MDNews - Cleveland-Akron-Canton

+++++++++++++++++++++++++++++++++++++++++++ + + +++++++++++++++++++++++++++++++++++++++++++ SPECIAL SECTION: WOMEN’S HEALTH  +++ +++ CERVICAL CYTOLOGY WHO, WHAT, WHEN, AND HOW OFTEN? By William K. Hahn, Jr., MD, FACOG Obstetricians and Gynecologists in 2009 has resulted in the re-thinking of the age old practice of yearly cytologic testing for most women. The new recommendations have left some clinicians and their patients uneasy in the advent of change. The understanding of the natural history of human papilloma virus (HPV) infec- tion and the addition of this testing has changed the face of cytologic screening. Through education and reassurance, our patients can be made comfortable with the new screening procedures. High-risk HPV (HRHPV) is now understood as the single etiologic agent in the genesis of pre-cancerous and cancer- ous lesions of the cervix; however, most women who become infected will not develop signifi cant abnormalities. Most patients will form an adequate immuno- logic response and clear their infection within 24 months. The incidence of HPV infection peaks in late adolescence and early 20s, and decreases thereafter. Persistence of HPV in older women cor- relates with increasing rates of high-grade squamous lesion (HGSIL) and subsequent malignancy in this group. Only 1 in 10 patients who contract HRHPV will go on to develop cytologic abnormalities of the cervix. Women who smoke are twice as likely to fail to clear HRHPV infection and go on to develop cervical neoplasia. The sensitivity of conventional and liquid-based cytology for the detection of cervical intraepithelial neoplasia (CIN) is 68% and 76%, respectively. The addition of HRHPV testing (available with liquid-based methods) increases the sensitivity to 92% for CIN 2 (moder- ate dysplasia) and 96% for CIN 3 (severe dysplasia). The above findings have led to revised recommendations for the routine screening for cervical neopla- sia. Adolescents only make up about 0.1% of all cases of cervical cancer and most all cervical intraepithelial neoplasia resolves in these patients. Accordingly, the new recommendations have excluded adolescents from cervical cytologic screening with the exception of those who are immunocompromised or HIV positive. Routine cytologic screening should begin at the age of 21 years and can be performed every other year. Routine HRHPV testing should not be per- formed in patients between the ages of 21 and 29 because 80% of patients will likely contract HPV during this time and it will not aid in determining which patients are at future risk of cervical neoplasia. Alternatively, refl ex HRHPV testing should be performed on patients whose cy tolog y shows Atypical Squamous Cells of Undetermined Signifi cance (ASCUS). Patients with ASCUS, who are found to have HRHPV, should undergo a colposcopic exam. Patients with ASCUS without HRHPV can undergo repeat cytologic exam in one year. Patients should begin combined cytologic/HRHPV testing at age 30. If both tests are negative, the patient can undergo repeat testing in three years. Patients who have a history of CIN 2 or CIN 3, are immunocompromised or HIV positive, or were exposed to 34 | Cleveland-Akron-Canton MD NEWS  MDNEWS.COM  JULY-AUGUST 2011 T HE RELEASE OF new rec- ommendat ions regarding cervical cytologic screening from The American College of SCREENING: diethylstilbestrol (DES) in utero should still undergo yearly testing. Patients should still undergo yearly pelvic exams, however, to screen for other gynecologic pathology. Routine cytologic testing may be discontinued between the ages of 65 and 70 after a patient has had three or more consecutive negative assessments and no abnormal results in the preced- ing decade. An open discussion should be conducted with each patient on an individual basis regarding this decision. The yearly well-woman visit should assess any change in sexual behavior that might increase a patient’s risk of new-onset exposure to HRHPV and the need for subsequent cervical cytologic surveillance. Women who have been immunized for HPV should be screened in the same fashion as non-immunized women. Patients with prior total hysterectomy for benign disease do not need vaginal cuff cytologic testing. Future research will address the utility of primary disease screening using HRHPV only as well as the utility of identifying specifi cally the subtypes of HRHPV pres- ent in an infected patient. Ongoing study of the impact of HPV vaccination in terms of retaining immunity and the potential to screen immunized patients with positive antibody titers in a less frequent interval will need to be completed. Dr. William Hahn is a board-certified obstetrician/gynecologist on the medical staff of Southwest General Health Center. Additionally, he is an assistant clinical professor in the School of Medicine at Case Western Reserve University. n

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