Items in FPM with MESH term: Uterine Cervical Neoplasms
New Tests for Cervical Cancer Screening - Article
ABSTRACT: The Papanicolaou (Pap) smear has been used to screen women for cervical cancer since 1940. Recently, a number of new technologies have been developed to improve the detection of cervical cancer and its precursors. However, there is substantial controversy about whether the new tests offer meaningful advantages over the conventional Pap smear. Ideally, these new tests will increase the early detection of meaningful Pap smear abnormalities, reduce the number of unsatisfactory smears and provide fewer ambiguous results. It is also hoped that these new screening methods will not increase the number of false-positive results, but will improve the productivity of cytology laboratories without substantially increasing costs. The new tests include liquid-based/thin-layer preparations to improve the quality and adequacy of the Pap smear; computer-assisted screening methods to improve Pap smear interpretation; and new-generation human papillomavirus testing methods that may be useful in triaging patients with atypical squamous cells of undetermined significance or low-grade squamous intraepithelial lesions. Evidence on these new tests is reviewed and the advantages and disadvantages of their use are discussed.
ABSTRACT: Atypical glandular cells on Papanicolaou smears are an unusual but important cytologic diagnosis. The Bethesda system classifies atypical glandular cells of undetermined significance (AGUS) as glandular cells that demonstrate nuclear atypia appearing to exceed reactive or reparative changes but lacking unequivocal features of adenocarcinoma. AGUS occurs in approximately 0.18 to 0.74 percent of all cervical smears. Because of the high likelihood that AGUS is associated with significant clinical disease, simply repeating the Papanicolaou smear is not sufficient for the management of AGUS. Unlike women with atypical squamous cells of undetermined significance, a significant percentage of women with AGUS will have more serious lesions, such as high-grade preinvasive squamous disease, adenocarcinoma in situ, adenocarcinoma or invasive cancers from sites other than the cervix. Colposcopic examination is recommended for all women with a cytologic diagnosis of AGUS. Those women with AGUS that is suspicious for adenocarcinoma should undergo cervical conization, even in the absence of detectable abnormalities on colposcopic examination.
The 2001 Bethesda System Terminology - Article
ABSTRACT: The 2001 Bethesda System for reporting cervical or vaginal cytologic diagnoses is an incremental change in the uniform terminology introduced in 1988 and revised in 1991. The 2001 Bethesda System includes specific statements about specimen adequacy, general categorization, and interpretation and results. In the adequacy category, "satisfactory" and "unsatisfactory" are retained, but "satisfactory but limited by" is eliminated. The new category of "atypical squamous cells" (ASC) replaces the category of "atypical squamous cells of undetermined significance" (ASCUS) and is divided into qualifiers of (1) ASC of "undetermined significance" (ASC-US) and (2) "cannot exclude high-grade squamous intraepithelial lesion (HSIL)," or (ASC-H). The categories of ASCUS, "favor reactive" and "favor neoplasia" are eliminated. The terminology for low-grade squamous intraepithelial lesions (LSILs) and HSILs remains unchanged. The category of "atypical glandular cells of undetermined significance" (AGUS) is eliminated to avoid confusion with ASCUS and is replaced by the term "atypical glandular cells" (AGC), with attempts to identify whether the origin of the cells is endometrial, endocervical, or unqualified. "Endocervical adenocarcinoma in situ" and "AGC, favor neoplastic" are included as separate AGC categories. The presence of normal or abnormal endometrial cells is to be reported in women who are at least 40 years of age. Educational notes and comments on ancillary testing may be added as appropriate.
ABSTRACT: The American Society for Colposcopy and Cervical Pathology developed guidelines in 2001 for the management of cervical cytologic abnormalities. The guidelines incorporate the Bethesda System 2001 terminology and data from randomized studies of atypical squamous cells, low-grade intraepithelial lesions, human papillomavirus testing, and liquid-based cytology to formulate evidence-based recommendations. Each recommendation is graded according to the strength of the recommendation and the quality of the evidence, and specific terminology is added to highlight management options. The effectiveness of each triage recommendation is determined by the percentage of grade 2 and 3 cervical intraepithelial neoplasia it detects. Colposcopy, repeat cytology, and human papillomavirus DNA testing are acceptable options in women with atypical squamous cells of undetermined significance, but human papillomavirus DNA testing is preferred if liquid-based cytology is used. Colposcopy is recommended for women with a diagnosis of "atypical squamous cells-cannot rule out high-grade intraepithelial lesion." Women with low-grade squamous intraepithelial lesions should be referred for colposcopy, and women with high-grade lesions should undergo colposcopy and endocervical assessment. Colposcopy and endocervical sampling are recommended in women with all subcategories of atypical glandular cells. Endometrial sampling and colposcopy are recommended in women older than 35 years with atypical glandular cells and in younger women with unexplained vaginal bleeding. Women with a diagnosis of "atypical glandular cells-favor neoplasia" or adenocarcinoma-in-situ who are not found to have invasive disease on colposcopy should undergo a diagnostic excisional procedure, preferably a cold-knife conization.
