Frequently Asked Questions on Cervical Dysplasia and

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Frequently Asked Questions on Cervical Dysplasia and

Transcript Of Frequently Asked Questions on Cervical Dysplasia and

Frequently Asked Questions on Cervical Dysplasia and Human Papillomavirus
A Reference Guide for Clinicians
Michael Fung-Kee-Fung, MB, BS, FRCSC Director, Gynecologic Oncology Program Head, Surgical Oncology Professor, Department of Obstetrics and Gynaecology, Department of Surgery University of Ottawa The Ottawa Hospital, General Campus Ottawa, Ontario, K1H 8L6
Myriam Nadia Amimi, MD, FRCSC, FACOG Obstetrician/Gynecologist Sault Area Hospitals Sault Ste. Marie, Ontario, P6A 2C4
Robbi Howlett, MASc, PhD (Candidate) Manager Ontario Cervical Screening Program Division of Preventive Oncology Cancer Care Ontario Toronto, Ontario, M5G 2L7
Michael K. Innes, MSc Research Associate Ontario Cervical Screening Program Division of Preventive Oncology Cancer Care Ontario Toronto, Ontario, M5G 2L7
Acknowledgements The authors acknowledge the staff of the Ontario Cervical Screening Program who assisted in preparing this book for publication.
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To ensure this document is readily available to clinicians, Frequently Asked Questions on Cervical Dysplasia and Human Papillomavirus: A Reference Guide for Clinicians may be photocopied in whole or in part for noncommercial use, provided that credit is given to the original source. Any other use, including republishing or redistributing in any form or manner, in whole or in part, requires explicit, written permission from the authors.
Additional information may be obtained by contacting: Ontario Cervical Screening Program Division of Preventive Oncology Cancer Care Ontario 620 University Avenue Toronto, Ontario, Canada M5G 2L7
Phone: (416) 971-9800 Ext. 1144 E-mail: [email protected] ISBN: 0-9782128-0-0 © 2007 Cancer Care Ontario, M. Fung-Kee-Fung and M. Amimi Reprinted with permission by the Ontario Cervical Screening Program, January, 2007 To order, contact: [email protected]
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Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Answers to Your Frequently Asked Questions 1. What is the status of cancer of the cervix in Canada? . . . . . . . . . . . . . 2 2. Is it true that adenocarcinomas represent a growing proportion of new
cervical cancers? Which groups of women are at greatest risk? . . . . . 2 3. What are the risk factors for cervical cancer? . . . . . . . . . . . . . . . . . . . . 3 4. What is the Cervical Cancer Prevention and Control Network?. . . . . . 4 5. What is the goal of the Ontario Cervical Screening Collaborative Group
(OCSCG)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 6. When did cervical cancer screening begin in Canada? . . . . . . . . . . . . . 5 7. Which provinces have screening programs? . . . . . . . . . . . . . . . . . . . . . 5 8. How many Papanicolaou (Pap) tests are taken annually? How many
are abnormal? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 9. What is the screening history of women with abnormal Pap tests? . . . 6 10. Is there evidence that the Pap test has prevented the occurrence of
cancer of the cervix? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 11. Why does cervical cancer screening sometimes fail? . . . . . . . . . . . . . . 7 12. How has Ontario developed and implemented a quality assurance
program? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 13. How can we improve the effectiveness of cervical
cancer screening?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 14. What patient education materials about dysplasia are effective?. . . . . 9
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15. How can patient compliance and follow-up be improved? . . . . . . . . . . 9 16. Are women of low socioeconomic status (SES) at increased risk? . . 10 17. What is HPV? How many types are there? . . . . . . . . . . . . . . . . . . . . . . 10 18. Which HPV types are “high-risk”?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 19. What is the role of HPV in cervical dysplasia and cervical cancer? . . 11 20. How is HPV transmitted?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 21. How common is HPV infection? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 22. What is the natural history of HPV infection? . . . . . . . . . . . . . . . . . . . 12 23. Does barrier protection decrease the risk of HPV? . . . . . . . . . . . . . . . 13 24. Are oral contraceptive users at increased risk for cervical cancer?. . 14 25. What about douching? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 26. Are smokers at increased risk for cervical cancer? By how much? Why
are smokers at increased risk for cervical cancer? . . . . . . . . . . . . . . . 15 27. How about passive smoke exposure? . . . . . . . . . . . . . . . . . . . . . . . . . . 16 28. What is the role of the male partner in dysplasia and cancer
of the cervix? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 29. Does the partner’s occupation affect the patient’s risk of developing . .
