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Melanie Cole (Host): Expert Insights is an ongoing medical education podcast. The Carle Division of Continuing Education designates that each episode of this enduring material is worth a maximum of 0.25 AMA PRA Category one credit. To collect credit, please click on the link and complete the episode’s posttest.

Today we’re talking about women’s health, screening for and management of cervical dysplasia. My guest is Aubrey Hudson, she’s a physician assistant in Obstetrics and Gynecology at the Carle Foundation Hospital. Aubrey, let’s just start with a little bit of the prevalence of cervical dysplasia and what is different about what we know about this disease today?

Aubrey Hudson (Guest): So the prevalence of cervical dysplasia and cervical cancer, we would want to differentiate. Cervical cancer rates have dropped dramatically in the last number of years, as we have the integrated cervical cancer screening. It is very – cervical dysplasia is not uncommon and the good news is most of the time, low grade cervical dysplasia actually will resolve on its own without much intervention.

Host: Let’s talk about the current screening guidelines, what’s going on today?

Aubrey: So, as of 2013, the American Society for Colposcopy and Cervical Pathology came out with new guidelines that really upended what we were used to. Historically we had been using just the Pap smear, done every year for all women and starting when they were first sexually active. Currently the recommendation is for screening starting at age 21 and screening through the age of 65 with a few stipulations. Women who have had a hysterectomy, who have not had any history of CIN-2 or greater can discontinue Pap smears. Also, women over 65 have to have met certain guidelines, in that they have not had CIN-2 or greater within the last 20 years and that they have had a certain number of negative screening Paps done within the last 10 years. That information can be referenced both out of the Pap smear order, there is a link to when you can start and when you can discontinue Paps within the Epic order here at Carle. There is also a smart phrase, which is called pap collection and it is embedded right in that smart phrase as to when it is appropriate to discontinue a Pap smear. The age from 21 to 29 the recommendation is for a Pap smear only. Starting at age 30, from 30 to 64 would be with a Pap and an HPV test together. This really improves catching the HPV positive women that might have a negative Pap but actually still have cervical dysplasia. There is gaining some more steam for primary HPV screening done in the 25 to 29 year-old population. We have not started to institute that greatly in our department, but I do think that’s something we’re going to see gaining speed in the near future.

Host: If women are having “testing” and there’s discordant results, what would you like providers to know about managing those results?

Aubrey: That’s a great question, so HPV16 and 18 really get highlighted and those positive tests are going to go straight to colposcopy regardless of their Pap result and I use – for the others, I think the harder ones are the HPV other group is positive or the Pap is ASCUS and HPV is negative, those really do take a little bit more digging in. The most important thing in interpreting those is knowing what the history is. If this woman has never had an abnormal Pap, it may be managed one way. Say an ASCUS, HPV negative in someone with no history of abnormal, they would come back in three years; whereas someone who has had a LEEP within the last two years, that women needs a colposcopy so it is really important to understand those discordant results. I like to use the ASCCP app on my phone or the ASCCP does have a detailed page pamphlet that you can use. The app is great because it takes you not only to the right place, it also lets you know what their risk of developing CIN-2, 3 or carcinoma in situ would be over the next five years so you can really understand their risk and communicate that to the patient as well as to why it’s so important to have follow up.

Host: Aubrey, what would you say is the most common misconception that you hear about Pap interpretation and recommended management?

Aubrey: Sure, I think there are two big things that I see. One is an over management and one is an under management. With those patients who do have an ASCUS, HPV negative and no history of abnormal, they really do not need a colposcopy. We sometimes get them sent to us for further workup when really they don’t need it and the other one also involves ASCUS. So the ASCUS, or atypical squamous cells of undetermined significance, is very, very different than AGCUS, which is atypical glandular cells of undetermined significance. These are not the same things. With ASCUS, we really do lean pretty heavily on what is the HPV result. So we need to look at both as to whether or not they need a colposcopy, whereas AGCUS, atypical glandular cells, needs a colposcopy no matter what. These glandular cells are the cells that are most concerning for the deeper problems in the cervix. There’s also concern there could be endometrial involvement. So in these women, depending on their age and other risk factors, they may also need an endometrial biopsy. This all may need to be done even if their HPV test is negative.

Host: What HPV test do you advise using?

