1. Don’t ASCUS, Don’t Tell:
Nuances of Cervical Cancer Screening
Kathleen McIntyre-Seltman
Magee Womens Hospital
University of Pittsburgh
Women’s Health 2012: The 20th Annual Congress

2. Disclosures
• In the last 2 years I have no conflicts of interest to
disclose
• Prior to this time, I gave lectures for which I was
compensated
– HPV vaccine
– HPV test
• I stopped giving those lectures when policy
required using company slides rather than my
own slides

3. Learning Objectives
As a result of this presentation, the learner will be able to:
• Discuss the epidemiology of HPV, cervical
cancer and pre-cancer
• Compare different strategies for cervical
cancer screening
• Counsel patients regarding new
screening guidelines

4. U.S. Prevalence of HPV Disorders
CA
8000
Cancer Precursor
HSIL
300,000
Trivially Abnormal Pap
ASCUS / LSIL
3 million
HPV INFECTION
9-10 million

5. The 2001 Bethesda System (Abridged)
INTERPRETATION/RESULT
Negative for Intraepithelial Lesion or Malignancy
Epithelial Cell Abnormalities
Squamous cell
Atypical squamous cells (ASC)
of undetermined significance (ASC-US)
cannot exclude HSIL (ASC-H)
Low-grade squamous intraepithelial lesion (LSIL)
encompassing: human papillomavirus/mild dysplasia/cervical intraepithelial
neoplasia (CIN) 1
High-grade squamous intraepithelial lesion (HSIL)
encompassing: moderate and severe dysplasia, carcinoma in situ; CIN 2 and
CIN 3
Squamous cell carcinoma
Glandular cell
Atypical glandular cells (AGC) (specify endocervical, endometrial, or NOS
Atypical glandular cells, favor neoplastic (specify endocervical or NOS
Endocervical adenocarcinoma in situ (AIS)
Adenocarcinoma
Other
AUTOMATED REVIEW AND ANCILLARY TESTING (Include as appropriate)
EDUCATIONAL NOTES AND SUGGESTIONS (Optional)

6. The 2001 Bethesda System (Abridged)
Epithelial Cell Abnormalities
Squamous cell
- Atypical squamous cells (ASC)
- of undetermined significance (ASC-US)
- cannot exclude HSIL (ASC-H)
- Low-grade squamous intraepithelial lesion (LSIL)
encompassing:
human papillomavirus
mild dysplasia
cervical intraepithelial neoplasia (CIN) 1

7. A Brief History of Cervical Screening
Before 1950’s:
• No screening in USA
• Colposcopy for screening in Europe and elsewhere
• Cone for severe dysplasia, hyst for CIS
1950’s – 70’s
• Pap screening
• Women and clinicians socicalized to annual exams
• Colposcopy appears in US
• Office treatment (cryo) of dysplasia
• CIN terminology
• Cause of cervical cancer unknown but known to be
related to sex

8. A Brief History of Cervical Screening
1980 – 90’s
• Early understanding of role of HPV
• The Bethesda System → ASCUS
• Understanding that Paps have lower sensitivity
• Aggressive “search and destroy” of low grade
changes
• LASER (80’s) and LEEP (90’s)

9. A Brief History of Cervical Screening
21st century
• More sophisticated understanding of HPV
epidemiology and natural history
• Distinction between HPV infection and
neoplasia
• HPV vaccination
• Novel approaches to screening

10. What the heck is ASCUS?
Squamous epithelial
cells that look
slightly abnormal but
do not fulfill TBS
criteria for LSIL

11. Risk of High Grade Disease
when Pap is minimally abnormal
PAP Any CIN CIN 3 or
Cancer
ASCUS 20-30% 3-8%
LSIL 50-70% 15-40%
Importance of minimally abnormal pap:
• Detecting high grade disease
• Identifying women at risk to develop high risk disease

12. Triage of ASC - US
what we learned from ALTS
• Approximately half ASC-US is HPV +
• HPV triage of ASC-US is cost effective
• 85% LSIL HPV + therefore HPV triage is not
useful
• ALMOST ALL CIN 3+ in HPV + group

13. What the heck is ASC-H?
Atypical squamous cells
not meeting criteria for
LSIL, but with one or a
very few small cells
suspicious but not
diagnostic of HSIL

14. Triage ASC-H
% HPV + % CIN 2+
ALTS data 84% 50%
Sherman Cancer 2006 108:298
Multi site –CAP review 50% 34%
Davey et al JLGT 14:206 2010
Ince et al 43%
GynOnc 2011 121:152
Univ Pittsburgh 2010 55% 35%

