Cervical cancer Commonest form of cervical cancer is Squamous Cell Carcinoma Strong correlation between HPV and smoking Week cofactors oncogenes lower immune response and oral contraceptive pill COC ID: 1010763
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1. How to do record a smear test and some practical tips…
2. Cervical cancerCommonest form of cervical cancer is Squamous Cell CarcinomaStrong correlation between HPV and smokingWeek co-factors: oncogenes, lower immune response and oral contraceptive pill (COC)Much rarer form of cancer, Adenocarcinoma, is not related to intercourse
3. Squamous cell cancer of the cervix<1000 deaths per year with cervical cancerBreast 14,500, lung 10,000, bowel and ovarian cancer more common. BUT… CaCx has simple safe screening test to detect early warning changes in the cells which can be treated to prevent cancers.Greek doctor (George Papanicolaou) invented smear test over 60 years ago in USA. ‘Pap test’Collects cells from squamo-columnar junction of the cervix
4. NHS CSP1998 – DOH required all English Health Authorities to set up a screening programme for women 20-64 Smears done at least 5 yearlyCurrent guidelines are 25-64y and 3- 5yearly intervals depending on age.
5. Why change of age?Cervical cancer very rare in under 25’sMaturing cervical cells can mimic abnormal cellsInflammatory cells more common in younger womenLead to over treatment in the pastLead to unacceptable risk and side effects of treatmentNo change to age in Scotland and Wales
6. Liquid based CytologyMethod of choice used by most areas now in UKThin Prep or Sure Path methods availableSamples taken with a soft ‘broom’Important only rotated one way (other wise material will be removed)Rinse broom head in vial of liquid (some areas removed the head of the broom and leave in the vial )
7. When to take a smearMid cycle is best BUTAny time in the cycle permissible as long as not bleeding/heavy dischargeIf discharge seen treat before taking smear
8. Does the test identify STI’s?May show Candida, trichomonas, HPV,actinomyces or non specific bacteriaDoesn’t detect Chlamydia, gonorrhoea or HIVGood practice to discuss sexual health at time of test and offer swabs at the same time and further information about local DOSH servicesIf taking swabs do smear test first to ensure enough cells on the sample
9. Equipment Bivalve vaginal speculum of various sizes (virgin to winterton)Consider woman's age, build, degree of relaxationTransport mediumAppropriate spatula (broom/brush)Choice of spatula – if wide ectropian will need different spatula as well as broomRequest form: use Open Exeter for pre printedTransport bagsGood illumination
10. What information is required?Check/record:Patient nameAddressPost codeDOBNHS numberGP details ID number ( smear takers code)Date of last smearRelevant past historyLMPCOC/POP/IUD/IUS/HRTAbnormal bleedingVisualisation of cervixTZ sampled?Abnormalities?
11. ProcedureExplain process and obtain consentExplain possible outcomes and how results will be communicated and actionedDiscuss HPV testing and potential outcomes/actionsComplete request formSet up area with required equipmentPosition patient and lightInsert speculum ( warmed in water of light lubrication with water based lubricant NOT KY jelly)
12. Assess cervixsquamous epithelium is pink and columnar epithelium is redWhen columnar epithelium is seen on the ecto-cervix this is called ECTOPATHY/EVERSIONWhite spots on the cervix are NABOTHIAN follicles and are benignPolyps ( fleshy growths) are benign – often removed if they obscure the TZ Cancer has sweet sickly smell and the cervix feels spongyDo not clean the cervix or wipe away mucous Visualise TZ and firmly rotate broom in the Os through 360 degrees twice- sample 1cm adjacent to TZ .
13. Inadequate smears: what went wrong?Squamous cells too scantyInsufficient material for assessmentCytoloytic smear – taken in second half of cycle ( more common with COC users)Contamination with lubricant/vaginal cream/spermicides- clogs up slidesLarge endometrial cells (menstrual cycle blood)Brush not mashed in pot quickly enough (dry cells)Only endo-cervical cells seen – TZ not properly identified
14. What can women do to avoid inadequate results?Avoid bathing with soap/detergents before smearNo douchingShower fineNo talcAvoid unprotected sex 24 hrsCorrect time of cycleIf used vaginal pessaries for thrush wait until next cycle before having smearIf vaginal atrophy is a problem ask for per smear treatments with HRT pessaries/gel prior to testing
15. How avoid repeat inadequates ?Possible causeCervix not visualisedCervix swabbed, cells discardedCervix not scrapedMaterial not transferred to pot quickly enoughDischarge/infection presentProposed solutionVisualise clearly before taking smearDo not swab cervixScrape firmly, a little blood rarely obscuresMash broom asap. It is not sufficient to just put broom in potTreat and repeat smear at 3m
16. ConsentNeed to obtain informed consentOpen honest accurate informationInevitable there will be some false positives and false negativesDiscuss how these risks are minimised
17. How to assess capacity to consentNeed sufficient time talking and listening to woman to determine levels of understandingExplain in a way that the woman is likely to understand the intervention, alternatives, risks and benefitsInvolve someone who can advocate for the woman?On what basis have you decided that she cannot consent?Discuss your concerns with someone who knows the woman well and ask them what they think the woman's views and wishes areDocument!