Cervix Cancer

Prevention and Early Detection

Obtaining CME Credit

This activity is accredited for up to 1 hour of AMA PRA Category 1 credit. To obtain CME credit for this module, complete the evaluation and return with $10 to TMA/POEP, 401 West 15th Street, Austin, TX 78701-1680.

Objectives
After completion of this module, the physician will be able to:
1. 2.

3.

4.

Identify women at risk for cervix cancer. Describe the probable etiologic factors that contribute to the development of cervix cancer. Explain why cervix cancer is suitable for screening. Describe the screening procedure for cervix cancer.

Objectives (continued)
After completion of this module, the physician will be able to:
5.

6.

7.

Describe the reporting system(s) used for Pap smear. Describe the recommendations for evaluation and follow-up of women with abnormal Pap test results. Encourage women to be screened for cervix cancer.

Cervix Cancer: A Global Problem

It is the second most common cancer site in women worldwide. It is the most common cancer site and cause of cancer death in women in many developing countries. Women with cervical cancer die at a younger age than those with any other non-childhood cancer.

Incidence Rates of Cervix Cancer in the United States

16 14 12 10 8 6 4 2 0 1973 1980 1985 1991 14.2 11.9 10.1 8.7 8.4 8.8 8.4 7.8
Age-adjusted to 1970 U.S. std. Pop.

Rates per 100,000

21-year trend (females only)

Source: SEER Cancer Statistics Review, 1973-1994.

Mortality Rates for Cervix Cancer in Texas

Counties with mortality rate above 5 per 100,000 Counties with Mortality rate above 2 per 100,000 but less than 5 per 100,000 Counties with mortality rate lower than 2 per 100,000

Relationships Between Age, Ethnicity, and Incidence of Cervix Cancer

45 40 35 30 25 20 15 10 5 0
15-19
Age-specific rate 1988-1992

Black White

Source: Herrero, Rolando. Journal of the National Cancer Institute Monographs, No. 21:3, 1996.

25-29

35-39

Age at diagnosis

45-49

55-59

65-69

75-79

85+

Cervical Cancer Among Blacks and Whites

14 12 10 8 6 4 2 0
75 77 79 81 83 85 87 89 19 73 91
Mortality rate

Black White

Year of death
Source: Herrero, Rolando. Journal of the National Cancer Institute Monographs, No. 21:3, 1996

Incidence of Invasive and Pre-invasive Cervix Cancer

70 60 50 40 30 20 10 0 1975
Source: SEER Registry Rates are per 100,000 and age-adjusted to the 1970 U.S. standard

Invasive Carcinoma in situ

1980

1985

1990

1995

Risk Factors for Cervix Cancer

No prior smear screening History of cervical dysplasia or genital warts Young age at first coitus Multiple sex partners High-risk male partner (e.g., multiple female partners) Sexually transmitted diseases Cigarette smoking Increasing age

The Normal Cervix

The Human Papillomavirus (HPV) and Cervix Cancer

HPV 16 and 18 E6 protein + p53 tumor suppressor gene product E7 protein + retinoblastoma tumor suppressor gene product

increased cellular proliferation

Promoters of Cervix Cancer

Smoking Diet Immunosuppression

Screening for Cervix Cancer

Cervix cancer is a disease suitable for screening because it meets the following criteria:

Its a common disease. It has serious consequences. It has a detectable, asymptomatic phase. Early detection and treatment decrease morbidity and mortality. The screening test is acceptable to patients, safe, and affordable.

Benefits of the Papanicolaou Smear

Sensitivity: 50-70% Specificity: 30-50% Inexpensive Minimal risk and discomfort to the patient

The Papanicolaou Smear: False Negative Results

Why do false negative results occur?

Inadequate smear technique/sample Improper laboratory preparation/evaluation Failure of health care provider to properly interpret and manage an abnormal result Failure of the patient to comply with recommendations for evaluation and treatment Invasive cancer at the time of initial evaluation

Cervix Cancer Screening: Recommendations for Frequency

Annually after the patient is sexually active or age 18 until negative x3; then at the discretion of the physician and patient based upon a consideration of risk factors.

The American College of Obstetricians and Gynecologist

Cervix Cancer Screening: Current Controversies

How often should Pap tests be performed? Should a woman who has had a hysterectomy continue to have periodic Pap tests? When should the Pap test be repeated if endocervical cells are not present? Should Pap tests be performed in patients older than age 60?

Pathology of Cervical Dysplasia

The 1988 Bethesda System

Reporting Cervical Cytologic Diagnosis

Statement about the adequacy of the specimen General categorization of the diagnosis Descriptive diagnosis

JAMA 267:1892, 1989.

The 1988 Bethesda System (continued)

Descriptive Diagnosis

Infection Reactive and reparative changes Epithelial cell abnormalities Nonepithelial malignant neoplasm (specify) Hormonal evaluation (vaginal smear only) Other

The 1988 Bethesda System (continued)

Epithelial Cell Abnormalities: Squamous Cells

Atypical squamous cells of undetermined significance (recommended follow-up specified) Squamous intraepithelial lesion (SIL)

Low grade SIL: HPV changes and/or CIN I High grade SIL: CIN II, CIN III, or CIS

Squamous cell carcinoma

The 1988 Bethesda System (continued)

Epithelial Cell Abnormalities: Glandualr Cells Presence of endometrial cells

Out of phase in a menstruating woman In a postmenopausal woman No menstrual history available

Atypical glandular cell of undetermined significance (recommended follow-up specified)

Endometrial Endocervical Not otherwise specified

The 1988 Bethesda System (continued)