15. Triage HPV
Magee Womens Hospital data
JLGT 14 2010
AGE %HPV+ o <40, approx half HPV+
20-29 58 o >40 approx one third
30-39 42 HPV+
o Approx 1/3 have CIN 2+
40-49 35
o NPV over age 40 100%
50-59 40
60-69 43

16. What is HPV?
DNA virus
circular genome
7 genes
– Early regulatory
– Late capsid assembly
2 capsid proteins coded by L1
and L2
More than 100 types identified
L1 unique to each type
Vaccine = L1 antigen

18. How is HPV Transmitted?
• Almost certainly requires
sexual contact
• Does NOT require
penetrative intercourse
• Skin/mucosa to
skin/mucosa contact

19. Who gets HPV?
• half of women within 3 yrs of starting sex
– 31% get HPV 16
– 20% get HPV 18
• 80% women by age 25
• ~100% of women with > 3 lifetime partners
What about men?

20. It’s easier to get HPV
than to get pregnant!
- Dame Margaret Stanley

21. Prevalence of HPV Infection
in US women
AULT: ClinObstetGynecol, Volume 51(3).September 2008.527-532

22. Prevalence of HPV
Schiffman, M. et al. J Natl Cancer Inst 2003;2003:14-19
Copyright restrictions may apply.

23. Prevalence of HR HPV by Age
Population Based – 4 cohorts

25. Acquisition Of HPV
Declines With Age
5.0%
4.0%
%Acquisition HPV 16
3.0%
2.0%
1.0%
0.0%
<25 25 - 34 35 -
-44 45--- 54 55- - 64  65
Age
Castle et al., J Inf Dis 2005;

27. Prevalence of HPV

28. Natural History of HPV
0–1 Year 0–5 Years 1–20 Years
Continuing CIN 2/3 Invasive
Infection AIS Cervical
Cancer
Initial
HPV
Infection
CIN 1
Cleared HPV Infection

29. Natural History of HPV Infection
• Clearance of virus (“sustained remission”) 80 –
90%
• Persistent expression of virus: 10 – 20%
These are the women at risk for cancer
Risk factors for persistence:
– Viral type and variant
– Younger age at acquisition
– Smoking
– Immune suppression
– Nutritional? Genetic? Other factors?

30. HPV Type and Cancer Risk
HPV TYPE % cancers % controls OR
HPV 16 53 3.0 434
HPV 18 11 1.0 248
HPV 45 4 0.5 197
HPV 31 3 0.6 123
HPV 52 2 0.2 200
HPV 33 2 0.2 373
Muñoz NEJM 2003

31. Carcinogenesis
• Integration of viral genome
• E6 and E7 alter control of cell growth
– Decrease tumor suppressors
– Increase tumor promoters
– Inhibits apoptosis
– Alter immune response, especially interferon
– Synergism results in cell immortalization

32. Success of Screening
Pap testing has decreased the rate of cervical
cancer by 75% (less in less resourced countries)
BUT:
• Relies on repeated testing (false negative rate of
1 pap between 30 and 50%)
• Requires highly trained cytologists
• Relies on visual pattern recognition
• Expensive

33. Natural History of HPV Infection
• Clearance of virus (“sustained remission”):
80 – 90%
• Persistent expression of virus: 10 – 20%
These are the women at risk for cancer

34. Cumulative Incidence CIN 3/CA
women with normal pap, single HPV test at entry
Khan et al JNC 2005; 97:1072 Pap NL/ASC/LSIL
Kaiser study of 20514 women

35. Development of CIN 3+ in 7 Countries
Dillner, J. et al. BMJ 2008;337:a1754

36. Primary HPV Screening
Rijkaart Lancet Oncol 2012:78
15 year follow up cohort Swedish women, age 30-60, screened q 5 yrs
HPV detected more abnormalities in first screen
HPV Cytol
BASELINE
CIN 2+ 1.34 1.07
CIN 3+ 0.86 0.75
Cancer 0.06 0.03
SUBSEQUENT ROUNDS 0.93
CIN 2+ 0.82 0.93
CIN 3+ 0.45 0.62
Cancer 0.02 0.07

37. Primary HPV Screening
ARTISTIC trial – primary screening in England: f/u after 3 rounds
Kitchener Eu J Cancer 47:2011:864
DETECTION CIN 2+ % of population
HPV CYTOL
Round 1 2.46 2.19
Round 2 0.74 0.89
Round 3 0.77 0.69
HPV - HPV + CYTOL - (nl) CYTOL abn (+)
Round 1 0.17 14.5 0.15 17.7
Round 2 0.27 4.2 0.58 2.26
Round 3 0.42 2.57 0.68 1.21

