Cervical Cancer Screening: Pap

and HPV Tests

 Each year, more than 13,000 women are diagnosed with
cervical cancer in the United States. Yet cervical cancer is
one of the most preventable cancers today. In most cases
cervical cancer can be prevented through early detection
and treatment of abnormal cell changes that occur in the
cervix years before cervical cancer develops.
 We now know that these cell changes are caused by human
papillomavirus, commonly known as HPV. The traditional
test for early detection has been the Pap test. For women
age 30 and over, an HPV test is also recommended. HPV
tests can find any of the high-risk types of HPV that are
commonly found in cervical cancer. (One HPV test has
recently been approved for use as primary cervical cancer
screening for women age 25 and older, followed by a Pap
test for women with certain results.)
 Current guidelines for cervical cancer screening are:
 Women should start screening with the Pap test at age 21.
(Screening is not recommended for women under age 21.)
 Starting at age 30, women have three options available for
screening:
 A Pap test alone every three years
 Co-testing with a Pap and HPV test, every five years
 An HPV test alone, every five years
 Depending on the results of the Pap and/or HPV tests, a
healthcare provider may recommend additional screening or
procedures, so some women may be screened more often.
 After age 65, women older than 65 who have had adequate
prior screening and are not otherwise at high risk can stop
screening. Women who have had a hysterectomy (with removal
of the cervix) also do not need to be screened, unless they have
a have a history of a high-grade precancerous lesions.
 The Pap test finds changes in the cells of the cervix (the mouth of the womb) that
are not normal. When a female has a Pap test, she is positioned on an exam table
and a device called a speculum is gently inserted to open the vagina. The
speculum allows the healthcare provider to view the cervix and upper vagina.
Once the provider can see the cervix, a “broom” device or a brush/spatula
combination will be used to collect the cells. While the technique is a little
different depending on the device chosen, in general, the provider will gently
rotate the device in the endocervix (the cervical canal) and the ectocervix (the
portion of the cervix extending into the vagina) to collect squamous and
glandular cells. The cells are sent to a laboratory where they are prepared and
evaluated under a microscope.
 The Pap test looks for any abnormal or precancerous changes in the
cells on the cervix. If the Pap test results show these cell changes, this
is usually called cervical dysplasia. Other common terms the
healthcare provider may use include:
 Abnormal cell changes
 Precancerous cells changes
 CIN (cervical intraepithelial neoplasia)
 SIL (squamous intraepithelial lesions)
 “Warts” on the cervix
 All of these terms mean similar things—it simply means that
abnormalities were found. Most of the time, these cell
changes are due to HPV. There are many types of HPV that
can cause cervical dysplasia. Most of these types are
considered “high-risk” types, which means that they have
been linked with cervical cancer.
 Just because a woman has cervical dysplasia, it does not
mean she will get cervical cancer. It means that her
healthcare provider will want to closely monitor her cervix
every so often – and possibly do treatment – to prevent
further cell changes that could become cancerous over time
if left unchecked.
 HPV Tests
 HPV tests can find any of the high-risk types of HPV that are most
commonly found in cervical cancer. The presence of any of these
HPV types in a woman for many years can lead to cell changes that
may need to be treated so that cervical cancer does not occur. The
HPV test is done at the same time as the Pap test by using a small
soft brush to collect cervical cells that are sent to the laboratory, or
the HPV testing sample may be taken directly from the Pap sample.
 A word about genotyping: two “high risk” HPV types
(also called “genotypes), HPV 16 and HPV 18, are
responsible for about 70% of cervical cancers
worldwide. Knowing if a woman has these types of
HPV gives healthcare providers more insight into her
risk for developing cervical cancer.
 Recently the cobas® test was approved for use with women age 25
and older for primary cervical cancer screening (meaning it can be
done alone without a Pap test). The test is followed by a Pap test for
women with certain results.  the exact test or tests used is not as
important as simply being screened regularly! .
 Preparing for a Pap and/or HPV Test
 steps to ensure you get the best possible results from your Pap or HPV
test.
 to schedule the test on a day when you do not expect to be on your
menstrual period. If your period begins unexpectedly and will be
continuing on the day of your test, try to reschedule the appointment.
 Avoid sexual intercourse 48 hours before the test.
 Do not douche 48 hours before the test.
 Do not use tampons, or vaginal creams, foams, films, or jellies (such as
spermicides or medications inserted into the vagina) for 48 hours before
the test
 Results
 There are many different systems that healthcare providers use to classify a
Pap test. Within each system, there are different degrees of severity or
abnormalities. The various classification systems and degrees of severity
include:
 Descriptive System: Mild dysplasia, Moderate dysplasia, Severe dysplasia
 CIN System CIN stands for cervical intraepithelial neoplasia. Results are
classified as CIN 1, CIN 2, CIN 3
 Bethesda System:
 ASC-US (Atypical Squamous Cells of Undetermined Significance): Means the
results look borderline between “normal” and “abnormal” – often not HPV-
related
 ASC-H (Atypical Squamous Cells-can not exclude HSIL):Borderline results, but
may really include High-Grade lesions.
 Low-Grade SIL (LSIL) and High-Grade SIL (HSIL): SIL stands for squamous
intraepithelial lesion. LSILs are considered mild abnormalities usually caused by
an HPV infection. HSILs are considered more severe abnormalities and have a
greater chance of progressing to invasive cancer.
 Women with abnormal Pap test results are usually examined
further for cervical problems. This may involve coming back
for a colposcopy and biopsy, or coming back in a few months
for another Pap test. If the Pap result is “ASC-US,” then a
HPV-DNA test may be done in the lab to see whether HPV is
causing this borderline “normal-abnormal” Pap result.
 What if Pap test results are abnormal?

