Cervical cancer screening - Dr. Sharafuddin - Gynecologist, Rasht

Cervical cancer screening - Dr. Sharafuddin - Gynecologist, Rasht

Dr. Behnaz Sharafuddin
Dr. Behnaz Sharafuddin
Rasht
+98 13 33 755 315

cervical cancer screening

by website of Dr. Behnaz Sharafuddin, specialist in gynecology, childbirth and infertility | March 26, 1403

Cervical cancer is one of the most common cancers among women, but fortunately it can be prevented or detected and treated in the early stages with screening methods. Cervical cancer screening includes tests that check for abnormal changes in cervical cells so that timely treatment can be performed if necessary. This process significantly reduces the risk of cancer and contributes to women's long-term health. In this article, we examine the importance of screening, available methods, and the reasons why doctors recommend it regularly.

Cervical cancer screening recommendations in the United States are based on systematic evidence reviews by major medical and advocacy organizations such as the United States Preventive Services Task Force (USPSTF), the American Cancer Society (ACS), and the American College of Obstetricians and Gynecologists (ACOG). Over time, a general coordination between these organizations has been established regarding the start and end of screening and the time intervals of its performance. Although there are no single guidelines to fully guide screening in the United States, the Affordable Care Act (ACA) requires that Medicaid and new private health insurance plans cover USPSTF grade A or B preventive services, including cervical cancer screening. They do not have a history of cervical cancer or high-grade precancerous lesions. • They are not currently under close follow-up for a recent abnormal result. • They are not immunocompromised (such as those with HIV). Include conventional or liquid-based cytology (Pap smear) tests.• For people over 30 years of age, approved HPV tests can be used to detect high-risk types of human papillomavirus (HPV).

Recommended screening intervals

1. 21 to 29 years old: Cytology test (Pap smear) is recommended every 3 years. 2. 30 to 65 years of age: There are three options: • Cytology every 3 years. • HPV testing alone every 5 years. • Combined testing (cytology and HPV) every 5 years. After complete removal of the uterus (hysterectomy with removal of the cervix), screening is only necessary if there is a history of cervical intraepithelial neoplasia (CIN 2 or higher) or adenocarcinoma in situ in the past 20 years. If the cervix remains after the hysterectomy (supraservical hysterectomy), Pap tests should be performed as scheduled. For those with muco-purulent discharge, cytology after Clean the secretions with a cotton swab dipped in saline. • The presence of external genital warts alone does not require repeated screening. • To collect more accurate cytology samples, it is recommended to use tools such as a cytobrush. • In case of abnormal results: manage according to published guidelines. • After an abnormal result, HPV testing or a combined test (HPV and cytology) is preferable to cytology testing alone. • Health care providers should counsel patients about abnormal results. Screening should be done for all people who have a cervix, regardless of their sexual orientation or gender identity (eg, gay, bisexual, or transgender people). Cervical cancer and reduce the incidence and mortality of this disease.

Counseling

People may think that a cytology (Pap smear) or HPV test is investigating conditions other than cervical cancer or may be confused by abnormal results. Healthcare providers, recognized as reliable sources of information about HPV infections and abnormal test results, play an important role in educating patients about HPV and modulating the psychosocial effects of abnormal results. Counseling should include an explanation of the risks, uncertainties, and benefits of screening.

Psychological Effects of Abnormal Results

Abnormal cytology results or a positive HPV test can lead to short-term anxiety, stress, fear, and confusion. This condition may reduce the patient's ability to understand and remember information and create an obstacle to follow-up care. Also, a positive HPV test result can create concerns about the sexual partner, anxiety about disclosure, and feelings of guilt, anger, and social stigma.

Counseling Approaches for HPV Positive • Neutral and non-stigmatizing presentation: Providers should explain the positive HPV result in a non-stigmatizing and neutral context and emphasize the common, asymptomatic, and transient nature of HPV infection. • Sharing between partners: Emphasize that HPV infection is commonly shared between partners and that the exact source of the infection often cannot be determined. • Delayed reaction: Explain that an HPV test may become positive years after initial exposure, due to reactivation of latent infection in both sexual partners (male and female). • Health of the male partner: Having an HPV infection should not cause concern about the health of the male partner.

