3. Epidemiology
Cancer of the uterine cervix is the third most
common gynecologic cancer diagnosis and cause
of death among gynecologic cancers in the
United States .
Unfortunately, in countries that don’t have access
to cervical cancer screening , it remains the
second most common type of cancer (17.8 per
100,000) and cause of cancer deaths (9.8 per
100,000) among all types of cancer in women.
4. Human papillomavirus (HPV) is central to the
development of cervical neoplasia and can be
detected in 99.7 percent of cervical cancers.
The most common histologic types of cervical
cancer are squamous cell (69 percent of cervical
cancers) and adenocarcinoma (25 percent)
Globally, cervical cancer accounted for an
estimated 530,000 new cancer cases worldwide
and for 275,000 deaths in 2008.
Eighty-six percent of new cervical cancer cases
will be seen in developing countries and mortality
rate is 52% worldwide.
5. Global incidence and mortality rates depend upon
the presence of screening programs for cervical
precancer and cancer and of human
papillomavirus (HPV) vaccination, which are most
likely to be available in developed countries. Due
to these interventions, there has been a 75
percent decrease in the incidence and mortality of
cervical cancer over the past 50 years in
developed countries
6. Risk factors
Early onset of sexual activity – Compared with age at first intercourse of
21 years or older, the risk is approximately 1.5-fold for 18 to 20 years
and twofold for younger than 18 years
Multiple sexual partners – Compared with one partner, the risk is
approximately twofold with two partners and threefold with six or more
partners
A high-risk sexual partner (eg, a partner with multiple sexual partners or
known HPV infection)
History of sexually transmitted infections (eg, Chlamydia trachomatis,
genital herpes)
History of vulvar or vaginal squamous intraepithelial neoplasia or cancer
(HPV infection is also the etiology of most cases of these conditions)
Immunosuppression (eg, human immunodeficiency virus infection)
Cervical cancer is less common in sexual partners of circumcised males
Low socioeconomic status is associated with an increased risk of
cervical cancer
Oral contraceptive use has been reported to be associated with an
increased risk of cervical cancer.
7. HPV
More than 150 types
of HPV are
acknowledged to exist
(some sources
indicate more than
200 subtypes).
Types 16and 18 are
generally
acknowledged to
cause about 70% of
cervical cancer cases.
Together with type
31, they are the prime
risk factors for cervical
cancer
High risk
16, 18, 31, 33, 35, 39,
45, 51, 52, 56, 58, 59,
68, 73, and 82
Probable high risk
26, 53, and 66
Low risk
6, 11, 40, 42, 43, 44,
54, 61, 70, 72, 81,
and CP6108
8. HPV INFECTION
HPV is spread through genital skin contact during
sex. The virus passes through tiny breaks in the
skin. HPV is not spread through blood or other
body fluid.
Condoms offer limited protection as they do not
cover all of the genital skin.
Warts on any other parts of the body rarely
spread to the genital area.
Blood- debatable
After it enters the body, HPV behaves in one of
two ways:
• it can stay dormant (inside the body’s cells)
• it can become active.
9. BENEFITS OF SCREENING:
Cervical cancer screening detects precancerous
lesions and early-stage disease, the treatment of
which decreases the incidence of cervical cancer
and cervical cancer mortality, respectively.
The United States adopted screening with the
Pap test in the 1950s and by the mid-1980s
cervical cancer incidence decreased by 70
percent
11. Discontinuing screening :
— The age to discontinue screening in older women
depends on whether or not they have received adequate
prior screening.
Adequate prior screening — In general, we
suggest not screening women aged 65 years and older
provided they meet the following criteria:
No increased risk (ie, history of abnormal screening,
current smoker or history of smoking, unknown screening
history, previous HPV-related disease, new partners,
immunocompromised, in utero diethylstilbestrol
exposure)
Adequate prior screening: two negative consecutive co-
tests or three negative Pap tests within the past 10 years,
with the most recent test within the previous five years
[43]
No history of high-grade dysplasia or worse
12. SPECIAL POPULATIONS
Immunocompromised women
Women with HIV – Women who are infected with
HIV are more likely to have persistent HPV infection,
increased rates of high-grade cervical dysplasia, and
are at increased risk for the development of cervical
cancer. ACOG suggests initiating annual Pap test
screening at age 21. We initiate screening one year
after the onset of sexual activity and screen yearly
with Pap test and human papilloma virus testing.
13. Atypical squamous cells of
undetermined significance (ASC-US)
Most common cytological abnormality.
