Cervical Cancer and Human Papillomavirus: Prevention and Screening

Abstract

Cervical cancer screening is an example of a successful preventative strategy that markedly reduces the incidence of invasive cervical cancer (ICC) and mortality from ICC among women. Evolving screening guidelines utilizing cytology from Pap tests and high-risk human papillomavirus (hrHPV) detection have improved the identification of precursor lesions which are treated to prevent the progression to ICC. Guidelines differ by patient age and immune status, but all persons with a cervix of ages 21–65 years, regardless of sexual orientation, sexual history, or gender identity, need to be screened regularly. Understanding the natural history of HPV and cervical abnormalities is essential for the proper triage of patients with positive testing to either repeat testing or referral for colposcopy. The HPV vaccine prevents infection with hrHPV and holds promise to significantly reduce the future incidence of cervical cancer and other cancers caused by hrHPV in men and women. Significant disparities exist in the United States and worldwide in HPV vaccination rates, cervical cancer screening rates, and the evaluation, treatment, and follow-up of abnormal findings in women. These disparities continue to allow cervical cancer to be a major cause of morbidity and mortality for women worldwide.

Review Questions

• 1. A 19-year-old woman presents to the clinic to establish care with a doctor for adults. She had routine care with her pediatrician and completed the HPV vaccine series. She has been sexually active for 2 years and is on oral contraceptives. She was recently diagnosed with chlamydia and treated. Her mother told her that she needs a Pap smear. Which of the following is recommended?

  • A. She should be tested for high-risk HPV now.

  • B. She should have a Pap test with HPV co-testing now.

  • C. She should have a Pap test at age 21.

  • D. HPV testing should be performed at age 21.

    The correct answer is C. Pap testing should not start prior to age 21, even in sexually active women. HPV testing is not recommended for screening in women under age 30 (25 in some countries) except as a reflex test for abnormal Pap results. Her recent chlamydia diagnosis does not change these recommendations [17, 30].

• 2. A 66-year-old woman, who moved to the United States from India 1 year ago, comes in to establish care. She does not believe she has ever had a Pap test. She has stopped menstruating and denies any postmenopausal vaginal bleeding or discharge. Which of the following is correct?

  • A. She is asymptomatic and over age 65. Pap screening is not needed.

  • B. She should be tested with yearly Pap smears for the next 20 years because of her unknown history.

  • C. She should receive the three-dose HPV vaccination series.

  • D. She should undergo Pap and HPV co-testing today.

    The correct answer is D. Women over 65 may exit screening if they have been screened adequately in the past 10 years, with the most recent test in the last 5 years. Clinical judgment should be used in recommendations for her screening, but she should be screened now for HPV and cervical cancer and again in 3–5 years since she has not been adequately screened in the past 10 years. Yearly Pap smears are recommended for some high-risk women, but would not apply unless she was DES exposed, infected with HIV, immunosuppressed, or had a history of cervical or vaginal malignancy within the last 20 years. HPV vaccination is not approved for persons over 45 years of age [17, 30].

• 3. An undocumented 40-year-old Hispanic woman, G1P1, presents to the free mobile clinic for a Pap test. She and her family move frequently to find work. She does not remember how long ago she had her last Pap, but thinks it may have been abnormal. She is unsure if she has ever had a colposcopy. She undergoes Pap and HPV co-testing today and the clinic social worker meets with her to discuss ways to get insurance and housing for her family, because they are homeless.

  Which of the following is the most important next step before the patient leaves the clinic today?

  • A. Tell her that she is high risk for cervical cancer and refer her to gynecology.

  • B. Have her sign a release of information to get old records from all the prior healthcare facilities where she received care.

  • C. Determine how she should be contacted to receive her Pap test results, and fully explain why follow-up is very important.

  • D. Discuss that colon cancer screening starts at age 45 if she does not have a prior history of colorectal cancer.

    The correct answer is C. Healthcare disparities should be considered when seeing patients, and lack of follow-up for abnormal results is a serious issue in certain populations. Hispanic patients are an ethnic group that often has poor follow-up for abnormal test results, and undocumented persons are at particularly high risk. There must be a secure plan to reach the patient and arrange for follow-up if the Pap test is abnormal. Telling her that she is high risk for cervical cancer is premature and may cause unnecessary anxiety. Obtaining prior medical records should be attempted, but the ability to follow-up on the current testing is more important at this visit. Colon cancer screening is important, but will not be needed for 5 years [57].

• 4. A 30-year-old woman presents with 9-year-old twins, a girl and a boy. She asks if her daughter should get the HPV vaccine. What are the current recommendations for HPV vaccination?

  • A. Both children should be vaccinated at age 11 with two doses.

  • B. The daughter should be vaccinated at age 11, the son at age 9.

  • C. The daughter should be vaccinated with three doses, the son with two doses.

  • D. Both children should be vaccinated now with two doses.

    The correct answer is A. For children aged 9–14, the ACIP recommends a two-dose schedule for male and female patients, usually at ages 11–12. Children are vaccinated at age 9 in cases of immunosuppression or sexual abuse. The vaccination is approved for persons age 9–45, so clinical judgment can be used when making vaccination recommendations for adults [50].

• 5. A 31-year-old woman with HIV comes in to establish primary care. She was diagnosed with HIV at age 27 and has had three normal annual Pap smears. Her most recent testing at age 30 was normal cytology and HPV negative. How often should she receive a Pap test in the future?

  • A. Every 3 years for life.

  • B. Every 5 years with HPV co-testing until age 65.

  • C. Annually, may discontinue at age 65.

  • D. Biannually for life.

    The correct answer is A. The current guidelines for HIV-positive women, which is based on limited data, recommend annual Pap starting at the time of diagnosis. At age 30, co-testing should be done. If co-testing is normal, the next testing can be delayed for 3 years. Screening does not end at age 65. These recommendations do not change based on the use of antiretroviral therapy, CD4 counts, or viral load [64].

• 6. A 32-year-old woman presents for care. She states that she is a virgin and is refusing a pelvic examination or Pap test. She said that she was told by her last physician that she was at very low risk for cancer, and therefore, Paps were not needed. Which of the following statements is correct according to current guidelines?

  • A. She is at risk of cervical cancer despite her sexual history, and she should be made to sign an “against medical advice” form if she refuses testing.

  • B. All women should be screened for cervical cancer despite sexual history starting at age 21.

  • C. She should self-test for HPV and only get a Pap if the results are positive.

  • D. Women who have sex with women, nuns, and virgins do not need Pap tests.

    The correct answer is B. All persons with a cervix should be screened for cervical cancer between the ages of 21 and 65, regardless of sexual history, sexual orientation, or gender identity. Although persons who have never had penetrating sexual intercourse with a man may be at lower risk, HPV is spread through other forms of contact. A prior history of sexual contact or sexual assault may be denied or not remembered by the patient. The idea of self-collection of a vaginal collection for HPV screening has merit and is being suggested for screening in some lower-resource settings, but there are no current guidelines to guide its use. If she refuses pelvic examination, she should not be pressured or traumatized, but relationship building and patient education may, in time, change her mind about the screening. Refusals of recommended care, and discussions of the risks to the patient of not screening, should be clearly documented in the medical record [17].