Cervical cancer screening: Clinical sciences

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Introduction0:00–1:04

Cervical cancer screening is a preventive procedure that evaluates asymptomatic patients for cervical abnormalities, especially high-grade precancerous cells, or dysplasia, and invasive cervical cancer.
Screening decreases cervical cancer incidence and mortality rates and is associated with higher cure rates for invasive cervical cancer due to timely diagnosis.
Risk factors for cervical cancer include previous treatment of a high-grade precancerous lesion, HIV infection, and a compromised immune system.
Additionally, high-risk HPV, or human papillomavirus, is associated with nearly all cases of cervical cancer. Guidelines for screening combine a patient’s current test results with their screening history to direct clinical decision-making, with consideration for the patient’s immunocompetence, presence of a cervix, and age.Your first step in assessing a patient who presents for cervical cancer screening is to obtain a focused history and physical exam.

History & Physical1:04–2:17

Knowing which screening test to perform and how often to perform it depends on a number of factors, including patient age, previous screening interval, results of past screening and treatment if available, whether the patient has had a hysterectomy, and their immune status, specifically whether they are HIV positive or currently take immunosuppressive medications.Because cervical cancer screening is only appropriate for asymptomatic patients, the history should be negative for any abnormal uterine or vaginal bleeding.
On the other hand, the physical exam includes a speculum examination to visualize the cervix, which should appear normal.
If the patient has had a hysterectomy with removal of the cervix, inspect the vaginal cuff, which should appear normal as well.
Here’s a clinical pearl! Any grossly visible abnormal lesions on the cervix should have a targeted biopsy for assessment.Your next step is to assess the patient’s immunocompetence.

Immunocompetent2:17–2:49

Most patients who undergo cervical cancer screening have a normally functioning immune system. For screening purposes, this means that your patient has a negative HIV status and does not currently take immunosuppressive medications for conditions such as inflammatory bowel disease, rheumatologic disease, organ transplant, or lupus.
If your patient is immunocompetent, you should then assess whether the cervix is present. Immunocompetent patients who have a cervix will undergo cervical cancer screening based on age.

Cervix is present2:49–3:26

Initiate screening at the age of 21. Patients between the ages of 21 and 24 are considered to be a special population for screening because of their low risk of cervical cancer, even with a high rate of HPV infection.
The recommended cervical cancer screening for this age group is cytology alone every 3 years to reduce false positives from the presence of a transient HPV infection.

Age 25-65 years3:26–5:49

Now the next age group, which is 25 to 65 years, is when most cervical abnormalities are identified. The first step for screening in this population is to calculate the patient’s immediate risk for having CIN3+, defined as cervical intraepithelial neoplasia 3 plus worse findings, such as adenocarcinoma in situ, or AIS, and invasive cervical cancer.
The patient’s immediate risk of having CIN3+ is based on their previous screening tests and any biopsy results. You can calculate the risk level by using published tables or inputting the patient’s information into the available smartphone app or web application from the American Society for Colposcopy and Cervical Pathology, or ASCCP, website.
Here are a few high-yield facts! Let’s take a moment to distinguish between the SIL classification compared to the CIN classifications.
SIL stands for squamous intraepithelial lesions, and refers to cytologic abnormalities, which are screening results. On the other hand, the CIN stands for cervical intraepithelial neoplasia, and refers to histological findings based on colposcopic biopsy results, and is considered diagnostic and prognostic.
While the risk of CIN can be predicted based on the SIL designation, only the CIN histology result is diagnostic of the actual dysplasia present.Now, CIN is a precancerous condition of the cervix that can be low grade, such as CIN1, or high grade, such as CIN2 or CIN3.
CIN1 refers to atypical cellular changes in the lower one-third of the cervical epithelium. CIN2 represents moderately atypical cellular changes confined to the basal two-thirds of the epithelium, while CIN3 describes severely atypical cellular changes encompassing more than two-thirds of the epithelial thickness, including full-thickness lesions.
Low-grade cervical lesions, or CIN1, are much less likely to progress to cervical cancer than high-grade lesions unless high-risk HPV is also present.Patients with an immediate CIN3+ risk of less than 4% are then stratified based on their 5-year CIN3+ risk, which is also calculated using the ASCCP website or smartphone app.

