cervical dysplasia

Pap smear

Less Screening Urged for Some for Cervix Cancer 
By DENISE GRADY

The American Cancer Society has issued new guidelines for cervical cancer screening that will allow some women to skip Pap tests entirely or have them less often.

The new guidelines, published in the November-December issue of the cancer society's journal CA, were developed to help reduce the number of women who are screened needlessly and get falsely positive or ambiguous results that lead to costly, unneeded and nerve-racking invasive procedures. About 50 million women a year in the United States have Pap tests.

"Close to three million women get abnormal results every year," Dr. Saslow said, "and only 13,000 have cancer."

Extract from http://www.ama-assn.org/insight/spec_con/patient/pat050.htm

What to expect You lie on the exam table with your legs placed in holders called stirrups.   Your doctor will look at the vaginal area for any signs of infection or other problems.   A device called a speculum will be used to widen the vagina so that the doctor can see the cervix.   The doctor will use a long cotton swab to collect cell samples from your cervix.   During the rest of the pelvic exam, the doctor will then check your fallopian tubes, ovaries, and uterus by inserting two gloved fingers inside your vagina. He or she will use the other hand to feel outside over the lower abdomen for any lumps or tenderness. This only takes a few minutes.

All the following information has been taken (much of it verbatim) from a wonderful website called
Pathology Simplified at http://www.erinet.com/fnadoc/path.htm It is owned by a pathologist, Dr. Pat Connelly and will tell you everything about the Pap smear as well as the pathology of breast and lung cancer. It is illustrated with charts and photographs.

• an adequate sample  - need training and experience (30% error) 
• proper processing 
• cytotechnologist for screening -  a tedious and difficult job< 
• pathologist to examine abnormal slides to determine degree of abnormality 
• report to physician who must recognize the significance and usually confirm it with a biopsy 
• treatment for the condition 



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What is a "negative" pap smear? -
Pap smear abnormalities have been classified by multiple schemes since it's inception.

Dr. Papanicolau devised a five class system - I to V. It really didn't classify cancer precursor lesions but was designed to convey how sure the Pathologist was that cancer was or was not present. 

"Dysplasia" is a term that was suggested by Dr. Ober and promulgated by Dr. Reagan to describe "less than cancer" lesions. Dysplasia was divided into four grades of slight, moderate, and severe dysplasia with CIS (carcinoma-in-situ) the worst lesion. 

Dr. Richart introduced the term "cervical intraepithelial neoplasia (CIN)" to emphasize the changes are a continuum and the levels or degrees of abnormality were somewhat artificial. Also, the term CIS was a poor term as the word cancer was used but the behavior was nothing like invasive (killing) cancer, but instead, very similar to severe dysplasia.

The latest method is the Bethesda classification system which provides:

• statement of specimen adequacy 
• +general categorization - WNL (within normal limits) normal smear 

                                       or Benign cellular changes (thought NOT to be cancer precursor)
                                       or ECA (Epithelial cell abnormality) the real abnormal Pap smear
• +descriptive diagnosis 

Cancer precusor lesions are divided into two categories -  low grade (lgsil) and high grade (hgsil 
There are two additional descriptive categories. Squamous carcinoma for smears with cancer and ASCUS (atypical squamous cells of undetermined significance) for cells which are uncertain.


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It usually takes several years to progress from the initial lesion to invasive cancer, but not always 

Note Mch 1 01: extract from
http://bmj.com/cgi/content/abstract/322/7285/526?lookupType=volpage&vol=322&fp=526&view=short

Conclusions: NHS [British National Health Service] policy for reporting normal smears needs to change to make it a definite requirement that the reporting of a "normal smear result" is accompanied by a sentence stating that this means a low risk for having or developing cervical cancer in the next five years.

 NEW YORK (Reuters Health) - According to the report in the September [2001] issue of the American Journal of Obstetrics and Gynecology (news - web sites), there is a lack of consensus among obstetricians and gynecologists on how to manage women who are told they have two particular abnormalities in their Pap test results <snip>

    Current guidelines for managing ASCUS recommend that physicians repeat the Pap test every 4 to 6 months for 2 years.  A colposcopy, a procedure in which a doctor examines the cervix with a magnifying instrument and biopsies tissue if necessary, is recommended only if the condition is found more than once, the study notes.

  But the report found that 23% of doctors said they perform a colposcopy and 24% said they would repeat the Pap test within 3 months, for women whose Pap test revealed ASCUS for the first time.  The investigators also found variations in the way doctors managed patients with AGUS (atypical glandular cells of undetermined significance), a rare diagnosis that is more closely linked with cervical cancer.  Nearly one quarter (23%) said they would repeat the Pap test for women whose test showed the condition for the first time.  Only 25% of doctors said they would perform surgical excision for women with recurrent AGUS despite guidelines recommending colposcopy and removal of abnormal cells in all patients.