Epithelial Cell Abnormalities: Glandular Cells (continued)

Adenocarcinoma (probable site of origin specified) Other epithelial malignant neoplasm: specify

Follow-up of Abnormal Papanicolaou Smears

Colposcopy: Magnified Inspection of the Cervix

Identifies the area of abnormality for biopsy Defines the extent of the cervical lesion Delineates the areas of greatest abnormality

Evaluation of the Abnormal Papanicolaou Smear

COLPOSCOPY
Satisfactory (entire lesion seen) Unsatisfactory (lesion extends into endocervical canal) Biopsy any visible lesion Endocervical curettage

Biopsy lesion

Histological Confirmation

Evaluation of the Abnormal Papanicolaou Smear

TREATMENT OF CERVICAL DYSPLASIA
Lesion confined to ectocervix Lesion extends into endocervical canal Cervical biopsies reveal microinvasion Ablation of excision of T-zone Excision of T-zone

Treatment of Cervix Dysplasia

Treatment Modality Destructive Methods

Cure Rate (5-year) Overall

85-95% 85-95%

Cryotherapy Laser ablation

Excision

Cervical conization LEEP

>90% >90%

Evaluation of the Patient with Cervix Caner

Histologic confirmation of cervix cancer by biopsy, followed by: HIV test Staging examination Metastatic survey Treatment planning

Evaluation of the Patient with Cervix Cancer

Staging examination

Complete physical and pelvic examination Palpation of the lymph node-bearing areas Cystoscopy/proctoscopy for advanced cancers Radiograph of the chest IVP and barium enema or computerized tomography of pelvis and abdomen Surgery for selected Stage I lesions Radiation therapy for all others

Metastatic survey

Treatment planning

Post Treatment Surveillance

Exams: Palpation of the node-bearing areas, Pelvic, Pap Year 0-2 2-4 5+ Frequency every 3-4 months every 6 months annually

Five Year Survival of Cervix Cancer by Stage of Disease

100% 80% 60% 40% 20% 0% 11% Stage 0 Stage I Stage II Stage III Stage IV 100% 85% 66%

39%

Role of the Primary Care Physician in Preventing Cervix Cancer

Identify patients who should be screened Educate patients regarding the importance and timing of Pap smears Conduct Pap smears properly Follow up abnormal Pap smear results

Barriers to Screening

Embarrassment, unpleasantness Lack of knowledge of recommended screening interval Financial barriers Lack of knowledge concerning the importance of screening

Summary
Cervix cancer is highly preventable Pap smear screening Treatment of precursor lesions (dysplasia)

Follow-up of abnormal Pap smear results is critical Colposcopically-directed biopsies Histologic evaluation and correlation with the Pap smear Definitive therapy

Reading List
1. 2.

3.

4.

American College of Obstetricians and Gynecologists. Recommendations on Frequency of Pap Test Screening. ACOG Committee Opinion 152. Washington, DC: ACOG, 1995. Anderson GH, et al. Organisation and results of the cervical cytology screening programme in British Columbia, 1955-85, British Medical Journal (Clin Res Ed) 296(6627):975-8, 1988. Broder S. The Bethesda System for reporting cervical/vaginal cytologic diagnoses: report of the 1991 Bethesda workshop. Journal of the American Medical Association 267:1892, 1992. Burack RC, et al. How reminders given to patients and physicians affected pap smear use in a health maintenance organization: results of a randomized controlled trail. Cancer 82(12):2391-400, 1998.

Reading List (continued)

5.

6.

7.

8.

9.

Creasman WT, et al. Early invasive carcinoma of the cervix (3 to 5 mm invasion): risk factors and prognosis. A Gynecologic Oncology Group study. Am J Obstet Gynecol 178(1 Pt 1):625, 1998. Devesa SS, et al. Recent trends in cervix uteri cancer. Cancer Nov. 15; 64(10):2184-90, 1989. Eaker ED, et al. Cervical cancer screening among women with and without hysterectomies. Obstet Gynecol 91(4):551-5, 1998. Frame PS, et al. Determinants of cancer screening frequency; the example of screening for cervical cancer. J AM Board Fam Pract 11(2):87-95, 1998. Hopman EH, et al. Positive predictive rate of colposcopic examination of the cervix uteri: an overview of literature. Obstet Gynecol Surv 53(2):97-106, 1998.

Reading List (continued)

10. 11.

12.

13.

Lobell M, et al. Barriers to cancer screening in MexicanAmerican women. Mayo Clin Proc 73(4):301-8, 1998. Ollayos CW. Update on the Papanicolaou smear: new issues for the 1990s. Mil Med 162(8):521-3, 1997. Paskett ED, et al. Clinic-based interventions to promote breast and cervical cancer screening. Prev Med 27(1):120-8, 1998. Peters RK, et al. Risk Factors for invasive cervical cancer among Latinas and non-Latinas in Los Angeles County. Journal of the National Cancer Institute 77(5):1063-77, 1986.

Other POEP CME Modules

Breast Cancer (and in interactive CD-ROM) Cancer in Special Populations Colorectal Cancer Head and Neck Caner Lung Cancer Nutrition and Cancer Risk Reduction Prostate Cancer Skin Cancer Surveillance of Cancer Patients

To order these modules in spiral bound or 35mm slide format, contact POEP at POEP@texmed.org or call 800-880-1300, ext. 1672.

Evaluation
To obtain CME credit for this module, complete the online evaluation and return with $10 to TMA/POEP, 401 West 15th Street, Austin, TX 78701-1680. Return to POEP online CME