 If a Pap test shows abnormal cells, additional tests may be

performed. These tests include:
 Colposcopy: A colposcopy is an examination of the vagina
and cervix using a lighted magnifying instrument called a
colposcope.
 Cervical biopsy: In a biopsy, the healthcare provider removes a small
amount of tissue for examination under a microscope to look for
precancerous cells or cancer cells. Most women have the biopsy in the
doctor’s office, and no anesthesia is needed. To do the biopsy, the
doctor will insert a speculum to hold the vagina open and take a very
small sample. After the sample is taken, it will be sent to a laboratory
where another doctor checks the tissue using a microscope. You may
experience some bleeding and discharge after the exam and
discomfort similar to menstrual cramps. Ibuprofen can be taken to
relieve these symptoms.
 Colposcopic biopsy: While viewing your cervix with a colposcope, the
healthcare provider removes a tiny portion of abnormal tissue from the
surface of the cervix with a special tweezers. The cells are then
examined under a microscope.
 Endocervical curettage: A procedure in which the mucous
membrane of the cervical canal is scraped using a spoon-shaped
instrument called a curette. This can be done in your healthcare
provider’s office and does not require anesthesia. There may be some
cramping and bleeding after the procedure.
 Cone biopsy: A cone-shaped sample of tissue is removed from the
cervix to see if abnormal cells are in the tissue beneath the surface of
the cervix. This specimen is much bigger than the biopsy done in the
office without anesthesia. A sample of tissue can be removed for a
cone biopsy using a LEEP cone procedure, which can be done under
local anesthesia, or a knife cone procedure, done in an operating room
under local or general anesthesia. You may have some vaginal
bleeding for about a week and some spotting for about three weeks
after the procedure.
 LEEP (Loop Electro-Surgical Excision Procedure): The
LEEP is performed using a small heated wire to remove
tissue and precancerous cells from the cervix. This
procedure can be done in your provider’s office and requires
local anesthesia. There may be some cramping during and
after the procedure. You may have moderate to heavy
vaginal discharge that lasts for up to three weeks.
 Women who are at high risk of cervical cancer because of a
suppressed immune system (for example from HIV infection, organ
transplant, or long-term steroid use) or because they were exposed to
DES in utero may need to be screened more often. They should
follow the recommendations of their health care team.
 Women of any age should NOT be screened every year by any
screening method.
 Women who have been vaccinated against HPV should still follow
these guidelines.
 Some women believe that they can stop cervical cancer screening once they have
stopped having children. This is not true. They should continue to follow
American Cancer Society guidelines.
 Although annual (every year) screening should not be done, women who have
abnormal screening results may need to have a follow-up Pap test (sometimes
with a HPV test) done in 6 months or a year.
 The American Cancer Society guidelines for early detection of cervical cancer do
not apply to women who have been diagnosed with cervical cancer, cervical pre-
cancer, or HIV infection. These women should have follow-up testing and
cervical cancer screening as recommended by their health care team.
 Importance of being screened for cervical cancer

 Cervical cancer was once one of the most common causes of cancer death for
American women. The cervical cancer death rate dropped significantly with the
increased use of the Pap test for screening. But the death rate has not changed much
over the last 15 years.
 Screening tests offer the best chance to have cervical cancer found early when
successful treatment is likely. Screening can also actually prevent most cervical
cancers by finding abnormal cervical cell changes (pre-cancers) so that they can be
treated before they have a chance to turn into a cervical cancer.
 Despite the recognized benefits of cervical cancer screening, not all American women
get screened. Most cervical cancers are found in women who have never had a Pap
test or who have not had one recently. Women without health insurance and women
who have recently immigrated are less likely to have cervical cancer screening.