Screening for Cervical Cancer



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Best Practices for Prevention in SBHCs

Louisiana's Preventive Services Improvement Initiative

Screening for Cervical Cancer




BACKGROUND

Cervical cancer mortality in the United states has decreased over the last five decades by over 70 percent in large part attributable to the introduction of the Papanicolaou (Pap) test. Cervical cancer, once the number one cancer killer of women, now ranks 13th in cancer deaths for women in the United States. When cervical cancer is detected early, the five-year survival rate is approximately 92 percent.” 1 The purpose of Pap testing is both to detect cervical cancer at an early stage and also to detect and remove high-grade lesions and thus prevent potential progression to cervical cancer.



AGE OF INITIATION

There is limited data on when is the optimal time to initiate cervical cancer screening (Pap smears). American College of Obstetrics and Gynecology (ACOG) 2012 revised recommendations are:


  • Women ages 21–29 should now receive cervical cancer screening once every three years instead of once every two years. Screening using either the conventional Pap or the liquid-based method is acceptable. Women younger than 30, however, should not be screened with co-testing with HPV testing.

  • Women age 30 to 65 who have had negative cervical cytology test results, the preferred screening strategy is now co-testing with the Pap test (using the conventional Pap or liquid-based method) combined with HPV testing once every five years. A Pap test alone (without HPV co-testing) once every three years is acceptable for women in this age group if HPV testing is not available.

  • Women with certain risk factors may need more frequent screening, including those who have HIV, are immunosuppressed, were exposed to diethylstilbestrol (DES) in utero, and have been treated for cervical intraepithelial neoplasia (CIN) 2, CIN 3, or cervical cancer.

Moving the baseline cervical screening to age 21 is a conservative approach to avoid unnecessary treatment of adolescents which can have economic, emotional, and future childbearing implications. ACOG previously recommended that cervical screening begin three years after first sexual intercourse or by age 21, whichever occurred first. Although the rate of HPV infection is high among sexually active adolescents, invasive cervical cancer is very rare in women under age 21. The immune system clears the HPV infection within one to two years among most adolescent women. Because the adolescent cervix is immature, there is a higher incidence of HPV-related precancerous lesions (called dysplasia). However, the large majority of cervical dysplasias in adolescents resolve on their own without treatment.

With the new screening recommendations, cervical cytology will not be obtained in most women younger than 21 years. An adolescent with a history of normal cytologic screening in the past should not be rescreened until age 21 years. If an adolescent has had a Pap test result of atypical squamous cells of undetermined significance (ASC-US) or low-grade squamous intraepithelial lesions (LSIL), or cervical intraepithelial neoplasia (CIN) 1 histology in the past, but has had two subsequent normal Pap test results, rescreening can be delayed until age 21 years. For adolescents with high-grade squamous intraepithelial lesions (HSIL); atypical squamous cells, cannot exclude HSIL (ASC-H); or CIN 2 or more severe, the current management guidelines detailed in this Committee Opinion should be followed. Once regression is established based on current criteria, rescreening can be delayed until 21 years of age. Annual cytologic screening also can be considered.

It is recommended that adolescents with human immunodeficiency virus (HIV) have cervical cytology screening twice in the first year after diagnosis and annually thereafter (6). Guidelines for treatment of cervical cytologic abnormalities in individuals with HIV infection can be obtained at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5804a1.htm. Sexually active immunocompromised adolescents, including those who have received an organ transplant or those with long-term steroid use, should undergo screening after the onset of sexual activity and not wait until 21 years of age. This screening should include Pap tests at 6-month intervals during the first year of screening and then annual Pap tests thereafter.
FREQUENCY

Every three years using conventional or liquid-based Pap tests according to the American Cancer Society (ACS). If the SBHC is unable to provide cervical cancer screening (Pap smears), the student should be referred for such services. SBHCs wanting to perform Pap smears onsite will need to make their own arrangements with an outside lab. As of July 1, 2008, OPH will no longer be able to pay for the cost of processing Pap smears collected in SBHCs. OPH encourages SBHCs to work closely with their local Parish Health Unit to determine how best to assure that students receive reproductive health services, including Pap smears, if indicated. Parish Health Units (PHU) will make every effort to see students that are referred by SBHCs promptly.


