(lifted from Society of Gynecologic Oncology: Clinical Practice Guidelines for Obstetrician – Gynecologists )

SCREENING AND PREVENTION

A. What are the recommended screening methods to decrease the incidence of cervical cancer?

RECOMMENDATION:

• Women should be screened via regular gynecologic examinations and cytologic tests (Papanicolau smear).
• Women should undergo treatment of precancerous abnormalities to decrease the incidence and mortality of cervical cancer.
•  Liquid based cytology may be offered as this has the advantage of doing HPV testing on the same preparation with a lower rate of unsatisfactory results than conventional smears.

Quality of evidence: 2a
Strength of recommendation: B

RECOMMENDATION:

• HPV DNA Testing should be used as part of co-testing for cervical cancer among women aged 30 and above.

Quality of evidence: 2b
Strength of recommendation: B

RECOMMENDATION:

• In low resource settings, visual inspection with acetic acid (VIA) may be done as an acceptable alternative to pap smear.

Quality of evidence: 1a
Strength of recommendation: A

B. Do cervical cancer screening recommendations differ among women at different age groups?

RECOMMENDATION:

• Screening should not be done among women less than 21 years old.

• Women aged 21-29 should have a Pap test every 3 years.

RECOMMENDATION:

• Women aged 30-65 years should undergo co-testing with Pap test and HPV test every 5 years. Another option for screening this age group is a pap test every 3 years.

Quality of evidence: 1 a
Strength of recommendation: A

RECOMMENDATION:

• Cervical cancer screening should be discontinued between 65 years and 70 years of age in women who have three or more negative cytology test results in a row and no abnormal test results in the past 10 years.

Quality of evidence: 2a
Strength of recommendation: B

Table 1. Cervical Cancer Screening Guidelines for Average-Risk Women.

These recommendations DO NOT apply to special HIGH-RISK populations who may need more intensive screening such as those with history of CIN2, CIN 3, Cervical Cancer, HIV infection or immunocompromised women.

• *Co-testing: Cytology plus HPV DNA test
• PSCPC — Philippine Society for Cervical Pathology and Colposcopy
• ACS — American Cancer Society
• ASCCP — American Society for Colposcopy and Cervical Pathology
• ASCP — American Society for Clinical Pathology

C. Can vaccination with HPV vaccines prevent cervical cancer?

RECOMMENDATION:

• Vaccination should be advised against HPV 16/18 as this is shown to efficacious against persistent HPV infection and CIN2+ lesions

• Vaccination against HPV 16/18 should not be given during pregnancy.

D. Should women who have completed HPV vaccine discountinue cervical cancer screening?

RECOMMENDATION:

• Women who have been immunized against HPV should be screened by the same regimen as non-immunized women. Vaccination does not eliminate the necessity to undergo the recommended cervical cancer screening

Table 2. Cervical Cancer Screening Guidelines for High-Risk Women (HIV Positive Women).

The following table summarizes the recommendations on cervical cancer screening for HIV-positive women by the following institutions:

• CDC — Center for Disease Control and Prevention
• NIH – National Institute for Health (US)
• ACOG — American College of Obstetrics and Gynecology
• HIV Medicine Association

RECOMMENDATION:

• Among HIV-negative immunocompromised women, screening should begin within 1 year of sexual debut and continued throughout their lifetime.

• Among HIV-negative immunocompromised women less than 30 years old, cytology should be done yearly. After 3 consecutive normal cytology tests, follow-up cervical cytology should be done every 3 years.

• For HIV-negative immunocompromised women 30 years old and above, co-testing with cervical cytology and HPV test should be done every 3 years as long as results are negative. Cytology on a yearly basis until 3 consecutive normal tests followed by testing every 3 years may be done in place of co-testing.

Quality of evidence: 3a
Strength of recommendation: C

Table 3. Cervical Cancer Screening Guidelines for High-Risk Women (HIV Negative Immunocompromised Women).

