated (three doses) with the quadrivalent HPV vaccine before starting cytologic (Pap) screening British Medical Journal March ; 348:g % risk reduction high grade cervical abnormalities NNT % risk reduction for other cervical abnormalities NNT 22 More research necessary to determine optimal screening in vaccinated individuals 7

8 HPV vaccine may further change how and when we screen 108,353 young women in Queensland, Australia, who were fully vaccinated (three doses) with the quadrivalent HPV vaccine before starting cytologic (Pap) screening British Medical Journal March ; 348:g % risk reduction high grade cervical abnormalities NNT % risk reduction for other cervical abnormalities NNT 22 More research necessary to determine optimal screening in vaccinated individuals 8

9 HPV vaccine may further change how and when we screen 108,353 young women in Queensland, Australia, who were fully vaccinated (three doses) with the quadrivalent HPV vaccine before starting cytologic (Pap) screening British Medical Journal March ; 348:g % risk reduction high grade cervical abnormalities NNT % risk reduction for other cervical abnormalities NNT 22 More research necessary to determine optimal screening in vaccinated individuals 9

10 Don t perform Pap smears on women who have had a hysterectomy for non-cancer disease "In women who have had a hysterectomy with removal of the cervix (total hysterectomy) and have never had CIN 2 or higher, routine cytology screening and HPV testing should be discontinued and not restarted for any reason." American College of Obstetrics and Gynecology 2012 American Cancer Society 2012 United States Prevention Task Force 2012 D recommendation: harms of screening outweigh benefits 10

11 Don t perform Pap smears on women who have had a hysterectomy for non-cancer disease "In women who have had a hysterectomy with removal of the cervix (total hysterectomy) and have never had CIN 2 or higher, routine cytology screening and HPV testing should be discontinued and not restarted for any reason." American College of Obstetrics and Gynecology 2012 American Cancer Society 2012 United States Prevention Task Force 2012 D recommendation: harms of screening outweigh benefits 11

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13 Annual Screening is not required for women aged 30 to 65 years 13

14 Will we miss cervical cancer? ALTS trial: ASCUS, LSIL Lesion Triage Study 2001 National Cancer Institute (ALTS trial) 30 additional research articles since original publication Liquid cytology alone sensitivity for cervical cancer is 80% This is a technique dependent test HPV testing is 96% sensitive for cervical cancer LSIL and ASCUS with HPV+ paps have low risk for CIN 2 or higher disease ASC-US = only 10 % risk of underlying CIN 2 or higher ASC-H cannot rule out HSIL = 40% risk of underlying CIN 2 or higher 14

15 Will we miss cervical cancer? HPV-75% Normal ASCUS LSIL HSIL Cancer 80-90% 75%??? 25% Years 43 % of CIN 2 lesions resolve 32 % of CIN 2 lesions resolve Progression from CIN 3 to Cancer may take 30 years 15

16 Will we miss cervical cancer? HPV-75% Normal ASCUS LSIL HSIL Cancer 80-90% 75%??? 25% Years 43 % of CIN 2 lesions resolve 32 % of CIN 3 lesions resolve Progression from CIN 3 to Cancer may take 30 years 16

17 Don t use HPV test on women younger than 30 years of age Pap smear has sensitivity of 80% > or = LSIL changes 21% of cervical cancers were diagnosed in women 21-30y reflex HPV testing can identify those patients needing colposcopy 17

18 HPV digene testing can be added to extend routine screening to 5 years Tests collectively for the 13 clinically most-significant high-risk (oncogenic) HPV types (16,18,31,33,35,39,45,51,52,56,58,59,68) HPV 16 and 18 account for 70% of all cervical cancers HPV 31 and 45 account for nearly 10% of all cervical cancers Reflex testing from Thin Prep specimen if ASCUS 20 ml buffered methanol / spatula / cytobrush Combination with PAP for patients older than 30 years. Digene : High Risk HPV test 1 ml transport medium / brush (cytobrush on steroids) 18

19 HPV digene testing can be added to extend routine screening to 5 years Tests collectively for the 13 clinically most-significant high-risk (oncogenic) HPV types (16,18,31,33,35,39,45,51,52,56,58,59,68) HPV 16 and 18 account for 70% of all cervical cancers HPV 31 and 45 account for nearly 10% of all cervical cancers Reflex testing from Thin Prep specimen if ASCUS 20 ml buffered methanol / spatula / cytobrush Combination with PAP for patients older than 30 years. Digene : High Risk HPV test 1 ml transport medium / brush (cytobrush on steroids) 19

20 HPV digene testing can be added to extend routine screening to 5 years Tests collectively for the 13 clinically most-significant high-risk (oncogenic) HPV types (16,18,31,33,35,39,45,51,52,56,58,59,68) HPV 16 and 18 account for 70% of all cervical cancers HPV 31 and 45 account for nearly 10% of all cervical cancers Reflex testing from Thin Prep specimen if ASCUS 20 ml buffered methanol / spatula / cytobrush Combination with PAP for patients older than 30 years. Digene : High Risk HPV test 1 ml transport medium / brush (cytobrush on steroids) 20

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22 Most dysplasia resolves HPV-75% Normal ASCUS LSIL HSIL Cancer??? 80-90% 75% 25% 81 % or mild dysplasia will resolve within 18 months 43% of CIN2 lesions resolve 32% of CIN3 lesions resolve Years 22

23 Most dysplasia resolves HPV-75% Normal ASCUS LSIL HSIL Cancer??? 80-90% 75% 25% 81 % or mild dysplasia will resolve within 18 months 43% of CIN2 lesions resolve 32% of CIN3 lesions resolve Years 23

24 Most dysplasia resolves Treat only lesions that are CIN2 or worse Potential harms of treating CIN include immediate, shortterm risks 87% of women reported bleeding 67% pain 63% discharge Reviews of obstetric outcomes found that cold-knife conization and Loop electrosurgical excision procedures were associated with an increased risk of preterm birth LEEP 1.7 times increased risk for birth before 37 weeks in one study 24

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26 What do I do with unexpected results? There s an app for that! American Society of Colposcopy and Cervical Pathology Bookstore Mobile Algorthyms App dp/b00g3k70bs/ref=sr_1_1? ie=utf8&qid= &sr=8-1&keywords=asccp +app 26