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Updates on Cervical Screening, Mammograms, and HPV Darren Adams, D.O., FACOOG June 4, 2010 Primary Care Symposium.

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Presentation on theme: "Updates on Cervical Screening, Mammograms, and HPV Darren Adams, D.O., FACOOG June 4, 2010 Primary Care Symposium."— Presentation transcript:

1 Updates on Cervical Screening, Mammograms, and HPV Darren Adams, D.O., FACOOG June 4, 2010 Primary Care Symposium

2 Conflicts of interest I do not own stock, lecture or act as a paid spokesman for any company.

3 Objectives 1. Review Mammogram Controversies and recommendations. 2. Review ACOG Cervical screening recommendations. 3. Discuss HPV vaccination guidelines.

4 Mammograms The USPTF is comprised of an independent panel of experts in Primary care and prevention No new trials performed, reviewed data that has been available for years.

5 Mammograms The USPTF states that the risk reduction afforded by Mammography in the 39-49 and 50-59 age ranges is the same ~0.85/0.86 However they state the Absolute risk in the 40’s is lower than other groups so potential harm may outweigh benefits 0.05 women could develop cancer 10-30 years from the small amount radiation exposure

6 Mammograms The recommendation to not screen in this age group reflects a value judgment both on the risks and benefits and acceptable cost These value judgments on risks and benefits based on a less than perfect screening modality There is no data about whether women would sacrifice years of life, for reduced anxiety of increased screening

7 Mammograms ACOG still recommends screening mammograms every 1-2 years in the 40-49 and annually after age 50

8 Mammograms HHS Secretary Kathleen Sebelius states that CMS would not be changing its mammogram coverage policy

9 Mammograms The USPSTF recommends against routine screening mammography in women aged 40 to 49 years. The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms. (grade C recommendation)

10 Mammograms The USPSTF recommends biennial screening mammography for women aged 50 to 74 years. (grade B recommendation) The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older. (grade I statement)

11 Mammograms The USPSTF recommends against teaching breast self-examination (BSE). (grade D recommendation) The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination (CBE) beyond screening mammography in women 40 years or older (grade I statement)

12 Mammograms The American College of Obstetricians and Gynecologists (ACOG) maintains its current advice that women in their 40s continue mammography screening every one to two years and women age 50 or older continue annual screening. Screening mammography every 1-2 years for women aged 40-49 years

13 Mammograms ACOG Screening mammography every year for women aged 50 years or older. BSE has the potential to detect palpable breast cancer and can be recommended. CBE every year for women aged 19 or older

14 Mammograms ACOG strongly supports shared decision making between doctor and patient, and in the case of screening for breast cancer, it is essential.

15 Breast Cancer Screening Recommendations Organization/NationStart Mammograms (age)Frequency (years) USPSTF502 AAFP401-2 American Cancer Society401 American College of Ob-Gyn401-2 A College of Preventive Medicine501-2 A College of Radiologists401 World Health Organization501-2

16 Hereditary Breast cancer Approximately 7% of breast cancer results from genetic mutations The majority (approximately 84%) of hereditary breast and ovarian cancer results from inherited mutations in two genes called BRCA1 (52%) and BRCA2 (32%). About 1 in 500 people carry a mutation in either the BRCA1 or the BRCA2 genes Generally, mutations in BRCA1 and BRCA2 are associated with a 45% to 87% risk of breast cancer by age 70

17 Hereditary Breast cancer The high survival rate of women diagnosed with early- stage breast cancer warrants heightened surveillance for women who carry mutations in BRCA1 and BRCA2 Screening should commence at an earlier age in recognition of the early age of onset of hereditary breast cancer The National Comprehensive Cancer Network, recommends the initiation of clinical breast examinations, mammography, and MRI at age 25

18 Surveillance for Hereditary Breast Cancer Cancer 2004;100:479-89 NEJM 2004;351:427-37 ProcedureAge to beginFrequency Breast self-exam18 yrsMonthly Clinical breast exam 25 yrsTwice a year Mammography25 yrsYearly MRI25 yrsYearly

19 “Red Flags” for Hereditary Breast and Ovarian Cancer Syndrome Breast cancer before age 50 Ovarian cancer at any age Male breast cancer at any age Multiple primary cancers Ashkenazi Jewish ancestry Relatives of a BRCA mutation carrier Cancer 2005 Dec 15;104(12):2807-16 Science 2003;302:643-6 American Society of Breast Surgeons, June 12, 2006


21 Cervical Screening The incidence of cervical cancer has decreased more than 50% in the past 30 years because of widespread screening with cervical cytology. The American Cancer Society estimates 11,270 new cases of cervical cancer in the United States in 2009, with 4,070 deaths from the disease

22 Cervical Screening Cervical cancer screening should begin at age 21 years The recommendation to start screening at age 21 years regardless of the age of onset of sexual intercourse is based in part on the very low incidence of cancer in younger women. It is also based on the potential for adverse effects associated with follow-up of young women with abnormal cytology screening results.