  ``Compared with published guidelines, practitioners undermanage patients with AGUS and overmanage patients with ASCUS,'' Dr. Karen Smith-McCune from the University of California, San Francisco, and her co-authors conclude.  ``These results are of particular concern, given the much higher rates of significant disease in patients with AGUS compared with ASCUS.''

A search on the web would lead me to believe that routine "pap" smears of the vagina after hysterectomy cannot really be justified - provided that the hysterectomy was not to treat cancer (Tishy)
http://www.nejm.org/content/1996/0335/0021/1559.asp

 
Background. Periodic, routine Papanicolaou smears of cells from the vagina are commonly examined in women who have undergone a hysterectomyfor benign gynecologic disease. The benefits of this method of screening are not known. 
<snip>
The probability of an abnormal Papanicolaou smear in this group of women was 1.1 percent, and the positive predictive value of the Papanicolaou test for detecting vaginal cancer was 0 percent (95 percent confidence interval, 0 to 33 percent). 
Conclusions. The prevalence of abnormal findings on cytopathological  examination of vaginal Papanicolaou smears after hysterectomy for benign gynecologic disease is extremely low. (N Engl J Med 1996;335:1559-62.) 


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http://text.nlm.nih.gov/cps/www/cps.15.html
Guide to Clinical Preventive Services

Women who have undergone a hysterectomy in which the cervix was removed do not benefit from Pap testing, unless it was performed because of cervical cancer. Post-hysterectomy screening has the potential to detect vaginal cancer, but the yield and predictive value are likely to be very low. Women who had hysterectomies performed in which the cervix was left behind probably still require screening. 


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NB "POEM" below refers to Patient Oriented Evidence that Matters . The site is intended for physicians 
http://www.infopoems.com/POEMs/JC039605.htm 
<major snip>
Recommendations for clinical practice 

The burden of proof for implementing a clinical policy for screening is evidence that an accurate test is able to detect disease in a way that leads to improved patient-oriented outcomes. Vaginal cytology for women who have undergone hysterectomy for benign pathology fails to meet this criteria. In this study vaginal cytologic examination resulted in abnormal test results in over 4% of women, potentially leading to more invasive testing, anxiety for the patient and increased cost, without documented benefit. The recommendations of the authors to decrease the frequency of vaginal cytologic screening to intervals of not less than 10 years for women without prior cervical abnormalities and every 5 years for women with antecedent cervical pathology is much more specific than current ACOG recommendations.
There is insufficient evidence to recommend routine vaginal smear screening in women after total hysterectomy for benign disease.

BMJ 1999;318:1246-1250 ( 8 May ) http://www.bmj.com/cgi/content/short/318/7193/1244
Effect of screening on cervical cancer mortality in England and Wales: analysis of trends with an age period cohort model
Peter Sasieni, senior scientist, Joanna Adams, scientific officer. 
Department of Mathematics, Statistics and Epidemiology, Imperial Cancer Research Fund, London WC2A 3PX

The number of women dying from cervical cancer in 1997 was 7% lower than in 1996 and has fallen by over 25% since 1992.1 Such rapid change must be at least partly due to cervical screening, although strong cohort effects have caused large fluctuations in cervical mortality in the past.2

Compared with women born in 1922, the risk for those born in 1957 is increased 1.5 times (95% confidence interval 1.2 to 1.9). The increased risk in women born since 1935 coincides with changing sexual behaviour associated with the "swinging '60s" and the widespread use of oral contraceptives in the early 1970s. 

 No significant trends occurred in mortality before the mid-1980s, but mortality subsequently fell progressively (and significantly). The reduction in relative risk was greatest in the youngest age groups and least in those aged over 70 years. 

Our analysis supports a beneficial effect of the national cervical screening programme (relaunched in 1988), which screens women aged 20-64. Before the relaunch screening had minimal effect on mortality. However, screening seems to have reduced cervical cancer mortality in 1997 by over 60% in those aged under 55. 

The estimated number of lives saved by screening (1300 in 1997) is lower than some have suggested but is in keeping with our case-control based estimate of 2300 cancers prevented (95% confidence interval 1100 to 3900).

If you are afraid, or have doubts about cervical smears please read and, er, digest.