The following table summarizes the recommendations on cervical cancer screening for HIV Negative Immunocompromised Women:

F. How should we manage women with abnormal Pap smears?

F1. Atypical Squamous Cells of Undetermined Significance (ASC-US)

RECOMMENDATION:

• For women with ASC-US cytology, reflex HPV testing should be done

• If HPV test cannot be done, repeat cytology at 1 year should be done.
• Colposcopy may be offered as another option.

Quality of evidence: 2a
Strength of recommendation: B

RECOMMENDATION:

• For women aged 21-24 years with ASC-US, cytology alone at 12-month intervals should be done. Reflex HPV testing may also be advised.

Quality of evidence: 2 a
Strength of recommendation: B

RECOMMENDATION:

• Women 65 years and older with ASC-US cytology should have reflex HPV testing done. Colposcopy should be done if HPV is positive. If HPV test is negative, repeat co-testing (preferred), or cytology alone (acceptable) in 1 year should be done.

Quality of evidence: 2a
Strength of recommendation: B

RECOMMENDATION:

• Pregnant women with ASC-US should be managed the same as in the non-pregnant population, except that deferring colposcopy until 6 weeks postpartum is acceptable.

• Endocervical curettage should not be done for pregnant women.

F2. Low-Grade Squamous Intraepithelial Lesion (LSIL)

RECOMMENDATION:

• Colposcopy should be done for women with LSIL cytology and with either positive HPV test or HPV test not done. If the HPV test is negative, repeat co-testing at 1 year is the preferred management, but colposcopy is also acceptable.

Quality of evidence: 1 a
Strength of recommendation: A

• For women 21-24 years with LSIL, follow-up with cytology at 12-month intervals should be done.

Quality of evidence: 2a
Strength of recommendation: B

RECOMMENDATION:

• For pregnant mothers with LSIL, colposcopy should be recommended.

Quality of evidence: 2 a
Strength of recommendation: B

RECOMMENDATION:

• Endocervical curretage should not be done in pregrnant women.

Quality of evidence: 3a
Strength of recommendation: E

RECOMMENDATION:

• For pregnant women 21 – 24 years old with LSIL, the same recommendations as for non-pregnant women of the same age group should be followed. Deferring colposcopy after 6 weeks postpartum is acceptable.

• For postmenopausal women with LSIL, the following options may be advised: HPV testing , repeat cytology at 6 and 12 months, and colposcopy.

F3. Atypical Squamous Cells: Cannot Exclude High-grade Squamous Intraepithelial Lesion (ASC-H)

RECOMMENDATION:

• For women with ASC-H cytology, colposcopy, should be performed regardless of HPV result.

Quality of evidence: 2 a
Strength of recommendation: D

• Women with HSIL cytology should undergo immediate loop electrosurgical excision (LEEP) or colposcopy.

Quality of evidence: 2a
Strength of recommendation: B

RECOMMENDATION:

• For women aged 21 – 24 years with HSIL, colposcopy should be done.

Quality of evidence: 2 a
Strength of recommendation: A

F5. Atypical Glandular Cells (AGC), Cytologic Adenocaronoma In Situ (AIS), Benign Glandular Changes

RECOMMENDATION:

• For women with all subcategories of AGC and AIS, except atypical endometrial cells, colposcopy with endocervical sampling should be done regardless of HPV status

Quality of evidence: 2 a
Strength of recommendation: A

• Endometrial sampling should be done in conjunction with colposcopy and endocervical sampling on women 35 years of age and older, and in those younger than 35 years but with clinical indications suggesting they may be at risk for endometrial neoplasia (unexplained vaginal bleeding, chronic anovulation, etc).

Quality of evidence: 2a
Strength of recommendation: B

RECOMMENDATION:

• For women with atypical endometrial cells, endometrial and endocervical sampling should be done. Colposcopy may also be acceptable.