Effective communication about the results

Providers should clearly explain the meaning of cytology and HPV test results to patients and provide necessary information about the next steps of screening or follow-up.

Counseling about smoking • Smoking screening: Providers should screen patients for smoking and offer smoking cessation counseling. • Effect of smoking on the progression of CIN: Explain that smoking (active or passive) can contribute to the progression of cervical intraepithelial neoplasia (CIN). Smoking is also associated with cervical squamous cell cancer in women with HPV type 16 or 18 infection.

Purpose of Counseling

Effective counseling can help reduce anxiety, increase patient awareness, improve follow-up care and prevent misunderstandings, and empower patients to manage their conditions.

Promote cervical cancer screening

Clinics can use evidence-based interventions. Use the guidelines of the Community Preventive Services Task Force to promote cervical cancer screening in their communities. Full resources for these interventions are available at the following link: Community Preventive Services Task Force Guidelines.

Increasing community demand for screening

Implementing interventions that increase community demand for screening can improve screening coverage. These interventions include: • Reminding patients: sending reminder messages about screening time. • Motivating patients: providing financial or non-financial incentives to encourage people to perform screening. • Education: holding educational group meetings or one-on-one consultations to increase awareness. • Media: using local media to inform about the importance of screening.

Increasing community access to screening

Interventions that increase access Facilitate screening, including: • reducing structural barriers: such as simplifying the process of going to clinics or expanding the working hours of screening centers. • reducing costs: reducing costs related to screening for patients through support programs or insurance. These include: • Evaluation and feedback: reviewing doctors' performance and providing feedback to them. • Providing incentives: such as financial or professional incentives for doctors and treatment staff. • Reminding doctors: sending reminders to doctors to screen patients.

Educational resources

Print and online materials to promote awareness about cervical cancer screening are available at the following links: • CDC: Cervical Cancer Screening • CDC: HPV Facts and Brochures

Role of Patient Guides

Patient guides can play an effective role in improving screening and follow-up of abnormal results. They can inform patients about the timing of screening, the necessary steps after abnormal results, and the importance of continuing care and help to remove the existing barriers.

Conclusion

The implementation of these multifaceted interventions, including increasing the awareness and access of the community to screening services and improving the provision of these services by the treatment staff, can effectively increase the coverage of cervical cancer screening and the health outcomes related to this. improve the disease.

Key messages about cervical cancer screening

When counseling patients about cervical cancer screening, service providers should mention the following points: • Prevention of cervical cancer: Cervical cancer can be prevented by regular screening tests such as Pap smear (cytology) and HPV testing. People at moderate risk should start having cytology tests starting at age 21. • Role of screening tests: • Cytology test: This test can identify abnormal cervical cells that may turn into cancer over time. • HPV test: This test detects the presence of HPV infection in the cervix and can be used alone or at the same time as a cytology test (as cotesting) for people 30 Used up to 65 years of age. • Reflex HPV test: For people over 25 years of age whose cytology results are reported as abnormal squamous cells of undetermined origin (ASC-US), HPV testing is used as a follow-up. • Importance of positive results in screening: Positive results of cytology and HPV tests indicate cervical precancerous lesions that are usually asymptomatic until they become invasive. Appropriate follow-up is necessary to prevent the occurrence of cervical cancer. • Characteristics of HPV infection: HPV infection is a common infection that is often controlled by the body without the need for medical intervention. A positive HPV test does not mean cancer. Tips for HPV infection between partners: HPV infection is usually shared between partners, and its exact source often cannot be determined. HPV testing may be positive years after initial exposure due to reactivation of latent infection in both partners (men and women).

These messages can help patients better understand the importance of screening, test results, and post-screening actions, and reduce anxiety. and be misunderstood.

Sexual partner management

The benefit of informing current and future partners about a positive HPV test result is unclear. But the following messages can be useful in counseling sexual partners: • No need for HPV testing for partners: Sexual partners do not need to be tested for HPV. • Transmission of HPV between partners: HPV infection is usually shared between partners. Therefore, the sexual partners of a person with HPV are also likely to have HPV infection. • Screening of female partners: Female partners of men who have previously been in contact with a woman with HPV should be examined according to the screening intervals of women at moderate risk. There is no evidence that more frequent screening is beneficial. • Condom use: Correct and consistent condom use may reduce the risk of HPV infection and help shorten the time it takes for the infection to clear in people with HPV infection. However:• HPV can infect areas of the body not covered by condoms.• Therefore, condoms may not completely protect against HPV infection.