cervical cancer? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 30. What is the role of parity in cervical dysplasia?. . . . . . . . . . . . . . . . . . 17 31. What about sexually transmitted agents other than HPV? . . . . . . . . . 17 32. Are any nutrients protective against cervical dysplasia
or carcinoma? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
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33. Can women who have sex with women (WSW) develop cervical dysplasia? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
34. What is the natural history of cervical dysplasia (i.e., regression, persistence, progression)?. . . . . . . . . . . . . . . . . . . . . 19
35. What is the ratio of pre-cancerous to invasive cervical lesions?. . . . . 20
36. What is the role of illness associated with immunosuppression (e.g., organ transplantation), immunosuppressive drugs, and connective tissue diseases (e.g., systemic lupus erythematosus [SLE]) relative to dysplasia/neoplasia? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
37. Are genital warts more prevalent among immunocompromised . . . . . . patients? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
38. What is the transformation zone? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
39. What is the Bethesda System? What are its strengths and weaknesses? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
40. What does it mean when a Pap test is reported as “satisfactory for evaluation”? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
41. Should a patient come back for a repeat Pap test if the endocervical component is absent? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
42. What is LSIL? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
43. What is the recommended follow-up for women with LSIL? . . . . . . . 24
44. What is HSIL? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
45. Why should HSIL be referred for colposcopy?. . . . . . . . . . . . . . . . . . . 25
46. How do LSIL and HSIL correlate with CIN 1, 2, and 3? . . . . . . . . . . . 25
47. What is the significance of “ASCUS” and “ASC-H” on a Pap test report? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
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48. How do you manage an ASC-H Pap test result? . . . . . . . . . . . . . . . . . 27
49. What are “atypical endocervical cells,” “atypical endometrial cells,” and “atypical glandular cells” on a Pap test? . . . . . . . . . . . . . . . . . . . . 27
50. What about endocervical adenocarcinoma in situ? . . . . . . . . . . . . . . . 28
51. What is the significance of “invasive adenocarcinoma” on a Pap test report? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
52. How has the Bethesda System affected colposcopy referrals?. . . . . . 30
53. Why is the Pap test a good screening test? . . . . . . . . . . . . . . . . . . . . . 30
54. How did the Pap test come to be? What about the Ayre spatula? . . . 31
55. What is the sensitivity and specificity of the Pap test? . . . . . . . . . . . . 31
56. What are the false-positive and false-negative rates associated with the Pap test? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
57. How often should Pap tests be done?. . . . . . . . . . . . . . . . . . . . . . . . . . 32
58. How do you take a Pap test? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
59. Does the method of sampling or choice of sampling instrument matter? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
60. For a conventional Pap test, should the cotton-tipped applicator still be used to sample the endocervical canal? What is the advantage of using the endocervical brush or broom? . . . . . . . . . . . . . . . . . . . . . . . 33
61. Should one or two slides be used when taking a conventional Pap test? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
62. How do you prevent “drying artifact” in a conventional Pap test?. . . 34
63. At what age should Pap test screening start? Why are low-risk patients screened every 2–3 years? . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
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64. What is the yield of abnormal Pap tests in teens with recent sexual activity? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
65. Should a virgin be screened with Pap tests? . . . . . . . . . . . . . . . . . . . . 36
66. What is the appropriate Pap test screening regimen for the elderly female patient? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
67. Should Pap tests be done in women after hysterectomy? . . . . . . . . . 36
68. Can a Pap test be done if a patient is menstruating? . . . . . . . . . . . . . 37
69. Can a Pap test be done during an active genital tract infection? . . . . 37
70. What is the significance of endometrial cells in a Pap test? . . . . . . . . 37
71. What is the role of vaginal estrogen cream in the management of an abnormal Pap test?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
72. Should an abnormal Pap test be repeated within a day or weeks of the first one?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
73. Is there any sense in doing a Pap test of a lesion that is clinically suspicious for cancer? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
74. What is liquid-based cytology (LBC)? How is LBC different from a conventional Pap test?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
75. What are the advantages and disadvantages of LBC? . . . . . . . . . . . . . 39