SPECIMEN COLLECTION


  • Cells should be collected before the bimanual exam

  • Avoid contaminating the sample with lubricant.

  • If testing for STDs is indicated, cell collection for cervical cytology should be undertaken first.

  • Ideally, the entire portio of the cervix should be visible when the sample is obtained.

  • Routine swabbing of the cervix prior to pap collection may result in cytologic samples of scant cellularity. This should be done only if there is excessive cervical mucus or discharge.


For conventional Pap tests:


First, label the slide with the patient's name and identification number. Using a speculum, the cervix is visualized, and a plastic or wooden spatula is used to scrape the zone of transformation. The spatula is then wiped on a clean glass slide. Before the cells dry, it is important to spray a fixative, either ether or alcohol. Next, a second specimen is taken from the endocervical canal using a cytobrush. It is important to rotate the spatula and cytobrush 360 degrees to ensure that the entire surface has been sampled. With the cytobrush, cells are then transferred onto the slide, and fixative is sprayed again onto the slide. The slide is then sent for cytologic evaluation.
For Liquid-Based/Thin Prep Pap tests:

For the liquid-based or Thin Prep® PAP test, after the sample is collected on the collecting device, instead of transferring it onto a slide, it is submerged into a vial of liquid fixative. The vial is then capped and sent to the laboratory.



DIAGNOSIS


Cytological analysis at qualified laboratory.

REFERRAL


It is critical that the SBHCs have referral systems in place before implementing cervical cancer screening (Pap smears) in the SBHCs. Specialists must be available to see students in referral for follow-up of abnormal Pap smears (colposcopy) when indicated. If a Pap smear is abnormal, then the patient should be referred for further evaluation and treatment according to the policy established for the handling of abnormal Pap smears by the SBHC. The policy should include a statement that a certified letter will be sent to notify a patient of abnormal results if the student is no longer attending the school and is unreachable by phone. A copy of the certified letter should be kept in the chart.

HEALTH EDUCATION


Teens should be educated that a pelvic exam does not equate to a Pap smear and that even if a Pap smear is not recommended at their age, sexually active females do need regular health care visits, including gynecologic care, and STD screening and prevention. This includes providing information on preventing vaginal infections and STDs.

REFERENCES

  • 1Saslow D, Runowicz CD, Solomon D, Moscicki AB, Smith RA, Eyre HJ, Cohen C; American Cancer Society. American Cancer Society guideline for the early detection of cervical neoplasia and cancer. CA Cancer J Clin. 2002 Nov-Dec; 52(6):342-62




  • Screening for Cervical Cancer, Topic Page. March 2012. U.S. Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspscerv.htm May 2012




  • ACOG Announces New Pap Smear and Cancer Screening Guidelines http://www.acog.org/~/media/Districts/District%20II/PDFs/USPSTF_Cervical_Ca_Screening_Guidelines.pdf?dmc=1&ts=20130626T1641534332 2012







  • Barbara S. Apgar, MD, MS; Anne L. Kittendorf, MD; Catherine M. Bettcher, MD; Jean Wong, MD; and Amanda J. Kaufman, MD; University of Michigan Medical Center. Update on ASCCP consensus guidelines for abnormal cervical screening tests and cervical histology. American Family Physician. 2009 July 15; 80(2): 147-155 www.aafp.org/afp




  • U.S. Preventive Services Task Force. Screening for Cervical Cancer: Recommendations and Rationale. AHRQ Publication No. 03-515A. January 2003. Agency for Healthcare Research and 7Quality, Rockville, MD. http://www.ahrq.gov/clinic/3rduspstf/cervcan/cervcanrr.htm




  • American Congress of Obstetricians and Gynecologists. Ob-Gyns Recommend Women Wait 3 to 5 Years Between Pap Tests. http://www.acog.org/About_ACOG/News_Room/News_Releases/2012/Ob-Gyns_Recommend_Women_Wait_3_to_5_Years_Between_Pap_Tests


Reviewed annually

Last revised July 1, 2013

Last reviewed July 1, 2014

7/1/2014




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