Additional messages: In addition to these messages, counseling for people with HPV (in the Counseling section) can also be helpful for partners.

Recommendations for screening in specific populations

Pregnancy• Pregnant women should Be screened at the same time intervals as recommended for non-pregnant people. Instruments such as swabs, Ayre spatulas, or cytobrushes can be used to collect samples for cytology testing during pregnancy. 1 year after starting sexual activity, but no later than 21 years of age.

• Screening in sexually active people with HIV:

• Screening should be done at the time of initial HIV diagnosis.

• Screening methods:

• Use traditional or liquid cytology (Pap smear test).

• Primary HPV testing is not recommended for people with HIV.

• HIV-positive people over 30 years of age, cotesting (cytology and HPV) can be performed.

• Screening intervals:

• Annual screening is recommended for people with HIV.

• After 3 years of consecutive normal results in cytology or cotesting, the screening interval can be increased to every 3 years.

• Lifelong screening for people with HIV is essential.

Additional guidance:

Providers should refer to the Guide to Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV for additional guidance on cervical cancer screening and management of results in these individuals.

Adolescent Screening

• High prevalence of HPV infection in adolescents younger than 21 years: HPV infections and squamous intraepithelial lesions The resulting SILs are more likely to recur spontaneously in adolescents than in older adults. For this reason, cervical cancer screening and HPV testing are not recommended for immune (non-immunocompromised) adolescents.

• This screening is necessary because of the high rate of development of abnormal cytology in adolescents with HIV.

HPV tests for cervical cancer screening

HPV clinical tests are used for the following purposes:

1. Cervical cancer screening as an initial test. 2. along with cytology test for cervical cancer screening.

3. Examining specific abnormal cytology lesions.

4. Follow up of abnormal screening results.

5. Follow-up after colposcopy in which CIN 2 or CIN 3 is not detected.

6. Follow-up after treatment of cervical precancers.

Important notes about HPV tests:

• These tests are only FDA-approved for cervical specimens and should not be used for oral or rectal specimens.• Testing is not recommended for low-risk (non-cancerous) HPV types such as types 6 and 11.

FDA-approved tests

• Cobas 4800 HPV test and Onclarity HPV test:

• They have the ability to detect 14 types of cancer-causing HPV (including types 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, and 68).• They can also detect types 16 and 18 separately.

• These tests are approved for primary screening for cervical cancer.

• Other HPV tests (such as Hybrid Capture 2, Cervista, and APTIMA):

• Approved for use in conjunction with a cytology test or to evaluate certain abnormal cytology results.

• These tests should not be used for primary HPV screening.

Not recommended situations For HPV testing:

1. Deciding on HPV vaccination. 2. Testing for low-risk types of HPV (such as 6 and 11).

3. Providing care to people with genital warts or their partners. 4. Testing in people under 25 years of age as part of routine cervical cancer screening. 5. Testing of oral or rectal specimens.

Automated sample collection for HPV testing

• Unlike cytology, HPV samples can be collected by the patient themselves and sent to healthcare facilities for analysis.

• Automated sample collection may be a way to increase screening rates in populations where screening rates are low.

• However, this method has not been approved by the FDA and is not approved by the FDA. It is not recommended by the United States Medical Organizations.

Follow-up of Abnormal Cytology (Pap) and HPV Test Results

Risk-based management guidelines (ASCCP 2019) for abnormal screening test results for cervical cancer and precancers provide actions based on patient risk data and clinical action thresholds. These guidelines are based on the risk of developing CIN 3 (not just test results).

Key points of the new management guidelines:

1. Referral to colposcopy may be delayed for low-risk patients:

• If the test is mildly abnormal (eg, HPV positive without malignant epithelial lesion, ASC-US HPV positive, or LSIL HPV positive) and there has been a negative HPV screening test or cotest in the past 5 years, follow-up in 1 year is recommended instead of colposcopy.

• Referral to colposcopy is recommended if In the 1-year follow-up, cytology test results are abnormal or HPV positive.