Quality of evidence: 2 a
Strength of recommendation: A

RECOMMENDATION:

• For pregnant women with AGC, management should be identical to that of non-pregnant women (Level 3a, Grade B), except that endocervical curretage and endometrial biopsy are unacceptable (Level 3a, Grade E).

Quality of evidence: 3a
Strength of recommendation: B; E

RECOMMENDATION:

• The endometrium should be assessed for post menopausal women with benign endometrial cells.

• Asymptomatic premenopausal women with benign endometrial cells, endometrial stromal cells or histiocytes, should not undergo further evaluation.

RECOMMENDATION: Post-hysterectomy patients with a cytologic report of benign glandular cells should not undergo further evaluation.

Quality of evidence: 2 a
Strength of recommendation: B

G. How should we manage women diagnosed with premalignant lesions?

G1. CERVICAL INTRAEPITHELIAL NEOPLASIA (CIN) 1 (also known as Low Grade Intraepithelial Lesion/LSIL using the two tier classification system)

RECOMMENDATION:

• Women with No Lesion or CIN 1 preceded by ASC-US or LSIL cytology, HPV 16+ or 18+, and persistent HPV, should undergo co-testing at 12 months. If CIN 1 is detected on endocervical sampling, management is thge same, but a repeated endocervical sampling  in 12 months should also be done.

Quality of evidence: 2 a
Strength of recommendation: B

• For women with no lesion or CIN 1 preceded by ASC-H or HSIL cytology, any of the following may be done:
  (1) diagnostic excisional procedure, or
  (2) co-testing at 12 and 24 months if colposcopic examination is adequate and the endocervical sampling is negative, or
  (3) a review of the cytologic, histologic and colposcopic findings.

RECOMMENDATION:

• For women aged 21-24 years with CIN 1 after ASC-US or LSIL cytology, a repeat cytology at 12-month intervals should be done.

Quality of evidence: 2 a
Strength of recommendation: E

RECOMMENDATION:

Quality of evidence: 2a
Strength of recommendation: B

RECOMMENDATION:

• For pregnant women with CIN 1, follow-up without treatment should be recommended.

• For women win CIN 2, CIN 3, or CIN 2,3 and adequate colposcopy, both excision and ablation may be done, except in pregnant women and young women.

RECOMMENDATION:

• For recurrent CIN 2, CIN 3, or CIN 2,3, or inadequate colposcopy, or endocervical sampling showing CIN 2, CIN 3, or CIN 2,3, a diagnostic excisional procedure must be done.

Quality of evidence: 2 a
Strength of recommendation: A

RECOMMENDATION:

• For young women with CIN 2,3 not otherwise specified, either excision, ablation, or observation with both colposcopy and cytology at 6-month intervals for up to 12 months may be done, provided that colposcopy is adequate.
• When a diagnosis of CIN 2 is specified in young women, the preferred management is observation with colposcopy and cytology every 6 months for 12 months. Treatment with either ablation or excision may also be done.
• When CIN 3 is specified or colposcopy is inadequate, excision or ablation should be done.

Quality of evidence: 2a
Strength of recommendation: B

RECOMMENDATION:

• For pregnant women with CIN 2, CIN 3, or CIN 2,3, additional colposcopic and cytologic examinations at intervals not more frequent than every 12 weeks should be done. Repeat biopsy during pregnancy is recommended only if the appearance of the lesion worsens, or if cytology suggests invasive cancer. However, deferring reevaluation at 6 weeks postpartum is acceptable. A diagnostic excisional procedure may be done only if invasion is suspected.

Quality of evidence: 2a
Strength of recommendation: B

G3.  Adenocarcinona-in-situ (AIS)

RECOMMENDATION:

• For women who have completed childbearing and have histologic diagnosis of AIS from a diagnostic excisional procedure, hysterectomy should be done.

Quality of evidence: 3a
Strength of recommendation: B

RECOMMENDATION:

• If future fertility is desired, conservative management may be done.

Quality of evidence: 2a
Strength of recommendation: A