Last partial update: August 2022 - Please read disclaimer before proceeding.

 

Incidence of Cervical Cancer

Cervical cancer is a disease that should not be underestimated. Prior to the introduction of Pap smear screening, cervical cancer was the most common gynaecological cancer in women and caused many deaths. This is still the case in underdeveloped countries.

The introduction of a coordinated Pap smear screening program in 1991 had a dramatic affect on this disease in Australia, resulting in a decrease in both the incidence and death rate for cervical cancer of about 33%.  More recently this hasd been replaced by testing for the Human Pappiloma Virus (the cause of cervical cancer.  At present each year screening prevents about 1,200 women developing cervical cancer and has resulted in Australia having the second lowest incidence of cervical cancer in the world and the lowest death rate.

Cervical cancer is caused by the cervix becoming infected with the Human Pappiloma Virus (HPV) which occurs during sexual intercourse with an infected partner. In Australia in 2020 about 900 new cases of cervical cancer were diagnosed and about 230 cervical cancer deaths occurred. The vast majority (75%) of these cases occurred in women who had inadequate or no screening in the last ten years.

These figures are likely to improve significantly iover the next 20 years as the beneficial effect of new HPV vaccination starts to be seen.

Two big changes in Cervical Cancer prevention

1. The HPV Vaccine

The new vaccination against HPV human pappiloma virus infection in the cervix, which is offered to both males and females, should dramatically reduce the incidence of this disease in the future. (Most women become infected with HPV within a few years of becoming sexually active and they will thus only be partially protected by the vaccination if they have it after this time. (The use of this vaccine is comprehensively discussed at the end of this topic.)

2. The new HPV screening test that has preplaced the Pap smear for routine cervical cancer screening

In December 2017 the Pap smear was replaced with a new screening test, the HPV test. (Discussed in detail below.) This test has reduced the frequency of testing to 5 years (for women who have a negative test)  and will hopoefully prevent an additional 300 cases of cervical cancer each year. The reduced testing rate will hopefully improve participation rates amongst women as only about 60% of women were having second yearly Pap smears.

Past low Pap smear testing rates and low current HPV testing are still causing problems

This less than optimal screening explains why cervical cancer still causes about 1.2% of cancer deaths and the tragedy is that these deaths often occur in young women: 50% before the age of 50.

Having said this, death from cervical cancer is still most common in older women and this is partly because screening is lowest in older women, especially in the 60 to 70 year age group. Older women who have not had a recent HPV test need to realise that they are significantly increasing their risk of developing cervical cancer.

The cervical cancer screening rate is also lower in low socio-economic groups, in non-English speaking women, and in country areas. This problem is especially prevalent in remote indigenous communities, where lack of screening for cervical cancer has meant that it is the most common cause of gynaecological cancer death. The rate in Indigenous Australian women is over five times that of non-Indigenous Australian women.

It is important that all women participate in the HPV screening program.

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What causes cancer of the cervix (cervical cancer)?

 There are two types of cervical cancer.

a. Squamous cell cancer of the cervix

The most common type of cervical cancer is squamous cell carcinoma (80%) and almost all of these cervical cancers occur following an infection of the cervix by the sexually transmitted human papilloma virus (HPV). (This is the virus that causes genital warts in both men and women.) Squamous cell cervical cancers are rare in women that have not had sexual intercourse. The virus is very contagious and most women are exposed to HPV infection within a few years of becoming sexually active. (The sexual transmission of HPV explains why squamous cell cervical cancers are more common in women who have multiple sexual partners and commence sexual intercourse at a young age.)

Smokers also have an increased risk.

Luckily, doctors are able to diagnose (and successfully treat) most of these lesions before they become cancerous because it usually takes a long time (about 10 years) for early pre-cancerous changes to develop into actual cancer and these early pre-cancerous changes in the cervix are readily identified by screening tests; either HPV tests or Pap smears (which the HPV test is about to replace. See Below.)