23 Cervical Screening In contrast to the high rate of infection with HPV in sexually active adolescents, invasive cervical cancer is very rare in women younger than age 21 years.

24 Cervical Screening Cervical cytology screening is recommended every 2 years for women aged 21–29 years, with either conventional or liquid-based cytology. Women aged 30 years and older who have had three consecutive cervical cytology test results that are negative for intraepithelial lesions and malignancy may be screened every 3 years.

25 Cervical Screening Certain risk factors have been associated with CIN in observational studies; women with any of the following risk factors may require more frequent cervical cytology screening: –Women who are infected with human immunodeficiency virus (HIV) –Women who are immunosuppressed (such as those who have received renal transplants) –Women who were exposed to diethylstilbestrol in utero –Women previously treated for CIN 2, CIN 3, or cancer

26 Cervical Screening It has been demonstrated, however, that the rate of dysplasia decreases as the number of sequential negative Pap test results increases

27 Cervical Screening Formal cost-effective analysis of data from this national program showed that the most cost-effective strategy for cervical cancer screening is cytology testing no more often than every 3 years in women with prior normal screening test results

28 Cervical Screening It is important to educate patients about the nature of cervical cytology, its limitations, and the rationale for prolonging the screening interval beyond every year. In addition, regardless of the frequency of cervical cytology screening, physicians also should inform their patients that annual gynecologic examinations may still be appropriate even if cervical cytology is not performed at each visit.

29 Cervical Screening Because cervical cancer develops slowly and risk factors decrease with age, it is reasonable to discontinue cervical cancer screening at either 65 years of age or 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. If screening is discontinued, risk factors should be assessed during the annual examination to determine if reinitiating screening is appropriate

30 Cervical Screening Women who had high-grade cervical intraepithelial lesions before hysterectomy can develop recurrent intra-epithelial neoplasia or carcinoma at the vaginal cuff many years postoperatively

31 Cervical Screening Women who have had a hysterectomy with removal of the cervix and have a history of CIN 2 or CIN 3—or in whom a negative history cannot be documented—should continue to be screened even after their period of post treatment surveillance. Whereas the screening interval may then be extended, there are no good data to support or refute discontinuing screening in this population.


33 HPV More than 100 genotypes of HPV have been discovered 30 of these effect the genital tract, and 15 of these have been associated with cervical cancer 70 % of cervical cancer result from infection with HPV 16 and 18 90% of Genital wart are caused by 6 and 11

34 HPV Human papillomavirus causes carcinogenesis in the transformation zone of the cervix, where the process of squamous metaplasia replaces columnar with squamous epithelium

35 HPV Human papillomavirus infections are commonly acquired by young women shortly after the initiation of vaginal intercourse but, in most, they are cleared by the immune system within 1– 2 years without producing neoplastic changes. The risk of neoplastic transformation increases in those women whose infections persist

36 HPV Since infection is sexually transmitted and is usually transient, the prevalence of HPV infections is highest among sexually active women in their 20s

37 HPV Clearance

38 HPV The majority of HPV infections are self- limited and spontaneously clear within a several-year period as a result of cell- mediated immunity By 23 months, more than 80% had cleared their HPV infections

39 HPV Although the clinical significance of HPV perinatal transmission is unknown, this route of transmission is well documented. A recent study of oral and genital HPV infections in infants born to both HPV-positive and HPV- negative women detected HPV DNA in 6% of the infants at birth, 13% at 6 weeks after birth, and 9% between 3 to 24 months of age

40 HPV There are 2 Vaccinations that are currently approved by the FDA: Gardasil Cervarix

41 HPV Testing for HPV is currently not recommended before vaccination

42 HPV Gardasil was approved for use in 2006 Gardasil is a quadra valent inactivated vaccine that protects against Low Risk HPV 6 and 11 and High Risk 16 and 18. Gardasil is approved for both Females and Males form age 9-26

43 HPV Gardasil is a recombinant vaccine Best given prior to exposure to HPV 3 dose series –Now –2 months after first dose –6 months after first dose –No booster recommended

44 HPV Gardasil should not be given to those with Yeast Allergy

45 HPV Cervarix approved in 2009 Cervarix is a bivalent vaccine that protects against High Risk HPV 16-18 3 dose series –Now –2 months after first dose –6 months after first dose –No booster recommended

46 HPV Cervarix should not be given to those with Latex allergy

47 HPV vaccination guidelines Organization/NationStart VaccineCatch Up ACIP 11-1213-2 6 American College of Ob-Gyn9-26 American Cancer Society11-18None World Health Organization9-13

48 HPV Vaccination of immunosuppressed patients is not contraindicated, yet they may not mount a robust response Males can be vaccinated with Gardasil but not Cervarix at this time

49 Future ? Anal Pap smears –4000 cases of anal cancer in women in 2003 and in contrast to cervical cancer the rates are increasing

50 Objectives 1. Review Mammogram Controversies and recommendations. 2. Review ACOG Cervical screening recommendations. 3. Discuss HPV vaccination guidelines.