38. Follow up HPV - women
outcome HPV - HPV- /Pap - Pap -
Kaiser No Cancer/100,000 3.8 3.2 7.5
Cal in 5 y
Kaiser CIN 3+ <1%
Portland
ARTISTIC CIN 3+ 0.48 0.42
Turkey cancer 1/2175 or 0.5%
Kaiser No Calif Katri et al Lancet Onc 2011:12:663
Kaiser Portland Khan et al JNCI 2005
ARTISTIC Kitchener Eu J Ca 2011:864
Sweden Bulkmanset et al 2009

39. Co Test Screening
ARTISTIC trial – primary screening in England: f/u after 3 rounds
Kitchener Eu J Cancer 47:2011:864
DETECTION CIN 2+ % of population
HPV - / cytol - HPV + / cytol + HPV + / cytol - HPV+ /cytol +
Round 1 0 2.23 1.48 32.6
Round 2 0.25 0.44 3.67 5.03
Round 3 0.42 0.48 2.77 2.2

40. Risk of Developing CIN
Cytol - / HPV + women
2020 women CYTOL - HPV + followed: ages 16-81, mean 28
Castle et al Cancer 95:2145 2002
Cytology detection of Pap showing: Cum risk
> ASCUS 16.8%
> LSIL 6.4%
> HSIL 2.2%
RISK FACTORS
• HPV 16/18
• young age
• high viral load

41. Risk of Developing CIN
Cytol - / HPV + women
1138 women followed, mean 54 months, age mean 41
Zhao et al,GynOnc 122:291 2011
HISTOL CIN 1+ HIGH GRADE CIN 2+
Total 24% 2.4%
< 30 27.6% 2.4%
> 30 21% 2.4%

42. HPV Types and Cancer Risk
ALTS trial: Number (%) women developing > CIN 3
2 yr f/u,women > 30, by cytology and HPV status at entry into trial
HPV status ASCUS LSIL
HC and/or PCR
HPV - 2% 5%
Oncogenic HPV + 15% 17%
Oncogenic HPV + / 16 - 8% 11%
HPV 16 + 32.5% 39%
Schiffman et al JNCI 2005

43. Self Collection of HPV
Zhou et al JNCI 2012
13,000 underscreened women in rural China
+ HPV 14.7 vs 15.6 clinician collected
Sensitivity to Detect Disease
SELF CLINICIAN Cytology VIA
HPV HPV
CIN 2+ 83% 95% 72% 48%
CIN 3+ 86% 98% 89% 65%

44. Self Collection of HPV
Zhou et al JNCI 2012
13,000 underscreened women in rural China
+ HPV 14.7 vs 15.6 clinician collected
Comparing Screening Techniques
Detection CIN 2+
SELF CLINICIAN Cytology VIA
HPV HPV
SENS 86 97 81 50
SPEC 81 83 94 87

45. HPV Screening: Summary
• More sensitive than cytology
• HPV q 3 yrs more sensitive than cytology q yr
• HPV testing detects CIN 2+ earlier than
cytology; detection “catches up” with
repeated cytology screening
• Negative predictive value of HPV very high,
meaning that women who are HPV – are
“protected” from dx CIN 3+ for several years

46. Current Screening Recommendations
starting and stopping
• Begin screening no earlier than age 21
• Continue until 65 or 70, then d/c:
– Unless hx CIN 3 or cancer in last 20 yrs
– Unless fewer than 3 paps in lst 10 yrs
• Stop screening after hyst when cervix removed
– Unless hx CIN 3 or cancer
– Continue age appropriate screening if cervix present

47. Current Screening Recommendations
Frequency
• Q 2 years 21-30
• Q 2 years > 30 unless cotesting
– After 3 neg tests, can increase interval to 3 yrs
• Q 3 years at earliest if pap and HPV both neg

48. ARHQ review 2011
When should screening start?
Initiation of screening no earlier than 21
• High prevalence but low persistence in
younger women
• < 25 high proportion false + paps
• Screening < 25 does NOT decrease cervical CA
Vesco KK et al Screening for Cervical Cancer: a systematic evidence review for
USPHSTF
No 86, AHRQ pub no. 11-05156-EF-1

