UPDATE ON CERVICAL DISEASE

The pap test is not a screening test for Std

Other findings that may be useful for all clinicians, as well as for those who practice in an STD clinic:

• The Pap test is not a screening test for STD
• All eligible women should undergo cervical cancer screening, regardless of sexual orientation (i.e., heterosexual, lesbian, or bisexual)
• Conventional cytology should be delayed if the patient is menstruating, and she should be advised to undergo a Pap test at the earliest opportunity
• If specific infections other than HPV are identified, the patient may need to undergo a repeat Pap test after appropriate treatment for those infections. However, in most instances, the Pap test will be reported as satisfactory for evaluation, and a reliable final report can be produced without the need to repeat the Pap test after treatment.
• The presence of a mucopurulent discharge should not delay the Pap test. The test can be performed after careful removal of the discharge with a saline-soaked cotton swab.
• When the Pap test is repeated because the previous test was interpreted as unsatisfactory, the patient should not be returned to regular screening intervals until the Pap test is reported as satisfactory and negative
• Cervical screening should not be accelerated for women who have genital warts and no other indication.

When colposcopic biopsy is indicated, take more than one sample

Stoler MH, Vichnin MD, Ferenczy A, et al; the FUTURE I, II and III Investigators. The accuracy of colposcopic biopsy: Analyses from the placebo arm of the Gardasil clinical trials. Int J Cancer. 2011;128(6):1354–1362.

The progress we have made in cervical cancer prevention is largely due to our ability to detect and treat precancer, particularly CIN 3, before it gains the capacity to invade. Until recently, few experts would have questioned the value of the partnership between cervical cytology screening and treatment of lesions detected on colposcopically directed biopsy.⁴ However, over the past decade, the accuracy of colposcopy for detection of high-grade lesions has been widely questioned, first by studies assessing static digitized cervigrams or colposcopy photo images, and more recently by studies comparing “real-time” colposcopy to histology obtained during colposcopy or excisional biopsy, or both.

The largest of these studies was conducted by Stoler and colleagues to compare the results of colposcopically directed biopsy and subsequent cervical excision among 737 women (16 to 45 years old) in the placebo arm of the quadrivalent HPV vaccine (FUTURE) randomized, controlled trials. In these trials, all women were referred for colposcopy according to a Pap triage algorithm, and one or more biopsies was taken from the area with the greatest apparent abnormality, as viewed by colposcopy. When excisional treatment was indicated, a biopsy of the worst-appearing area was taken again just before the excision.

Each patient’s most severe pathology-panel diagnosis for the excisional specimen was compared with:

• the most severe biopsy result from the preceding 6 months (excluding the biopsy taken on the same day as the excisional procedure) (Analysis 1)
• the biopsy taken on the same day as the definitive excisional procedure (Analysis 2).

When CIN 2 and CIN 3 are managed similarly, a discrepancy of one degree between colposcopically directed biopsy and the excisional specimen is considered sufficient agreement. Therefore, in this study, a difference of one degree in histologic diagnosis was considered agreement.

High-grade disease was more likely to be underestimated
on the same-day biopsy

Colposcopically directed biopsies obtained within 6 months before definitive treatment (Analysis 1) had lower overall agreement with the excisional specimen than biopsies collected on the same day as definitive treatment (Analysis 2). However, underestimation of high-grade disease was lower (26% overall underestimation of CIN 2 or 3 or adenocarcinoma in situ [AIS]) on earlier biopsy specimens than on those collected on the same day as definitive treatment (57% overall underestimation of CIN 2 or 3 or AIS).

Conversely, overestimation, or removal, of disease was higher (36%) in biopsies collected within 6 months before the excisional treatment, compared with biopsies collected on the same day as definitive treatment (5%).

The investigators suggested that any discrepancy in accuracy between the biopsy obtained at treatment and the biopsy obtained earlier might be the result of less diligent colposcopic evaluation and biopsy placement when the colposcopist knew that definitive therapy would immediately follow. Another possibility, they noted, is that lesions biopsied as early as 6 months before definitive treatment may have regressed in the process of tissue repair or were completely removed by the biopsy.