CIN3+ risk less than 4%5:49–8:17

If the 5-year CIN3+ risk is less than 0.15%, the patient should undergo routine cervical cancer screening. Patients with a CIN3+ risk of less than 0.15%, with a negative history of abnormal screening, may undergo cytology alone every 3 years; or HPV-based testing every 5 years, which could be high-risk HPV testing alone, or a cotest if the patient is age 30 years or greater.
Patients with a positive history of abnormal screening should undergo HPV-based testing every 5 years instead of cytology alone.
This is because HPV-based testing is more effective than cytology at long-term risk prediction for CIN3+. If the 5-year CIN3+ risk is between 0.15 and 0.54%, the patient should undergo 3-year surveillance with HPV-based testing.
Lastly, if the 5-year CIN3+ risk is between 0.55 and 3.99%, the patient should undergo 1-year surveillance, again with HPV-based testing.
Time for a clinical pearl! A Pap test, also called a Pap smear, is a method of cervical cancer screening that uses cytologic methods to look for abnormal cells, while an HPV test is a cervical cancer screening tool that looks specifically for the human papillomavirus.
Current methods of cervical cancer screening include pap testing alone, often called cytology; cotesting, which combines the pap test with an HPV test; and a more recent method of high-risk HPV testing alone without a pap test, which can be used in certain populations.
So, when performing HPV-based testing, you could either perform a co-test, or just a high-risk HPV test, depending on the clinical situation and availability of resources in your area.
For those patients who have an immediate CIN3+ risk calculated at 4% or greater, you should consider colposcopy or expedited excisional treatment.

CIN3+ risk 4% or greater8:17–8:52

Here’s another clinical pearl! Cervical cancer screening of patients who are pregnant is similar to screening of patients who are not pregnant.
Additionally, colposcopy is safe to perform during pregnancy, but performing an endocervical curettage, an endometrial biopsy, and treatment without a biopsy are unacceptable.

Age older than 658:52–9:25

Okay, our last age group includes individuals older than 65 years. These patients require no further screening once they have had adequate negative screening results.
Adequate negative results mean either 3 consecutive negative cytology results, 2 consecutive negative high-risk HPV test results, or 2 consecutive negative co-testing results within 10 years before stopping screening, with the most recent test being up to date within the recommended screening interval.

Cervix is absent9:25–11:00

Now let’s take a step back and talk about immunocompetent patients who have an absent cervix after hysterectomy. First, assess the patient’s indication for hysterectomy.
If the hysterectomy was performed for a benign condition, for example due to leiomyomata, and not for uterine or cervical cancer, further assess the patient’s history of CIN2, CIN3, or AIS.
If the history is negative for CIN2, CIN3, or AIS in the past 25 years, no further screening is required. However, if the patient had high-grade dysplasia greater than 25 years ago, continued 3-year surveillance is considered acceptable if the patient’s life expectancy and ability to be screened are not significantly compromised by serious health issues.
If the history is positive for CIN2, CIN3, or AIS in the past 25 years, continue 3-year surveillance with HPV-based testing for a total of 25 years from the time of initial treatment.For patients who undergo hysterectomy to treat CIN2, CIN3, or AIS, you should perform 3 consecutive annual HPV-based tests followed by 3-year surveillance with HPV-based testing for 25 years following the hysterectomy.
Of course, if testing is ever abnormal, recalculate the CIN3+ risk and follow recommendations for further evaluation and treatment.
Finally, let’s talk about cervical cancer screening for a patient who is immunocompromised. This is someone who is HIV positive or who currently takes immunosuppressive medications for a chronic illness.

Immunocompromised11:00–11:39

Begin screening within one year of insertional sexual activity and continue for the patient’s lifetime. Patients who are under the age of 30 years should undergo annual cytology alone for the first three years, followed by cytology every 3 years afterward.
Once the patient reaches 30 years of age, perform cytology alone or co-testing every three years. Alright, as a quick recap… The way you do cervical cancer screening varies based on the patient's age, screening history, presence of a cervix, and immune status.

Review11:39–12:10

For immunocompetent patients with a cervix present, you need to apply age-based screening. If the cervix is absent, you’ll need to find out why they had a hysterectomy so you know how to proceed.
Finally, the screening method for immunocompromised patients is also