Aubrey: We here at Carle have an HPV test that differentiates HPV16, HPV18, and then other. Not all HPV tests do that, which is why in the guidelines you will sometimes see that it says HPV typing is optional or something along those lines. I think that having the separate types is very important because HPV16 and 18 really are – I mean they cause 70% of cervical cancers. They really are more aggressive and really are a horse of a different color, and so that is much more helpful than just having a test that says HPV positive or HPV negative.

Host: Who doesn’t fit into the guidelines Aubrey?

Aubrey: So women who have HIV are probably the biggest thing that we want to think of. They do need annual Pap smears, and the CDC recommends from the time of diagnosis. Of course we’re not going to do a Pap on an infant if they’re diagnosed then, so then I think there’s some room for decision making, but HIV is really separate from this. And then also women who are severely immunocompromised. Say, someone who has had an organ transplant and is at that level of immunosuppression. And women over 65, again stopping at 65 is only if certain stipulations are met. If they’ve had CIN-2 or greater in the last 20 years or if they’ve ever had cervical cancer, those are not women who are ready to stop and may not be, that’s a more nebulous population there. So 65 is not a hard stop; it is a stop with stipulation.

Host: Give us a little bit of a clinical decision, analysis of what treatment or management you would do when someone’s determined to have cervical dysplasia.

Aubrey: So some of that depends on age, which really has – that is something that is very much changed from where we were say 20 years ago. We really are much less aggressive with women between the age of 21 and 24. Often their management would be to repeat a Pap in a year and we’ll do that up to a couple of years before we even do anymore investigation. So one thing I try to help the patients understand is the difference between colposcopy and treatment. Colposcopy is really just a diagnostic test. It is more of a confirmation test to see if what we saw in the Pap smear is actually really there. So that’s always the first step is colposcopy. And then the colposcopy result really guides are decision. So from that, if we see CIN-3, almost the vast majority of the time we’re doing a LEEP procedure in the office, the looped electrosurgical excisional procedure, which is both diagnostic and treatment. If we are seeing persistent disease after a LEEP, then sometimes we will move to a cone biopsy, which is done in the operating room, and hysterectomy is the ultimate treatment if we have dysplasia that is not treated with these local approaches, though the vast majority of the time, if caught early, the cervical dysplasia can be managed mostly in the office and with close follow up, usually with these less minor, less invasive treatments.

Host: In your opinion, Aubrey, where do you see immunization fitting into this picture of diagnosis and testing and management and co-testing, where do you see that going?

Aubrey: I think eventually our guidelines will change in regard to women who have had the HPV vaccination, especially if it was done before sexual activity and now we have the 9 strain vaccine, so I think eventually we may see the guidelines let up potentially for the younger women or change or maybe even management, but I do think we are seeing less HPV16 and 18 with the women who have been vaccinated versus not. So I think there is great hope that we will eventually see so much less disease and that potentially could change things, but it is slow change because we really do want to make sure that we’re not getting too lais se faire about things too quickly and not gaining unnecessary reassurance.

Host: Wrap it up for us, what you would like other providers to take away from this segment, and really as far as screening and management of cervical dysplasia.

Aubrey: I think it’s both exciting and frustrating that cervical cancer is so much less problematic if we can catch it in the dysplasia stage. So it’s really important to let women know that, and if they’re there for something and you see they are overdue for a Pap smear, if you don’t feel comfortable collecting it that day, set them up. Don’t let them walk out of the office without an appointment for a physical so you can do their Pap smear. Sometimes their only entrance into the medical world might be a convenient care visit or something else, and I understand there are a lot of other things pulling at us, but using a health maintenance activity to see hey are they due, and letting them know you are a young, healthy woman but this is something that is potentially very early treatable if we catch it. So I think the role of the vaccine is exciting. We have a cancer that we may be able to prevent with vaccines but it’s still trying to catch all those and letting the public and letting everyone know how important it is.

Host: Thank you so much for being on with us today and sharing your expertise and explaining the screening and management. Thank you again. You’re listening to Expert Insights with the Carle Foundation Hospital. For a listing of Carle providers and to view Carle sponsored educational activities, please visit carleconnect.com, that’s carleconnect.com. We hope the information gained will be applicable to your work and life. This is Melanie Cole, thanks so much for tuning in.