49. ARHQ Review 2011:
Should LBC be recommended?
LBC compared with conventional cytology
• LBC less unsatisfactory Paps
• Possible increase in minor abnormalities
• NO DIFFERENCE in detection CIN 2+
• Unclear whether cost-effective
Vesco KK et al Screening for Cervical Cancer: a systematic evidence review
for USPHSTF
No 86, AHRQ pub no. 11-05156-EF-1

50. ARHQ review 2011:
Should HPV screening be recommended?
HPV primary screening +/- cytology triage
• HPV more sensitive for CIN 2+ (30-50%)
• HPV less specific (3-5%)
• Similar rate of colpo referral with cytol triage
• Less invasive cancer in HPV screened cohorts
Vesco KK et al Screening for Cervical Cancer: a systematic evidence review for
USPHSTF
No 86, AHRQ pub no. 11-05156-EF-1

51. ARHQ 2011:
Should HPV/Pap Cotesting be recommended?
• Cumulative CIN 3+ equal
• CIN 3+ detected earlier
• 50-60% more sensitive than cytol alone
• 5% less specific in women >30
• No impact in women <30
• Minimal benefit compared with HPV screening
Vesco KK et al Screening for Cervical Cancer: a systematic evidence review
for USPHSTF
No 86, AHRQ pub no. 11-05156-EF-1

52. ARHQ review 2011:
Should HPV be used to triage minor
abnormalities?
Triage of minor abnormalities
• Increased detection of CIN 2+ (12%)
• Possible detection of CIN 3+ earlier in women
<30
• Increased referral to colposcopy
Vesco KK et al Screening for Cervical Cancer: a systematic evidence review for
USPHSTF
No 86, AHRQ pub no. 11-05156-EF-1

53. ARHQ review 2011:
What are the harms of HPV testing?
Harms of HPV testing
• Increased anxiety, fear, distress immediately
but resolved at 6 mo f/u
Vesco KK et al Screening for Cervical Cancer: a systematic evidence
review for USPHSTF
No 86, AHRQ pub no. 11-05156-EF-1

54. ARHQ review 2011:
Conclusions
• 21 reasonable age to start screening
• LBC equal sensitivity to CC but may decrease
unsatisfactory slides - ? Cost effectiveness
• HPV primary screening “appears promising”
when paired with cytology triage
• Co testing HPV/Pap similar to HPV only with
cytol triage; does not add to sensitivity
Vesco KK et al Screening for Cervical Cancer: a systematic evidence review
for USPHSTF
No 86, AHRQ pub no. 11-05156-EF-1

55. Cervical Cancer Screening
Future Directions
• Decreased frequency of screening using
cytology only (reflex HPV testing for ASC-US)
ages 21-30: Q 3 years
• Primary HPV screening >30
– Reflex cytology
– Q 3-5 years

56. How can we prevent cervical cancer?
Secondary prevention
• Screen for cancer precursors
• Diagnose and treat cancer precursors
Primary prevention
• Education
• Vaccine

57. Who Needs Referral for Colposcopy?
• Non adolescents with > ASC US HPV +
• Women > 30 with HPV Pap screening
– ASCUS: IF HPV 16/18 +
– ASCUS: IF either Pap or HPV abnormal after 1 yr
• Menopausal women: can repeat LSIL if desired – or HPV
test – or colpo
• ANY AGC

58. How can we prevent cervical cancer?
Secondary prevention
• Screen for cancer precursors
• Diagnose and treat cancer precursors
Primary prevention
• Education
– GET WOMEN TO BE SCREENED
• Vaccine

59. HPV Vaccines
• Gardasil®
– Quadrivalent against 6/11/16/18
– FDA approved 2006 for women ages 9 – 26
– FDA approved 2009 for men
• Cervarix®
– Bivalent against 16/18
– FDA approved 2009
• Both synthetic VLPs
• Both given time 0, 2 mo, 6 mo

60. Efficacy of Vaccine
% decrease
Women neg for all vaccine viral types >99%
Women pos for at least 1 viral type OR 40 – 60%
off protocol (missed or late doses)
Similar for bivalent and quadrivalent vaccines
• Cross protection in phylogenetically related HPV families
• Bivalent or quadrivalent vaccine 59%  in CIN 2/3 due to
HPV 31/45

61. Summary
• HPV is necessary but not sufficient for cancer
• Everybody gets HPV, but most people clear the infection
• Current screening with cytology has limitations
• Primary HPV screening is the future, likely with cytology
triage
• Vaccination is a safe and effective way to prevent HPV
related disease
• Rapid HPV test self collected specimen combined with
VIA /treat in underresourced environments is cost
effective
CERVICAL CANCER CAN BE NEARLY ELIMINATED!