ADULT HIV CARE

Cervical Dysplasia and Cancer Guideline

Introduction

Medical Care Criteria Committee, February 2007

Cervical dysplasia is the abnormal growth of the epithelial tissue at the squamocolumnar junction (where squamous cells on the surface of the cervix meet columnar cells in the cervical opening) of the cervix. Several classification systems are used to describe dysplasia, but they are not interchangeable. Table 1 provides a comparison of dysplasia nomenclature.

Table 1: Comparison of Cytological and Histological Classification of Cervical Dysplasia
Bethesda Classification (2001) (cytology) Cervical Intraepithelial Neoplasia (CIN) (hystology) WHO Terminology (cytology)
  • ASC-US
  • ASC-H
Atypia
LSIL CIN I Mild dysplasia
HSIL
  • CIN II
  • CIN III
  • CIS
  • Moderate dysplasia
  • Severe dysplasia
  • Carcinoma in situ
Cancer Cancer Cancer
ASC-H: atypical squamous cells, HSIL cannot be excluded; ASC-US: atypical squamous cells of undetermined significance; CIS: carcinoma in situ; LSIL: low-grade squamous intraepithelial lesion; HSIL: high-grade squamous intraepithelial lesion.

Screening

February 2007

RECOMMENDATIONS
  • Clinicians should obtain cervical Pap tests at baseline, 6 months after baseline, and then annually as long as results are normal (see Table 2).
  • Colposcopy should be performed for women with abnormal Pap tests. Follow-up would then vary on a case-by-case basis.
  • Clinicians should repeat abnormal Pap tests every 3 to 6 months thereafter until there have been two successive normal cervical Pap tests. Women with cervical HSIL also should be referred for high-resolution anoscopy and/or examination with biopsy of abnormal tissue (see Anal Dysplasia and Cancer).
  • Clinicians should obtain at least an annual Pap test in HIV-infected women who have undergone either a supracervical or total hysterectomy.
Table 2: Established Cervical Neoplasia Screening Timeline
Screening Strategy & Population Frequency

Pap smear

  • Women ≥18 or when sexually active, whichever occurs first

 

Baseline, 6 months after baseline, then annually, as long as results are normal

  • Perform annually as long as results are normal. Abnormal results should be repeated every 3 to 6 months until two successive normal Pap tests are reported.
  • Patients with a history of anogenital condyloma or abnormal cervical/vulvar histology should receive an annual anal Pap test (see Anal Dysplasia and Cancer).

Colposcopy

  • Any female with abnormal Pap test results

Case-by-case basis

  • Colposcopy should be performed for women with abnormal Pap tests. Follow-up would then vary on a case-by-case basis. Women with cervical HSIL should be referred for high-resolution anoscopy and/or examination with biopsy of abnormal tissue.

The purpose of cervical screening is to prevent the development of invasive cancer by identifying and treating individuals with precursor lesions that are at risk for progression to cancer. Widespread screening of all women with cervical cytology or Pap tests has led to a decline in morbidity and mortality from cervical cancer. The benefit of screening and treatment protocols for cervical abnormalities in HIV-infected women is also well-established. Although cervical cytology (Pap tests) has lower sensitivity compared to actual tissue histology, colposcopy with Pap tests has increased the effectiveness of the evaluation of women with HIV infection, particularly those women with a report of atypical squamous cells of undetermined significance (ASC-US) by delineating likely abnormal tissue for biopsy and histologic evaluation [1].

Recurrent dysplasia on the vaginal cuff can be seen in women with a history of cervical dysplasia, and both HIV and HPV infections both increase the risk of vaginal intraepithelial neoplasia. Therefore, women who have undergone a hysterectomy should still receive annual Pap tests.

References:
  1. Franco EL, Duarte-Franco E, Ferenczy A. Cervical cancer: Epidemiology, prevention and the role of human papillomavirus infection. CMAJ 2001;164:1017-1025. [PubMed]

Cervical Cancer

February 2007

In the earlier years of the HIV epidemic, women presenting with invasive cervical cancer had very aggressive disease with poor response to traditional therapy and a high degree of recurrence [1,2]. In 1993, invasive cervical cancer was added as an AIDS-defining illness to underscore the need for comprehensive gynecologic evaluation in HIV-infected women [3]. Since that time, screening and treatment programs have been established for HIV-infected women and may partly explain the lack of a significantly increased incidence of invasive cervical cancer in women living with HIV. It appears that factors other than immunosuppression, such as smoking, can act as promoters of this disease.

Presentation

Usually patients with cervical cancer have very few symptoms and, when they do present with symptoms, more advanced disease is often found. Vaginal bleeding and post-coital bleeding are the most common symptoms. Malodorous vaginal discharge, pelvic pain, back pain, and lower abdominal pain are also common. Weight loss, leg pain, edema, and obstructive uropathy indicate advanced disease.

Management of Cervical Cancer

RECOMMENDATIONS
  • Clinicians should refer HIV-infected women to a gynecologic oncologist or surgeon trained in management of cervical cancer when possible. Appropriate staging, management, and therapy for cervical cancer should be determined by a gynecologic oncologist or clinician with similar training and experience.

In general, standard therapy used to treat immunocompetent patients applies to HIV-infected women. Management and therapy should be based on the stage of disease. Treatment may include cone biopsy, total hysterectomy, radical hysterectomy, radiation therapy, chemotherapy, and combined modality therapy with radiation and chemotherapy. The increased risk for treatment failure and high recurrence rate (up to 40%) demand close follow-up.

References:
  1. Maiman M, Fruchter RG, Guy L, et al. Human immunodeficiency virus infection and invasive cervical carcinoma. Cancer 1993;71:402-406. [PubMed]
  2. Maiman M, Fruchter RG, Serur E, et al. Recurrent cervical intraepithelial neoplasia in human immunodeficiency virus-seropositive women. Obstet Gynecol 1993:82:170-174. [PubMed]
  3. Centers for Disease Control and Prevention. 1993 Revised classification system for HIV infection and expanded surveillance case definition for AIDS among adolescents and adults. MMWR Recomm Rep 1992;41(RR-17):1-13. [PubMed]

All Recommendations

Medical Care Criteria Committee, February 2007

ALL RECOMMENDATIONS: CERVICAL DYSPLASIA AND CANCER
Screening 
  • Clinicians should obtain cervical Pap tests at baseline, 6 months after baseline, and then annually as long as results are normal (see Table 2: Established Cervical Neoplasia Screening Timeline).
  • Colposcopy should be performed for women with abnormal Pap tests. Follow-up would then vary on a case-by-case basis.
  • Clinicians should repeat abnormal Pap tests every 3 to 6 months thereafter until there have been two successive normal cervical Pap tests. Women with cervical HSIL also should be referred for high-resolution anoscopy and/or examination with biopsy of abnormal tissue (see Anal Dysplasia and Cancer).
  • Clinicians should obtain at least an annual Pap test in HIV-infected women who have undergone either a supracervical or total hysterectomy.
Cervical Cancer 
  • Clinicians should refer HIV-infected women to a gynecologic oncologist or surgeon trained in management of cervical cancer when possible. Appropriate staging, management, and therapy for cervical cancer should be determined by a gynecologic oncologist or clinician with similar training and experience.