76. Is there a role for naked-eye inspection of the cervix after acetic acid application as an adjunct to Pap testing in the family doctor’s office? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
77. Is there a role for automated (computer-assisted) systems in cervical screening? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
78. Is there a role for HPV DNA testing in cervical screening? . . . . . . . . 41
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79. What test can we use for HPV testing? . . . . . . . . . . . . . . . . . . . . . . . . 42 80. How is the HPV test done? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 81. What is the sensitivity and specificity of HPV testing? . . . . . . . . . . . . 44 82. What is primary HPV screening?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 83. What is triage HPV testing?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 84. Who should get HPV screening? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 85. What do you do with a patient who is positive for high-risk HPV? . . 47 86. What is colposcopy?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 87. What is the sensitivity and specificity of colposcopy?. . . . . . . . . . . . . 48 88. Why is colposcopy important? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 89. Why is colposcopy not used as a screening tool along with
the Pap test?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 90. What is the level of accuracy of cervical biopsy and colposcopy? . . . 49 91. When should a patient be referred for colposcopy? . . . . . . . . . . . . . . 49 92. Should a family doctor still do Pap tests if the patient is being
followed by a colposcopist? When do patients referred for colposcopy return to their family doctor for future annual Pap tests? . . . . . . . . . 50 93. What is endocervical curettage (ECC)? . . . . . . . . . . . . . . . . . . . . . . . . 50 94. What is the utility of ECC? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 95. Should an ECC be performed by curette or endocervical brush or broom? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 96. Is ECC necessary at the time of cervical cone biopsy? . . . . . . . . . . . . 51
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97. What happens to warts (condyloma) in pregnancy? . . . . . . . . . . . . . . 52
98. What is considered safe local therapy for genital warts in pregnancy? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
99. Is cervical screening different in pregnant women? . . . . . . . . . . . . . . 53
100. Can an endocervical brush or broom be used when doing a Pap test during pregnancy? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
101. How is dysplasia followed and treated during pregnancy? . . . . . . . . . 54
102. Is a postpartum Pap test important? Is it necessary to do one even if the prenatal Pap was normal? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
103. How does HPV affect the neonate? . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
104. Should pregnant women with HPV be delivered by caesarean section? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
105. Does HPV infection affect the spontaneous abortion rate or increase morbidity during pregnancy? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
106. How is the follow-up of the HIV-positive woman different? Why? . . . 56
107. What surgical treatment modalities exist for the management of cervical neoplasia? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
108. What are the non-surgical options for treatment of cervical neoplasia? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
109. Do LEEP treatments affect future fertility and/or pregnancy outcome? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
110. How do you follow patients with cone biopsies that have margins positive for neoplasia? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
111. What is the current status of HPV vaccines? . . . . . . . . . . . . . . . . . . . 59
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112. Will the advent of an HPV vaccine affect cervical screening? What about colposcopy? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
113. What are the key issues in understanding the prophylactic vaccine and its relationship with cervical cancer? . . . . . . . . . . . . . . . . . . . . . . 61
114. Where is the prophylactic vaccine made and is it infectious? . . . . . . 62 115. What is the status of recommendations of the vaccine
in North America? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 116. Who should get the vaccine?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 117. What are the emergent questions regarding the implementation of an
HPV vaccine? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 118. Where can I get more detailed information on the prophylactic
vaccine and cervical cancer screening? . . . . . . . . . . . . . . . . . . . . . . . . 65 References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 Appendix A: Ontario Modified Bethesda System, 2001 (Revised Terminology) . . . . . . . . 109 Appendix B: Revised (2005) Ontario Cervical Screening Practice Guidelines . . . . . . . . . 114 Appendix C: Ontario Cervical Screening Reference Card . . . . . . . . . . . . . . . . . . . . . . . . . . 116 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
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