Pap Smears

• Cancer is a leading cause of death in Americans. About 1 in 4 deaths in the US are due to cancer.
• Over ½ million die per day.
• 1.4 million people were diagnosed last year alone.
• Racial discrepancies exist in stage presentation & mortality.
  • African Americans are 3x more likely to die due to a lack of screening and late stage presentation than Caucasians. Hispanics are 2x as likely to die.

How can we prevent cancer?

• Have a healthier lifestyle
• Make screening available & accessible
  • Use available screen tests: women have mammograms, pap tests and colorectal screenings. Men have prostate and colorectal screenings
•  Early detection

1 in 3 women will have cancer

• Breast is #1 in the US and world wide
• Cervix is #2 in the US
• Colorectal Cancer: if you add up ALL the GYN cancers together, it equals the rate of colorectal cancer.

Cervical Cancer:

• 13,000 new invasive cervical cancers a year. Of those 4,5000 will die.
• Risk factors
  • STDs
  • Early intercourse
  • Number of partners (you sleep with everyone your partner has slept with)
  • Low socioeconomic status
  • High risk male partner
  • HPV (At least 50% of people have HPV: in urban areas at least 85-90% of people have HPV)

• Stage of Diagnosis
  • Comparing Newark to the rest of the US. In the US cervical cancer is diagnosed early but in Newark it is diagnosed LATE.
• Gender Disparities
  • In the 80’s the discovery of PSA for prostate cancer screening increased survival rates of both Caucasians and African Americans. Unfortunately however, no such trend is cervical cancer has been seen.
• Cause
  • HPV can transform cells causing cancer.
  • It’s currently believed that HPV has been around since the days of primordial ooze (which means its been around for a long time)
  • An HPV vaccine may be in our near future!
• HPV
  • Its ubiquitous – its everywhere!
  • Condoms do NOT entirely protect from HPV
  • The status of the persons immune system will determine prognosis.
  • HIV is synergistic with HPV – they both can transform cells.
• If Cervical Cancer is found early, the basement membrane will be intake, but a tumor emboli may be present in the lymph. A lesion 1 mm deep is 100% curable – so make sure you catch it early!
• Dr. Papanicolau
  • A doc who thought – why don’t we take a tongue depressor and scrape it across a cervix and then spread the cells onto a slide? And the Pap test was born!
    • Today a cytobrush or a cotton swap (for pregnant women) are rotated in the endocervical canal and the slides can be either smeared onto a slide and fixed, or the slides can be placed in liquid fixative material and spun down to remove any background material.
    • The woman may be slightly uncomfortable, and may experience spotting for 1-2 days following.
  • Abnormal cells on a slide will have a high nucleus : cytoplasm ratio, more mitotic figures and will be BLUE (blue = bad)
  • The pap test has been widely used since the 40s/50s and incidence of cervical cancer has decline dramatically but not to zero which means there is a still a population of patients that are not being reached.
  • Latency from finding dysplasia to the progression of cancer is variable. If someone has an intact immune system it can be 6-20 yrs. w/ an immunocompromised state it can be as short as 2 yrs
• Accuracy of the test
  • 20% of the time there are false negatives
  • Usually these are due to unusual histological findings (like adenocarcinoma which is rare in cervical ca).
  • Though its not 100% accurate, 50% of cervical cancer patients have NEVER had a pap smear – so this can be improved.
• Recommendations
  • 3 yrs after 1^st sexual intercourse or age 21
  • Up to 30 there should be an annual screening (cytology alone)
  • After the age of 30, if there were 3 consecutive negative results the patient should talk with their practioner. They can then be checked every 2-3 yrs with cytology alone.
  • Combined use of cervical cytology test and FDA approved test for high risk types of HPV. If both are negative, the patient can be re-screened with the combined test every 3 yrs
  • Caveats (this is  the buzz word of this unit):
    • Immunosuppressed patients (corticosteroids or HIV)
    • DES in utero (this was a high dose estrogen used to prevent miscarriages. The children effected by this drug have higher rates of aggressive cervical cancer and are now in their 50s-60s)
  • Discontinuous pap screening is determined on an individual basis.
    • Ex: if someone had fibroids and a hysterectomy but never had an abnormal pap they don’t have to go for a an annual exam if they discuss it with their practioner.
    • Even if patients don’t have an annual pap exam, they should see an GYN annually for a breast, rectovaginal, abdominal, and colorectal exam.

Now onto a letter from a patient. It addressed several questions:

• Is dysplasia contagious?
  • NO. Dysplasia occurs when cells lose the ability to control growth and can then develop into cancer. They do not have a usual appearance under the microscope.
    • When talking with patients avoid saying abnormal.
• Can my kids get it?
  • No, your children cannot get it. However if you are pregnant and you have HPV it can be transmitted in utero.
  • HPV is transmitted sexually so there is almost zero risk. Even if you share bathsoap, the risk is still zero.
• Can I have sex?
  • Sure you can, but if you have a new partner you should use condoms for a lot of reasons other than HPV.
  • If your patient is in a monogamous relationship and he has the same HPV that she does, it will not necessarily make hers worse.
  • If her partner has a different strain of HPV, she may not be immune to it and  can be infected with it.
  • A condom is good to use to avoid passage of infection, but it doesn’t prevent transmission bc HPV can be anywhere, not just where the condom is.
• A lot of patients feel depressed or “dirty” when they learn they have HPV. 75-85% of the population has HPV.  A study was done on college aged women, and it found that 85% cleared the virus in 2 yrs. So of those exposed to HPV MOST will clear it the virus. So encourage your patients to not be depressed, and inform them that it is a very prevalent disease.
• Lastly, tell your patient not to run out and accuse their partner if they are diagnosed with HPV. Chances are your patient had it for years.

Back to the Reproductive System Index