51 References 1: ACOG Committee on Practice Bulletins--Gynecology. ACOG Practice Bulletin no. 109: Cervical cytology screening. Obstet Gynecol. 2009 Dec;114(6):1409-20. PubMed PMID: 20134296. 2: American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 99: management of abnormal cervical cytology and histology. Obstet Gynecol. 2008 Dec;112(6):1419-44. PubMed PMID: 19037054. 3: Committee on Adolescent Health Care. ACOG Committee Opinion No. 436: evaluation and management of abnormal cervical cytology and histology in adolescents. Obstet Gynecol. 2009 Jun;113(6):1422-5. PubMed PMID: 19461460. 4: American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 99: management of abnormal cervical cytology and histology. Obstet Gynecol. 2008 Dec;112(6):1419-44. PubMed PMID: 19037054. 5: American College of Obstetricians and Gynecologists. ACOG Practice Bulletin. Clinical Management Guidelines for Obstetrician-Gynecologists. Number 61, April 2005. Human papillomavirus. Obstet Gynecol. 2005 Apr;105(4):905-18. PubMed PMID: 15802436.

52 References 6: Lebovic GS, Hollingsworth A, Feig S. Risk assessment, screening and prevention of breast cancer: A look at cost-effectiveness. Breast. 2010 Apr 15. [Epub ahead of print] PubMed PMID: 20399656. 7: Smith RA, Cokkinides V, Brooks D, Saslow D, Brawley OW. Cancer screening in the United States, 2010: a review of current American Cancer Society guidelines and issues in cancer screening. CA Cancer J Clin. 2010 Mar-Apr;60(2):99-119. Review. PubMed PMID: 20228384. 8: US Preventive Services Task Force. Screening for breast cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2009 Nov 17;151(10):716-26, W-236. Erratum in: Ann Intern Med. 2010 Feb 2;152(3):199-200. PubMed PMID: 19920272. 9: Bevers TB, Anderson BO, Bonaccio E, Buys S, Daly MB, Dempsey PJ, Farrar WB, Fleming I, Garber JE, Harris RE, Heerdt AS, Helvie M, Huff JG, Khakpour N, Khan SA, Krontiras H, Lyman G, Rafferty E, Shaw S, Smith ML, Tsangaris TN, Williams C, Yankeelov T; National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: breast cancer screening and diagnosis. J Natl Compr Canc Netw. 2009 Nov;7(10):1060-96. Review. Erratum in: J Natl Compr Canc Netw. 2010 Feb;8(2):xxxvii. Buys, Sandra [corrected to Buys, Saundra]; Yaneeklov, Thomas [corrected to Yankeelov, Thomas]. PubMed PMID: 19930975. 10: Javitt MC, Hendrick RE. Revealing Oz behind the curtain: USPSTF screening mammography guidelines and the hot air balloon. AJR Am J Roentgenol. 2010 Feb;194(2):289-90. PubMed PMID: 20099408.

53 References 11: DeAngelis CD, Fontanarosa PB. US Preventive Services Task Force and breast cancer screening. JAMA. 2010 Jan 13;303(2):172-3. Erratum in: JAMA. 2010 Feb 17;303(7):621. PubMed PMID: 20068215. 12: Berg WA. Benefits of screening mammography. JAMA. 2010 Jan 13;303(2):168-9. PubMed PMID: 20068213. 13: Murphy AM. Mammography screening for breast cancer: a view from 2 worlds. JAMA. 2010 Jan 13;303(2):166-7. PubMed PMID: 20068212. 14: Woloshin S, Schwartz LM. The benefits and harms of mammography screening: understanding the trade-offs. JAMA. 2010 Jan 13;303(2):164-5. PubMed PMID: 20068211. 15: Woolf SH. The 2009 breast cancer screening recommendations of the US Preventive Services Task Force. JAMA. 2010 Jan 13;303(2):162-3. PubMed PMID: 20068210.

