1. Dr Kirtan Krishna MS , DNB, Fellowship in Fetal Medicine
Assistant Professor, OBG - PESIMSR , Kuppam
Consultant Fetal Medicine – Cloud 9 hospitals, Bangalore

2. PAP SMEAR
Dr. Kirtan Krishna

3. SECONDARY PREVENTION
Screening may help in early detection of cervical abnormalities

4. Community low resource settings
Tests Available
Visual Inspection
VIA
VILI
Pap Smear
Conventional
LBC
HPV DNA Testing
Cervicography
Pap Net
Polar Probe
Community low resource settings
Still Experimental

5. PAP SMEAR
PAP smear sampling of cervix involves scraping of cervical surface and a portion of non visualised cervical canal using various sampling devices

6. Cervical cancers and cervical pre-cancers are classified into 2 main types of cervical cancer: squamous cell carcinoma and adenocarcinoma.
About 80% to 90% of cervical cancers are squamous cell carcinomas.

7. Making pap smear more accurate
Try not to schedule an appointment for a time during the menses. The best time is at least 5 days after the menses stops.
Don't use tampons, birth-control foams or jellies, other vaginal creams, moisturizers, or lubricants, or vaginal medicines for 2 to 3 days before the test.
Don't douche for 2 to 3 days before the test.
Avoid sexual intercourse for 2 days before the test.

8. HOW TO TAKE A PAP SMEAR ?
Spatula is rotated through 360 degrees maintaining contact with ectocervix
Do not use too much force [bleeding /pain]
Do not use too less force [inadequate sample]
Sample is smeared evenly on the slide and fixed immediately
Both sides of spatula are to be smeared

9. HOW TO TAKE A PAP SMEAR ?
Endocervical sample is collected using an endocervical brush
Insert the cytobrush into canal, so that last bristles of brush are visible
Rotate the brush through 180 degrees. [more rotations increase the chance of bleeding]
Sample is rolled on the slide and fixed.

11. FIXATION OF SMEAR
Fixation is done immediately with fixative like 95% alcohol or cytofix spray to avoid air drying
Spray should be kept at inches, to avoid destruction of cells by propellent in the spray
Smear should monolayer for proper penetration of cell surface by fixative

12. Liquid based cytology
Insert the cytobrush into canal, so that last bristles of brush are visible
Rotate the brush through 180 degrees. [more rotations increase the chance of bleeding]
Detach the brush and immerse in the liquid(alcohol)

13. There is no evidence that LBC improves the accuracy of screening
Advantages of technique
LBC is semi-automated
It creates a uniform spread of epithelial cells that are easier to read by cytotechnicians and cytopathologists
reduces the rate of unsatisfactory samples.
The LBC sample may also be used for reflex testing for HPV DNA and other biomarkers like chlamydia at a later date
Several slides can be prepared from one smear

14. SCREENING GUIDELINES

15. American cancer society(ACS)
American society for colposcopy and cervical pathology (ASCCP) and American society for clinical pathology(ASCP)2012
U.S. Preventive Services Task Force (USPSTF)
2012
American colloege of Ostetricians and Gynacologists (ACOG)
Society of Gynaecological Oncology (SGO)and the American society for colposcopy and cervical pathology (ASCCP) :Interim clinicalguidance for primary hr HPV testing 2015
When to start screening
Age 21 . Women aged < 21 years should not be screened regardless of age of sexual initiation or other risk factors
Age 21(A recommendation) Recommend against screening woman aged < 21years ( D recommendation)
Age 21 regardless of the age of onset of sexual activity .Women aged < 21 years should not be screened regardless of age of sexual initiation and other behaviour relatedrisk factors ( Level A evidence)
Refer to major guidelines

16. Screening method and intervals
Cytology (conventional or liquid based)
yrs
30-65yrs
Every 3years
Every 3 years
Every 3yrs
Every 3 yrs
Not addressed
HPV co – test (cytology+ HPV test administered together)
HPV co testing should not be used for women aged <30 years(D)
Every 5 years
HPV co testing should not be usd for women aged <30 years(D)
Every 5 years(A)
HPV co testing should not be used for women aged <30 years(A)
Primary hr HPV testing( as an alternative to cotesting or cytology alone )
For women aged years , screening by hpv testing alone is not recommended in most clinical settings
Every 3 years . Recommend against primary hr HPV screening in women aged <25 years of age .

