Background The conventional smear has been the most successful screening test Screening every 35 years has reduced in 70 reduction in cervical cancer Aims and objectives of the CPS Reduces both incidence and mortality from cervical cancer ID: 1044407
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1. NHS Cytology Screening Programme
2. BackgroundThe conventional smear has been the most successful screening testScreening every 3-5 years has reduced in 70% reduction in cervical cancer
3. Aims and objectives of the CPSReduces both incidence and mortality from cervical cancerContinue to improve the programme by offering systematic, efficient screening for the diagnosis of pre-malignant diseaseTo offer timely, appropriate investigation and treatment where indicated
4. ScreeningIncidence: -15% of all cancers in women world wide - Ranks 7th in the UK amongst cancers in womenScreening - Pre-invasive phase of dysplasia (CIN) - Latent period ( CIN3…10-15y…cancer) -Simple test
5. NHS CSP HistoryA population –based, organised (call and recall) programme was launched in 1988 at 5 yearly intervalsThe priorities for the first round were to improve population coverage and fail-safe follow up systemsThe priorities for the second round (1993-1998) were to improve the quality of programme co-ordination, smear taking and laboratory interpretation
6. NHS CSPAge Group 25-64 years (England)Screening interval 3 yearly up to 50 5 yearly up to 64Outcomes Normal recall Early recall Referral – Colposcopy/Oncologist
7. Sample TakerMust visualise the cervixEnsure the whole of the transformation zone is sampledMust record this information on the cytology request form
8. Transformation ZoneSite where metaplastic process takes placeExtends from the original squamocolumnar junction to upper limits of squamous metaplasiaArea where the majority of pre-malignant conditions occur
9. NHS CSP Development The priorities for the third round were to maintain current achievements and to improve the quality of the screening test by considering: - Liquid based cytology - Reflex HPV testing - Computer assisted screening
10. Liquid based cytologyA thin layer of cells is made from a representative cell sample taken from a cell suspensionAll cell types should be present in slide preparation
11. AdvantagesExcellent fixationCrisp cellular detailClean backgroundRepresentative cell sampleThin layer of dispersed cell over controlled area
12. AdvantagesPreparation – takes less time to screenUnsatisfactory rate decreasedIncreased pick up rate of abnormality
13. Sample adequacyRepresentative sample from TZ, so if dyskaryotic changes are present these can be readily identifiedSufficient quantity of squamous cells, but endocervical and /or metaplastic do not need to be presentUltimately the sample taker determines what is adequate sampling for the individual patient based on clinical history and visual inspection of the cervix
14. Unsatisfactory SamplesReasons for inadequate reports:Insufficient cellular materialObscured by polymophsLubricant
15. Nature of AbnormalityNegativeBorderlineMild dyskaryosisModerate dyskaryosisSevere dyskaryosisSevere dyskaryosis ? Invasive carcinomaGlandular neoplasia or ? Glandular neoplasiaInadequate
16. DyskaryosisAbnormal nucleus, immature cells, thin epitheliumMild dyskaryosis – CIN 1 can revert to normal Moderate and severe dyskaryosis are referred to colposcopy for further investigation
17. Grade of dyskaryosisMild dyskaryosis suggests CIN 1 (abnormality confined within epithelium)Moderated dyskaryosis suggests CIN 2 (Thinner epithelium as cells not maturing/more immature cells)Severe dyskaryosis suggests CIN 3 ( immature cells, abnormal nuclei, thin epithelium)
18. DyskaryosisCytological degree of dyskaryosis should be taken to indicate the minimum degree if CINManagement should be based in degree if dyskaryosisDyskaryotic cells which are difficult to grade should be coded and managed as moderate dyskaryosis
19. Slide ScreeningPrimary Screening (8mins) Negative AbnormalRapid review (1-2mins) CheckerConfirmed negative Pathologist REPORT REPORTMaximum of 40 slides/day/screener
20. ReportReport on sample contentsTransformation zone sampledRecommendations for management
21. RecommendationsNormal recall (3-5 yearly)Early recall ( 3,6,or 12m)Referral for colposcopyUrgent referral to Gynaecological oncologistHPV testing
22. HPV TriageAll cervical sample with Borderline or mild dyskaryosis test results will be tested for HPV to distinguish between women who need referral to colposcopy and women who can safely be returned to routine recallWomen who test positive for HPV will be referred to colposcopyWomen who are HPV negative will be returned to routine recall
23. Test of Cure Follow up of treated CINHPV testing will be used following treatment for CINWomen who are cytology negative and HPV negative will proceed to 3y recall – avoiding the need for 10 years of annual testsWomen who are cytology +ve or HPV +ve at 6months post treatment will be re- colposcoped
24. HPV triage outcomesApprox. 70% of BNC/Mild cases are HPV +veOf these approx. 5% have more significant disease on histologyWith the Test of Cure approx. 90% are HPV -ve
25. Management of patientInadequate or unsuitable -Repeat smear within 3m -3 inadequate in a row then refer to colposcopy Borderline -HPV test: - if +ve refer to colposcopy, if –ve routine recallMild dyskaryosis -HPV test : if +ve refer to colposcopy, if –ve routine recall3 abnormal results in 10 years -refer to colposcopy
26. Direct referralDirect referral from Cytology laboratory to Colposcopy unitLaboratory issue result to GP/Sample takerCopy sent to colposcopyColposcopy admin book appointment for womanGP sent letter giving the details of appointmentAppointment letter sent to woman from the colposcopy unitWoman has option to change appointment time
27. Management of patientsModerate Dyskaryosis - refer to colposcopy Severe Dyskaryosis -refer to colposcopy? Invasive - urgent referral to gynaecologist
28. Management of patientsColposcopyTreat abnormal (high grade)AbnormalReassess with colposcopyBiopsyNegative or low gradeFollow up with cytology and possible colposcopyNegativeDischarge to GP Recall as appropriate
29. Management of patients after treatmentAll grades of CIN, if fully removedUse of HPV testing in determining ‘Test of Cure’HPV +Ve – monitored at colposcopy 6 or 12m repeat may be advisedHPV negative – discharged back to GP on 3 year recallIf CIN is not fully removed remains under care of colposcopy team
30. Request form ‘Open Exeter’Loaded into GP computer systemPrinted as required
31. Cancer reform strategyMinimising the time taken to get results back to women, aiming to inform women of the results of the cervical screening test within 2 weeks of it being taken
32. Cytology specimen bagsReadily identifiable cytology transport bags
33. Take home messageCervical smear is a screening test and is not 100% sensitiveFalse negative rates of <5% are unlikely to be achieved in primary screeningRegular cervical smears every 3-5 years, competently obtained and reported can prevent 80-90% of invasive cancerHPV testing will become more important in future development of the NHS CSP
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