2. Prompt treatment for high-risk patients:

• If cytology is HSIL and HPV testing is positive for type 16, LEEP (loop electrosurgical excision) is preferred. Colposcopy and biopsy are not required to confirm the diagnosis.

• If the patient has not been screened or rarely screened (more than 5 years have passed since the previous screening) and the result of HSIL cytology is HPV positive (regardless of the type), treatment with LEEP is preferred.

3. Cytology test for positive HPV initial tests:

• If initial screening with HPV has been performed and the result is HPV positive, cytology is recommended to determine the next steps of management.

• If the HPV genotype is positive for types 16 or 18, colposcopy is recommended.

4. Management of HPV types 16 and 18:

• HPV 16: highest risk and prompt treatment should be considered for HSIL results. Colposcopy is recommended for all other cases.

• HPV 18: Highly associated with cancer (especially adenocarcinoma). Colposcopy is recommended even if the cytology test is normal, and endocervical sampling is also acceptable.

5. Preference for HPV or cotesting for follow-up:

• HPV test or cotesting is more accurate than cytology alone in following up abnormal results. • In cases where HPV or cotesting is recommended for follow-up (every 3 years), cytology is performed only annually. Follow-up after treatment of high-grade precancerous lesions (moderate or severe dysplasia):

• Initial tests include HPV or cotesting at 6, 18, and 30 months.

• For long-term monitoring, tests are performed every 3 years. 7. Surveillance for at least 25 years after treatment: • Surveillance continues even if the patient is over 65 years of age.

• In case of hysterectomy, vaginal screening should continue.

Digital management tools:

• Use of electronic applications or websites such as ASCCP can help make these guidelines easier to apply.

In-clinic services for patients with access Limited:

• Clinics where access to follow-up services may be difficult may be better off providing in-clinic colposcopy and biopsy services.

Follow-up of abnormal cytology (Pap) and HPV test results

The 2019 ASCCP guideline provides risk-based management for abnormal results of screening tests for cervical cancer and precancers. These guidelines are designed based on the risk of CIN 3 (cervical intraepithelial neoplasia grade 3) to determine appropriate interventions.

Key points of the management guidelines:

1. Postponement of colposcopy for low-risk patients:

• If the test results are at least abnormal (for example: HPV positive without malignant lesion, ASC-US HPV positive, LSIL HPV positive) and there is a negative HPV or cotest in the last 5 years, follow-up in one year is recommended instead of colposcopy.

• If the cytology results at the one-year follow-up are abnormal or HPV positive, referral to colposcopy is recommended. It will be.

2. Rapid treatment for high-risk patients:

• If HSIL (high-grade intraepithelial lesion) and HPV type 16 are positive, LEEP (electrosurgical loop lesion removal) is recommended instead of colposcopy with biopsy.

• If the patient has not been screened for more than 5 years and the cytology result of HSIL is positive with HPV, treatment with LEEP is preferred.

• Shared decision making with the patient is recommended, especially in the absence of a confirmatory biopsy. Concerns related to cancer, the effects of treatment on future pregnancies and the possibility of follow-up should be investigated.

3. Follow-up of positive HPV tests:

• For all positive HPV results, a cytology test is necessary to determine the next step.

• If HPV is positive for type 16 or 18, colposcopy is recommended.

• For positive HPV other than type 16 and 18, if the cytology test is normal, a follow-up in one year is recommended.

4. The priority of HPV or cotesting over cytology alone:

• HPV or cotesting is more accurate than cytology alone in identifying the disease.

• If HPV or cotesting is recommended at 3-year intervals, annual cytology is sufficient.

5. Surveillance after treatment of precancerous lesions:

• Duration of surveillance: At least 25 years after treatment, even if the patient's age exceeds 65 years.

• Initial testing: HPV or cotesting at months 6, 18, and 30.

• Long-term surveillance: Every 3 years for HPV or cotesting, and annually for Cytology.

6. Vaginal screening after hysterectomy:

• Vaginal screening should continue if the patient undergoes a hysterectomy during surveillance.

Suggestions for clinics:

• Clinics where patients may have poor adherence to follow-ups should provide colposcopy and internal biopsy services to ensure access to appropriate care.

Assistive technologies:

• Electronic tools, including ASCCP apps and websites,

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