Option 1: repeat cytology in 12 months
If negative – cytology in 3 years
If ASC or greater – COLPOSCOPY
Option 2: Preferred: reflex HPV Testing
If positive: colposcopy
If negative: repeat co testing in 3 years
14. HPV Positive, cytology negative
Option1: repeat cotesting in 12 months
If HPV positive or ASC-US +: COLPOSCOPY
If HPV negative or cytology –ve: rescreen with
cotesting in 3 years
Option 2: reflex test for HPV16 or HPV16/18
genotypes
If HPV16 or HPV 16/18 +ve: colposcopy
If HPV16 or HPV 16/18 –ve: co test in 12 months
15.
16. PAP Smear
PAP smear sampling of cervix involves
scraping of cervical surface and a portion of
non visualised cervical canal using various
sampling devices
17. Transformation zone
Cervix develops from 2 embryonic sites
* from Mullerian duct - lined by columnar
epithelium
* from urogenital plate - lined by stratified
squamous epithelium
Point at which columnar and squamous
epithelium meet is called as original squamo-
columnar junction
20. How to take a Pap Smear ?
Proper technique is very important
More problems are due to improper sampling
than screening
Not to be collected during menses
Avoid vaginal contraceptives, vaginal medications
for at least 48 hrs before taking smear
Abstinence for 24 hrs
Postpartum smear should be taken only after 6 -
8 weeks of delivery
Pregnancy is NOT a contraindication for pap
smear.
25. An optimal cervical specimen includes sampling of the squamous
epithelium (Ectocervix) and columnar epithelium (Endocervix)
and in particular the TRANSFORMATION ZONE, where the
majority of cervical neoplasias arise.
26. COLLECTING PAP SMEAR :
SPATULA
Choose the contoured end of the spatula which
best conforms to the cervix and the
transformation zone.
Rotate the spatula 360o about the circumference
of the cervix, while maintaining firm contact with
the epithelial surface.
With a clockwise rotation beginning and ending at
9 o'clock (or counter-clockwise rotation from 3
o'clock to 3 o'clock), the collected material is
retained on the upper horizontal surface as the
instrument is removed.
27. COLLECTING PAP SMEAR :
CERVICAL BRUSH
These brushes have circumferential bristles that
come into contact with the entire os surface on
insertion.
The brush need only be turned 1/4 turn.
Roll the brush across the slide by twirling the
handle.
Not recommended for pregnancy.
28. PLACEMENT ON SLIDE
Spread : quick and even , cellular material in a
monolayer on the slide.
Thin out large clumps of material as much as
possible, avoide excessive manipulation which
can damage cells.
Fix the specimen by either immersing the
slide in 95% ethanol or coating the slide with a
surface fixative.
29. Spread the material collected on the spatula / cervix
brush evenly over the slide with a painting action and
single smooth stroke motion using both sides
31. Bethesda system
Results :
Within normal limits ( WNL )
Benign cellular changes - this term was removed and group was included in
WNL in 2001
Reactive or Reparative changes – seen with atrophy, inflammation, surgery,
radiation, IUCD, tampoons
Infections – trichomoniasis, fungal, bacterial, HSV.
32. Normal cervix-cytology
Squamous cells
Exfoliated indivisual cells
Navicular in shape with abundant cytoplasm and small, dark, round /oval,
pyknotic nuclei
Glandular cells
Many times seen in clumps - linear or honeycombed pattern.
Slightly larger and basal nuclei
33. Bethesda system - results
Epithelial cells abnormalities
Squamous cells
• ASCUS
• ASCUS-H - suggestive of high grade lesion
• LSIL - changes associated with HPV, atypical changes, mild dysplasia/
CIN1
• HSIL – moderate to severe dysplasia / CIN2, 3 and Ca In Situ
• HSIL – where invasion cannot be ruled out
• Squamous cell carcinoma
34. PAP Descriptive CIN Bethesda
Class-1 negative negative WNL
Class 2
Inflammatory, squamous,
koilocytic atypia
Reactive, reparatative
changes, ASCUS,
LSIL(HPV)
Class 3
Mild dysplasia
Moderate dysplasia
Severe dysplasia
CIN1
CIN2
CIN3
LSIL(HPV)
HSIL
HSIL
Class 4 Ca In Situ CIN3 HSIL
Class 5 Invasive Invasive Invasive
35. HPV Vaccine
Bivalent vaccine (CERVARIX)
Quadrivalent vaccine (GARDASIL).
Gardasil, also prevents HPV types that cause
most genital warts
Both vaccines are given in 3 shots over 6 months.
36. HPV VACCINE
HPV vaccination is recommended with either
vaccine for 11 and 12 year-old girls.
It is also recommended for girls and women age
13 through 26 years of age who have not yet
been vaccinated or completed the vaccine series;
HPV vaccine can also be given to girls beginning
at age 9 years
Research suggests that vaccine protection is
long-lasting.
Current studies have followed vaccinated
individuals for six years, and show that there is no
evidence of weakened protection over time