In October 1997 I had a routine smear, a bit late. We only get them every 5 years in the UK. The result was: 'abnormal cells detected- call back in 6 months'. I did, thinking, 'oh they've made a mistake'. Same again and this time I was scared. My doctor took smears to eliminate any possible bacterial infections. I had one, it was treated. Fingers crossed, all would be OK. It was not and to cut a very long story short I had a colcoscopy today. OK, so you have to spread you legs and think of Antonio Banderas or whoever turns you on. A camera lens looks at your fanny, nothing more. The doctor uses Q-tip thingies. I watched on the monitor while the gyn/ob took samples and sprayed my cervix with dye. The picture turned into something which would have made money in the Tate or Gugenheim - the bad bits were black and the rest bronze. The bad bits were abnormal cells and would I like them treated now? YES. The doctor proceeded to inject me with local anaesthetic (straight into the cervix). I got to hold the hand of the nurse who reminded me of Uriah Heep. I babbled about a.s.m. and how wonderful it is. To be honest, I didn't feel much. Dental injections are worse.

I was 'earthed' and got to hold a tube to prevent the doctor from being gassed by the smell. The procedure is known as "Loop excision of the transformation zone". It involves looped wires on pen size applicators and cauterization

It took about 5 minutes. If the nurse and doctor had had an iota of humour I would not have noticed a thing. Then a huge tampon was inserted. I was told not to have sex or tampons for 6 weeks, that I might bleed for 6 weeks  and that smoking was the cause of all my problems,

Then I was told off because I didn't have someone to help me home.

And my message is?

If you can open your legs for sex, you can open them for smears. Get it done, get it treated if necessary.

And DO NOT FEEL GUILTY. 

Joanna
For an *impersonal* description visit http://www.parkviewmed.com/colposcopy.htm

Women may soon be able to take a vaccine to protect themselves against cervical cancer, one of the most common malignancies to affect women. 

Cervical cancer affects over 400 000 women a year worldwide and results in the death of 200 000 of them. It is caused by infections with oncogenic strains of the human papillomavirus. 

Human papillomavirus is sexually transmitted, and infections are common in both developing and developed countries. Up to 25% of sexually active young women in Canada and the United States are infected with it (Canadian Medical Association Journal 2000;163:503-8). 

<snip>

All forms of the vaccine were well tolerated, with the most common side effect being pain at the injection site. One subject had transient microscopic haematuria and one experienced a mild rise in liver function tests, which remitted. The work is considered promising, but it remains to be seen if such vaccines will protect against naturally acquired genital infections. Future vaccines will likely be constructed to protect against multiple oncogenic strains
 

Extracts fromhttp://www.ama-assn.org/sci-pubs/sci-news/1998/pres_rel.htm#joc81423
TESTING FOR HPV EFFECTIVELY DETECTS EARLY  CERVICAL CANCER
Procedure more effective than repeat Pap tests, eliminates  further testing for most at-risk women
    WASHINGTON, D.C. — DNA testing for the human papillomavirus (HPV), a sexually transmitted infection, may be more effective in detecting early cervical  cancer in women with abnormal Pap smears and eliminate additional screening  tests for a majority of high-risk women, according to an article in the May 5  issue of The Journal of the American Medical Association (JAMA), a theme issue on cancer. 

     M. Michele Manos, Ph.D., M.P.H., of the Kaiser Permanente Division of  Research in Oakland, and colleagues studied 995 women with abnormal Pap smear results of unknown origin (called atypical squamous cells of  undetermined significance, or ASCUS) from a total of 46,009 women undergoing  routine Pap screening and screening for HPV, which is associated with almost all cervical cancers. The researchers tried to determine whether DNA testing for  HPV is more effective in detecting disease that is potentially pre-cancerous  (known as high-grade squamous intraepithelial lesions, or HSILs) in women with ASCUS Pap results than performing a repeat Pap test. Only women who were positive for HPV would then be referred for colposcopy, a procedure that examines the cervix through a special magnifying instrument called a  colposcope. 
<snip>
     "Testing for HPV can clarify the nature of an equivocal Pap result," Dr. Cox    writes. "Although the HPV assay used by Manos et al was not able to detect all HSILs, the reassurance provided by a negative result was substantially higher than that provided by repeat Pap testing. … The use of HPV testing must be accompanied by full understanding of the usually benign nature of an HPV infection so that the diagnosis of low-grade SIL [squamous intraepithelial lesions] made on this basis is not unduly concerning." 
(JAMA. 1999;281:1645-1647)

HPV and CIN http://lib-sh.lsumc.edu/fammed/pted/hpvmid.html
HPV, or Human Papilloma Virus is commonly  called the wart virus. There are over 60 types of  HPV that have been identified. Other types, such as  16, 18, 31, 33, and 35 may not cause warts but  can cause changes to the cells of your vagina or  cervix, such as dysplasia. HPV is one of the most  frequent causes of cervical dysplasia. In addition, cigarette smoking has been found to be a cause.  Women who smoke concentrate the chemicals  nicotine and cotinine into their cervix, which harms  the cells. Men also concentrate these chemicals  into their genital secretions, and can bathe the cervix with these chemicals during intercourse.