ABSTRACT: The American Society for Colposcopy and Cervical Pathology sponsored a consensus conference in 2001 to develop evidence-based guidelines for women with histologic abnormalities of the cervix. The options for management of cervical intraepithelial neoplasia 1, 2, and 3 are ranked according to the strength of the recommendation and the quality of the evidence. Follow-up with repeat cytology at six and 12 months or DNA testing for high-risk types of human papillomavirus at 12 months is the preferred management approach for women with cervical intraepithelial neoplasia 1 and satisfactory initial colposcopy. If results from repeat cytology are reported as atypical squamous cells of undetermined significance or greater, or if DNA human papillomavirus testing is positive for oncogenic types of the virus, repeat colposcopy is preferred. When the initial colposcopy is unsatisfactory, a diagnostic excisional procedure is preferred. Follow-up without treatment is acceptable only in women who are pregnant and adolescents with cervical intraepithelial neoplasia 1 who had unsatisfactory colposcopy. Biopsy-confirmed cervical intraepithelial neoplasia 2 and 3 requires treatment except during pregnancy and in compliant adolescents with cervical intraepithelial neoplasia 2 and negative endocervical curettage. When colposcopy is satisfactory, treatment includes ablative or excisional procedures. A diagnostic excisional procedure is recommended in women with biopsy-confirmed cervical intraepithelial neoplasia 2 or 3 and unsatisfactory colposcopy.
Cancer Screening in the Older Patient - Article
ABSTRACT: Although there are clear guidelines that advise at what age to begin screening for various cancers, there is less guidance concerning when it may be appropriate to stop screening. The decision to stop screening must take into account patients' age; overall health and life expectancy; the natural history of the disease; and the risks, expense, and convenience of the screening test, and any subsequent testing and treatment. The U.S. Preventive Services Task Force and the American Academy of Family Physicians suggest that Papanicolaou smears can be discontinued in women at 65 years of age, provided they have had adequate recent normal screenings. Evidence suggests that cessation of breast cancer screening at approximately 75 to 80 years of age is appropriate, although American Geriatric Society guidelines recommend cessation at a more advanced age. Studies support continuing colon cancer screening until approximately 75 years of age in men and 80 years of age in women for patients without significant comorbidities. Prostate cancer screening, if conducted at all, may be discontinued at approximately 75 years of age in otherwise healthy men. Ultimately, the decision to screen or to discontinue screening must be made after careful discussion with each patient, using evidence-based guidelines and individual patient preferences.
Cervical Cancer - Article
ABSTRACT: Cervical cancer is the second most common type of cancer in women worldwide, after breast cancer. A preponderance of evidence supports a causal link between human papillomavirus infection and cervical neoplasia. The presence of high-risk human papillomavirus genital subtypes increases the risk of malignant transformation. Widespread use of the Papanicolaou smear has dramatically reduced the incidence of cervical cancer in developed countries. Accurate and early recognition of abnormal cytologic changes prevents progression of the disease from preinvasive to invasive. Research is under way to determine if efforts to reduce the false-negative rate of the Papanicolaou smear should include rescreening programs and fluid-based technology. Once cervical cancer is diagnosed, clinical staging takes place. Early-stage tumors can be managed with cone biopsy or simple hysterectomy. Higher stage tumors can be treated surgically or with radiotherapy. Advanced metastatic disease may respond to radiation therapy and concurrent chemotherapy. Protein markers for detection of recurrence and vaccines for prevention of cervical cancer are under investigation.
ABSTRACT: Menopause is the permanent cessation of menstruation resulting from the loss of ovarian and follicular activity. It usually occurs when women reach their early 50s. Vasomotor symptoms and vaginal dryness are frequently reported during menopause. Estrogen is the most effective treatment for management of hot flashes and night sweats. Local estrogen is preferred for vulvovaginal symptoms because of its excellent therapeutic response. Bone mineral density screening should be performed in all women older than 65 years, and should begin sooner in women with additional risk factors for osteoporotic fractures. Adequate intake of calcium and vitamin D should be encouraged for all postmenopausal women to reduce bone loss. Coronary artery disease is the leading cause of death in women. Postmenopausal women should be counseled regarding lifestyle modification, including smoking cessation and regular physical activity. All women should receive periodic measurement of blood pressure and lipids. Appropriate pharmacotherapy should be initiated when indicated. Women should receive breast cancer screening every one to two years beginning at age 40, as well as colorectal cancer screening beginning at age 50. Women younger than 65 years who are sexually active and have a cervix should receive routine cervical cancer screening with Papanicolaou smear. Recommended immunizations for menopausal women include an annual influenza vaccine, a tetanus and diphtheria toxoid booster every 10 years, and a one-time pneumococcal vaccine after age 65 years.
ABSTRACT: New data have emerged since publication of the American Society for Colposcopy and Cervical Pathology's 2001 consensus guidelines for management of abnormal cervical cytology and histology. The 2006 guidelines include recommendations for special populations (i.e., adolescents and pregnant women). Human papillomavirus testing is now included for management of atypical glandular cytology, for follow-up after treatment for cervical intraepithelial neoplasia, and in combination with cytologic screening in women 30 years and older. The preferred management of atypical squamous cells of undetermined significance in adult women is reflex human papillomavirus DNA testing. Colposcopy is recommended for adult women with low-grade squamous intraepithelial lesion, atypical glandular cells, high-grade intraepithelial neoplasia, and atypical squamous cells-cannot exclude high-grade intraepithelial neoplasia. Cervical intraepithelial neoplasia, grade 1 can be managed conservatively in adult women, but treatment for cervical intraepithelial neoplasia, grades 2 and 3 is recommended. Immediate treatment is an option for adult women but not for adolescents with high-grade squamous intraepithelial lesion. Conservative management of adolescents with any cytologic or histologic diagnosis except specified cervical intraepithelial neoplasia, grade 3 and adenocarcinoma in situ is recommended. Colposcopy is preferred for pregnant women with low-grade squamous intraepithelial lesion and high-grade squamous intraepithelial lesion, but evaluation of the former may be deferred until no earlier than six weeks postpartum. Treatment during pregnancy is unacceptable unless invasive carcinoma is identified.