17. American cancer society(ACS)
American society for colposcopy and cervical pathology (ASCCP) and American society for clinical pathology(ASCP)2012
U.S. Preventive Services Task Force (USPSTF)
2012
American colloege of Ostetricians and Gynacologists (ACOG)
Society of Gynaecological Oncology (SGO)and the American society for colposcopy and cervical pathology (ASCCP) :Interim clinicalguidance for primary hr HPV testing 2015
When to stop screening
Aged >65 years with adequate negative prior screening and no history of CIN 2 or higher within the last 20 years .
(Adequate negative prior screening results are defined as 3 consecutive negative cytology prior 2 negative co test within previous 10 years , with the recent test performed within 5 years)
Aged >65 years with adequate screening history and are not otherwise at high risk for cervical cancer(D)
Aged >65years with adequate negative prior screening results and no history of CIN2 or higher(A)
Not addressed

18. NHS In the UK, the NHS Cervical Screening Programme screens:
women between 25 and 49 years every 3 years
women between 49 and 64 years every 5 years.

19. WHO guidelines 2013 Age at initiation – 30 yrs 30 – 49 yrs
Screening even once in a lifetime would be beneficial. Screening intervals may depend on financial, infrastructural, and other resources
3 screening tests – HPV preferrable, VIA & treat, cytology f/b colposcopy

21. National Guideline
Three (3) smears per lifetime, with a 10-year interval between each smear, commencing at not earlier than age 30 years.
LSIL and ASCUS: repeat the smear in 12 months’ time - If the diagnosis remains the same or worsens, refer for colposcopy If negative on the second smear - normal screening cycle.
HSIL and AGUS: refer to a colposcopy. If negative on colposcopy and cytology, the client can be discharged. If positive, treat.

22. A positive HPV test does not mean that a woman has cancer.
WHAT IS THE HPV TEST?
The HPV test is a very accurate way to tell if high-risk HPV is present in a woman’s cervix.
This test can use the same sample of cells taken for the Pap test.
A positive test result means a woman has high-risk HPV.
A positive HPV test does not mean that a woman has cancer.

23. HPV-based screening
Large RCTs, such as the ARTISTIC in the UK and a recent meta-analysis - HPV-based screening 60-70% better protection against invasive cervical cancer when compared to conventional or liquid based cytology.
It is expected that HPV-based screening will replace cytology-based screening, at least in women aged 30 or older.

25. Why no screening before 25yr?
Due to the rarity of invasive disease in women below 25.
HPV infection very common in younger age groups; the early identification of clinically insignificant lesions that are likely to regress - increase the risk of over-investigation and over-treatment - adversely impact reproductive outcomes

26. How Pap tests are reported

28. Features of dysplasia
1.enlarged cells with increased nucleocytoplasmic ratio. 2.Abnormal nucleus –in size,shape and number. 3.Irregularity of nuclear outline. 4.Hyperchromatic nuclei. 5.Condensation of chromatic material. 6.multinucleation.

29. MILD -nucleus occupies less than half of total area of cytoplasm
-cells are of superficial/intermediate type.
-nucleus occupies less than half of total area of cytoplasm

30. MODERATE Cells are of superficial,intermediate, parabasal type.
nucleus-1/2 to 2/3 of cytoplasm.

31. SEVERE Cells are of basal type.
Round,oval,polygonal or elongated –fibre cells with elongated tail of cytoplasm-tadpole cell

32. Unsatisfactory Smears
Should be repeated in 2-4 months
Papsmears which lack an endocervical component can be repeated in 1 year
If any of the following risk factors present should be screened every 6 months
-high risk HPV positivity
-previous glandular abnormality
-immunosupression
-inability to visualize endocervical canal
-non compliance
-history of ascus or greater abnormalities in the past without three interval normal pap

33. Take home message Screening is more important than the method
Universal sreening
Start from 21 – 25 yrs,
Every 3yrs upto 65 yrs or 5yrs with HPV co testing
Inadequate smears repeat after 3 months
Boderline smears repeat after 6 months
Missing endocervical glandular cells – repeat after 1 yr