Download Pap Smears

Pap Smears
Maintaining Execellence
With Understanding
Objectives
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Review historical evolution
Explain new guidelines for paps
Discuss sampling techniques
Interpreting results
Deliver information to clients
Cervical Cancer
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Not recognized until C16
1700s
Bernardino Ramazzini
Professor of Medicine
University of Modena & Padua
De Morbis Artificium Diatriba
–Described cervical cancer
–Absence of disease in nuns
Cervical Cancer
Late C19
• Early onset sexual activity
• Multiple partners
• Association with other STD
George Papanicolaou
George Papanicolaou
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•Greek Physician
•Immigrated to USA
•Research – hormones in guinea pigs
•Swabbed cervix- distinct cells
•Performed same on wife
•1925 chance encounter volunteers showed
signs of cancer
• •Screening test delayed 30 years
• •1954 Atlas of Exfoliative Cytology
Impact of Screening
Cancer of the Cervix
(mortality/100,000)
Where are we failing Globally?
• While mortality is falling in the developed
world
• Mortality is rising in the developing world
Estimated numbers of new cases & deaths
from cervical cancer by Province in Canada
2002
Newfoundland/Labrador
Prince Edward Island
Nova Scotia
New Brunswick
Quebec
Ontario
Manitoba
Saskatchewan
Alberta
British Columbia
Total for Canada
New Cases
25
10
55
35
280
510
45
45
170
160
1350
Deaths
15
5
20
10
75
150
15
15
40
50
390
Cervical Cancer—Cause?
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Cervical Cancer Cause?
•Herpes simplex virus
•Major player
•Observation: 50% women with cervical cancer
had HSV 2
• •Women with HSV antibodies 10x more likely to
develop cervical cancer
• 1973 International Conference
• on Herpes virus and Cervical Cancer
Association ≠ Causation
HPV?
Harald zur Hausen
•Relationship between
condyloma & genital cancer
•Isolated HPV 6 & 11 in genital
warts
1983, zur Hausen’s Lab
•Identified HPV 16 &18
•Cervical cancer biopsies
HPV Types in Benign & Malignant
Lesions
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LESION
PROMINENT HPV TYPE
Skin warts
plantar warts --------------------------- 1
common wart -------------------------- 2,27
flat wart ---------------------------------- 3,10,28,41
• Anogenital lesions
• condyloma acuminata ---------------- 6,11
• cervical, vulvar intraepithelial neo- 6,11,16,18,31
HPV Types in Benign & Malignant
Lesions
LESION
PROMINENT TYPE
• Benign head & neck lesions
• oral papilloma --------------------- 2,6,11,16
• laryngeal papilloma -------------- 6,11
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Malignancies
cervical cancer -------------------- 16,18,31,35
other anogenital cancers ------- 6,16,18
oral cancer ------------------------- 3,6,11,16,18,57
esophageal cancer --------------- 6,11,16,18
HPV
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•Most common STI
•Infects 550,000 Canadians annually
•Most transmit from skin to skin contact
•Most infections go unnoticed and resolve
spontaneously within 24 months
• •Persistent infection with HPV 16 or 18 can
lead to cervical cancer
HPV Epidemiology
•Majority of sexually active adults
have genital HPV infection at some
time in their life
•Most infections are transient and
resolve spontaneously within 24
months
Cervical Cell Maturation
Mature
Squamous
layer
Squamous
Suprabasalar
layer
Parabasal cells
Parabasal cells
Sampling
• What is required for an adequate specimen?
--Columnar Cells
--Squamous Cell
-- SCJ (squamocolumnar junction)
New Guidelines Clear as mud!
