With Understanding Objectives Review historical evolution Explain new guidelines for paps Discuss sampling techniques Interpreting results Deliver information to clients Cervical Cancer ID: 929547
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Slide1
Pap Smears
Maintaining
Execellence
With Understanding
Slide2Objectives
Review historical evolution
Explain new guidelines for
paps
Discuss sampling techniques
Interpreting results
Deliver information to clients
Slide3Cervical Cancer
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
Slide4Cervical Cancer
Late C19
Early
onset sexual activity
Multiple
partners Association with other STD
Slide5George
Papanicolaou
Slide6George Papanicolaou
•
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
Slide7Impact of Screening
Slide8Cancer of the Cervix (mortality/100,000)
Slide9Where are we failing Globally?
While mortality is falling in the developed world
Mortality is rising in the developing world
Slide10Estimated numbers of new cases & deaths from cervical cancer by Province in Canada 2002
New Cases Deaths
Newfoundland/Labrador 25 15
Prince Edward Island 10 5
Nova Scotia 55 20
New Brunswick 35 10 Quebec 280 75Ontario 510 150Manitoba 45 15
Saskatchewan 45 15
Alberta 170 40
British Columbia 160 50
Total for Canada 1350 390
Slide11Cervical Cancer—Cause?
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
Slide12Association
≠ Causation
Slide13HPV?
Slide14Harald
zur
Hausen
•Relationship between condyloma & genital cancer •Isolated HPV 6 & 11 in genital warts
Slide151983, zur
Hausen’s
Lab
•
Identified HPV 16 &18 •Cervical cancer biopsies
Slide16HPV Types in
Benign
&
Malignant
Lesions LESION PROMINENT HPV TYPESkin warts plantar warts --------------------------- 1common wart -------------------------- 2,27flat wart ---------------------------------- 3,10,28,41Anogenital lesions condyloma
acuminata
---------------- 6,11
cervical,
vulvar
intraepithelial
neo- 6,11,16,18,31
Slide17HPV Types in
Benign
&
Malignant
Lesions LESION PROMINENT TYPEBenign head & neck lesions oral papilloma --------------------- 2,6,11,16laryngeal papilloma -------------- 6,11
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
Slide18HPV
•
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
Slide19HPV 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
Slide20Slide21Slide22Cervical Cell Maturation
Mature
Squamous
layer
Squamous
Suprabasalar
layer
Parabasal
cells
Parabasal
cells
Slide23Sampling
What is required for an adequate specimen?
--Columnar Cells
--Squamous Cell -- SCJ (squamocolumnar junction)
Slide24Slide25New Guidelines Clear as mud!
Slide26Plan: phased approach to cervical correspondence to women similar to breast and colorectal screening
programs
. Rational: The high rate of spontaneous regression of dysplastic changes annual screening results in unnecessary
colposcopic
examination and treatment with annual screening
Slide27Cervical Screening Program: 2012 Guidelines
Clarify
the start and stop age for cervical screening
Identify
the optimum interval for screening
Identify the exceptions
Slide28Cancer 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
Slide29Notification 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
Slide30CCO 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
Slide31Current Protocol
Slide32The Ideal World---$ 90.00
Slide33Abnormal 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
Slide34Follow-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???
Slide35What 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
Slide36The Pelvic Exam
Slide37Equipment
Proper lighting
Gloves
Speculum (range of sizes)
Sampling equipment for
Paps and culturesHave two of everything to avoid having to avoid delaysDraping material (often paper)
Slide38Exam Environment
Comfortable room temperature
Foot of the table away from the door
Windows covered
Ideally elevate head of table
Privacy and confidentiality
Slide39Pap Smear
Slide40Liquid Based Cytology
Slide41Speculum Insertion
Slide42I 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
Slide43Condom or large glove finger can
help
if Vaginal walls obscure cervix
Slide44Slide45Slide46Slide47Slide48Slide49Slide50Informing 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 herUse language like—”healthy”, “well-estorgenized “, “natural changes”Do not use “normal” or “abnormal”
Slide51Further 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 “pre-
cancer”meaning “has the potential”.Reduce the fear that a pap smear that is not negative…is positive for cancer
Slide52What 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.
Slide53Colposcopy Referrals
Prepare that patient for the assessment, defuse the anxiety if you can
The pelvic exam is
e
nhanced 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.
Slide54Colposcopy
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.
Slide55Summary
Clear patient education and communication
Empower the patient
Respect and accommodate, cultural and physical restrictions.
Be the patient advocate at all times.
Slide56Questions?
Slide57Slide58