54 References 16: Lyman GH. Breast cancer screening: science, society and common sense. Cancer Invest. 2010 Jan;28(1):1-6. PubMed PMID: 20001293. 17: Rhea S. Critics pan screenings report. Mammogram policy could boost mortality rates. Mod Healthc. 2009 Nov 23;39(47):10-1. PubMed PMID: 19972676. 18: Hopkins R. Truth, justice and screening mammography. J Ark Med Soc. 2010 Feb;106(8):173. PubMed PMID: 20218034. 19: New mammography guidelines go against standard screening recommendations. Mayo Clin Womens Healthsource. 2010 Apr;14(4):3. PubMed PMID: 20195223. 20: Neal L, Tortorelli CL, Nassar A. Clinician's guide to imaging and pathologic findings in benign breast disease. Mayo Clin Proc. 2010 Mar;85(3):274-9. Review. PubMed PMID: 20194153; PubMed Central PMCID: PMC2843107.

55 References 21: Gemignani ML. The new mammographic screening guidelines: what were they thinking? Obstet Gynecol. 2010 Mar;115(3):484-6. PubMed PMID: 20177276. 22: Lee CH, Dershaw DD, Kopans D, Evans P, Monsees B, Monticciolo D, Brenner RJ, Bassett L, Berg W, Feig S, Hendrick E, Mendelson E, D'Orsi C, Sickles E, Burhenne LW. Breast cancer screening with imaging: recommendations from the Society of Breast Imaging and the ACR on the use of mammography, breast MRI, breast ultrasound, and other technologies for the detection of clinically occult breast cancer. J Am Coll Radiol. 2010 Jan;7(1):18-27. PubMed PMID: 20129267. 23: Thrall JH. US Preventive Services Task Force recommendations for screening mammography: evidence-based medicine or the death of science? J Am Coll Radiol. 2010 Jan;7(1):2-4. PubMed PMID: 20129260. 24: Beal K, McCormick B. Consensus statement: APBI from ASTRO (Int J Radiat Oncol Biol Phys 2009;74:987-1001). Int J Radiat Oncol Biol Phys. 2010 Feb 1;76(2):638; author reply 638-9. PubMed PMID: 20117295.

56 References 25: Armstrong EP. Prophylaxis of cervical cancer and related cervical disease: a review of the cost-effectiveness of vaccination against oncogenic HPV types. J Manag Care Pharm. 2010 Apr;16(3):217-30. PubMed PMID: 20331326. 26: Carlos RC, Dempsey AF, Patel DA, Dalton VK. Cervical cancer prevention through human papillomavirus vaccination: using the "teachable moment" for educational interventions. Obstet Gynecol. 2010 Apr;115(4):834-8. PubMed PMID: 20308846. 27: Smith EM, Parker MA, Rubenstein LM, Haugen TH, Hamsikova E, Turek LP. Evidence for vertical transmission of HPV from mothers to infants. Infect Dis Obstet Gynecol. 2010;2010:326369. Epub 2010 Mar 14. PubMed PMID: 20300545; PubMed Central PMCID: PMC2838362. 28: Broomall EM, Reynolds SM, Jacobson RM. Epidemiology, clinical manifestations, and recent advances in vaccination against human papillomavirus. Postgrad Med. 2010 Mar;122(2):121-9. Review. PubMed PMID: 20203463.

57 References 29: Muñoz N, Kjaer SK, Sigurdsson K, Iversen OE, Hernandez-Avila M, Wheeler CM, Perez G, Brown DR, Koutsky LA, Tay EH, Garcia PJ, Ault KA, Garland SM, Leodolter S, Olsson SE, Tang GW, Ferris DG, Paavonen J, Steben M, Bosch FX, Dillner J, Huh WK, Joura EA, Kurman RJ, Majewski S, Myers ER, Villa LL, Taddeo FJ, Roberts C, Tadesse A, Bryan JT, Lupinacci LC, Giacoletti KE, Sings HL, James MK, Hesley TM, Barr E, Haupt RM. Impact of human papillomavirus (HPV)-6/11/16/18 vaccine on all HPV-associated genital diseases in young women. J Natl Cancer Inst. 2010 Mar 3;102(5):325-39. Epub 2010 Feb 5. PubMed PMID: 20139221. 30: Szarewski A. HPV vaccine: Cervarix. Expert Opin Biol Ther. 2010 Mar;10(3):477-87. Review. PubMed PMID: 20132062. 31: Nour NM. Cervical cancer: a preventable death. Rev Obstet Gynecol. 2009 Fall;2(4):240-4. PubMed PMID: 20111660; PubMed Central PMCID: PMC2812875. 32: Gabutti G. Vaccine against papilloma virus: a review of the clinical studies. J Prev Med Hyg. 2009 Jun;50(2):79-89. Review. PubMed PMID: 20099437. 33: Campos-Outcalt D. The case for HPV immunization. J Fam Pract. 2009 Dec;58(12):660-4. PubMed PMID: 19961821.



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