. Rational: The high rate of spontaneous
regression of dysplastic changes annual
screening results in unnecessary
colposcopic examination and treatment
with annual screening
Plan: phased approach to cervical
correspondence to women similar to
breast and colorectal screening programs
Cervical Screening Program: 2012
Guidelines
• Clarify the start and stop age for cervical
screening
• Identify the optimum interval for screening
• Identify the exceptions
Cancer Care Ontario (CCO) Cervical
Screening Guidelines
Initiation
(When to begin obtaining Pap tests)
Age 21 if sexually active
If not sexually active by age 21, delay
until sexually active
Interval
(Frequency of Pap Tests)
Every 3 years
Cessation
(When to stop obtaining Pap tests)
Age 70 if 3 or more negative tests in past
10 years
Notification of Women Cancer Care
Ontario Timeline
• •August 2013: privacy notices mailing begins
• •September 2013: results letters of Paps
done since July 1, 2013 mailing begins
• •October 2013: 30-69 need q3yr screening
privacy notification & invitation
• •November 2013: 30-69 invited for their first
screen
• Lead Scientist Ontario Cervical Screening
Program Cancer Care Ontario
CCO New Guidelines
• •“Although HPV testing is the preferred
screening test for cervical cancer and remains
a goal, we continue to recommend cytology
as the primary screen tool.” (CCO)
• The absence of T-zone is not a reason to
shorten the screening interval
Current Protocol
The Ideal World---$ 90.00
Abnormal result following
inappropriate screening: ? Follow-up
• Juvavunski Hospital
–Refuse referrals in women ˂ 21, unless high
grade
• CCO
–Abnormal paps should be managed according
to protocol regardless of the appropriateness
of the screening
Follow-up following discharge from
colposcopy
• •If treated for high grade – perform annual
pap smears
• •If no treatment – perform to q-3-year
screens after 3 negative paps
• Based on cessation of screening
• at age 70→ 3 normal smears in
• 10 years???
What about the woman who still
wants an annual pap?
• •Explain the rational behind 3 year screening
• –Annual screening results in more abnormal
paps
• –Most abnormalities will resolve spontaneously
• –Acting on abnormal papas results in
interventions that are not risk free
• •$ is not just that of the pap provider
• –The lab will not get paid and they will go after
the patient
The Pelvic Exam
Equipment
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Proper lighting
Gloves
Speculum (range of sizes)
Sampling equipment for Paps and cultures
Have two of everything to avoid having to avoid
delays
• Draping material (often paper)
Exam Environment
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Comfortable room temperature
Foot of the table away from the door
Windows covered
Ideally elevate head of table
Privacy and confidentiality
Pap Smear
Liquid Based Cytology
Speculum Insertion
I can not find the Cervix!
• •Relax, take a deep breath
• •Unless she forgot to tell you about her
hysterectomy, it is there.
• •Avoid diving in and out with the speculum
and think about the anatomy
• Ask the patient to make a fist with both hands
and push them under her hips, fingers down
Condom or large glove finger can help
if Vaginal walls obscure cervix
Informing the Patient/Client of
Abnormal Pap Results
• Begin layering in education and understanding
at the time of the history/examination
• “Paps are a screening tool not a diagnostic
tool
• Share any findings with her
• Use language like—”healthy”, “wellestorgenized “, “natural changes”
• Do not use “normal” or “abnormal”
Further to Informing the Patient
• Empower her throughout the appt. to ask
questions and make informed choices.
• Help her understand that dyspasia is not
cancer, but will be referred to as “precancer”meaning “has the potential”.
• Reduce the fear that a pap smear that is not
negative…is positive for cancer
What is ASCUS?
• Abnormal Squamous Cells of Undetermined
Significance!!! What?
• It is important to compare this finding with
the clinical findings
• The Bethesda Cervical Screening –gives us and
understanding of the cells that are assessed as
“not normal” but not dysplastic---ie ASCUS
favouring atropic changes.
Colposcopy Referrals
• Prepare that patient for the assessment,
defuse the anxiety if you can
• The pelvic exam is enhanced by fiberoptic
lighting and magnafication.
• Acidic acid 5% (vineger) is used to bathe the
cervix and highlight the abnormal patches on
the cervix.
• A biopsy may be taken to diagnose the
abnormality, following the abnormal pap.
Colposcopy
• Prepare her for the fact that the referral
will involve several visits, including initial
assessment, treatment (if necessary) and
follow up visits to insure the cervical cells
have returned to normal.
Summary
• Clear patient education and communication
• Empower the patient
• Respect and accommodate, cultural and
physical restrictions.
• Be the patient advocate at all times.
• Questions?