The natural history of HPV infections - Most HPV infections of the cervix resolve by themselves without causing long-term harm

In all there are over 100 different types of HPV with about 40 different types of HPV causing anogenital and oral disease. The viruses are common in the community and about 80% of sexually active women will develop a cervical infection with a type of HPV, mostly within five years of initiating sexual intercourse. (Most (60%) of these women are only infected with one type of HPV.) The risk that such an infection will develop into cervical cancer varies according to the type of HPV infection and only about 16 types of HPV are higher risk types that can cause cervical cancer. The most commonly involved types are 16 and 18, which together cause about 80 per cent of cervical cancer both here and overseas. (In Australia HPV 16 causes 60% and HPV 18 20%.) (Type 16 also causes cancer of the mouth and pharynx and its incidence is related to the number of partners that the woman or man chooses to have oral sex with.) The other 124 types that cause cervical cancer are less of a cervcal cancer risk.  

Most women have no idea they have the infection unless they have obvious genital warts or an abnormal Pap smear. In men warts are more easily seen but not all men with a HPV infection will have visible penile warts.

As mentioned, about 80 per cent of women (and men) develop an HPV infection within a few years of commencing sexual activity. The majority (up to 90%) of these infections resolve by themselves irrespective of whether the initial infection is due to a high-risk or low-risk type of HPV by about 36 months, with the average time for resolution to occur being about eight months. By themselves, these initial infections cause only a mild abnormality on the Pap smear and, like the HPV infection that causes them, these mild Pap smear abnormalities usually go without treatment and do not progress to cancer. Thus, in a woman aged less than 30, it is extremely likely that a low grade Pap smear abnormality is just an indication that the woman has recently contracted a cervical HPV infection. It is not an indication that an early cancer exists.

By the age of 30 to 35, only about 5% of women will have a current infection. This is partly because most women have been previously exposed to common HPV infections that they have subsequently eradicated. In doing this some (about 25%) develop an immunity to the type of HPV asscociated with their infection which prevents them becoming infected again with that type. (Immunity to one type of HPV does not usually give immunity against all other types and it is very unusual for women to show immunity to both HPV16 and HPV18. This means that HPV vaccination is of some benefit to almost all women as it will give protection to the high risk type they don't have. See section on vaccination at the end of this section.)

Another factor is that many women in this age group have entered long term (monogamous) relationships and women in such relationships are much less likely to be exposed to a new HVP infection. 

Thus current HPV infection is less commonly found in women over 30 who have screening fo the virus. However, the presence of HPV in these women is more likely to indicate chronic infection that may lead to cancer and needs to be taken more seriously.

Overall, about 0.1% of women with an HPV infection go on to develop cervical cancer. The development of cervical cancer requires a high-risk type of virus to alter the genes of a cervical cell in a way that promotes abnormal cell growth and replication, probably by the incorporation of some of the virus’s genetic material into the DNA of its ‘host’ cervical cell. For this to occur, it is thought that additional cancer-causing factors must also be present, such as cigarette smoking or the presence of impaired immunity (for example due to increased stress).

Women who are exposed to a strain of HPV and clear the infection gain a lifelong immunity to that strain of HPV. However, infection with other strains can occur.

Prevention of HPV infections

While the use of condoms is vital in minimising the risk of contracting many important sexually transmitted diseases, including HIV and syphilis, they are of little use in preventing the spread of HPV infections as the virus is transmitted by genital skin-to-skin contact. As stated before, 80% of the population develop the disease; it is the ‘common cold’ of sexually transmitted diseases.

b. Adenocarcinomas (glandular cancers)

The second type of cervical cancer is adenocarcinoma. It arises from glandular cells that make vaginal mucous and these cells lie mostly in the cervical canal. Pap smears attempt to sample cervical canal tissue but it is a more difficult process, especially gaining tissue from higher in the canal where adenocarcinomas more commonly arise. (It is not uncommon for such tissue to be absent from the sampled material.) This relative inaccessibility means that cervical adenocarinomas are more difficult for Pap smears to detect and also means they are more difficult for doctors investigating abnormal smears to view. For this reason, the Pap smear prevention program has had very little effect on the incidence of cervical adenocarcinoma, which has hardly changed. However, as most are caused by HPV infection, They are probably not caused by a HPV infection and thus are not thought to be sexually transmitted. Luckily they are far less common, accounting for only 20 per cent of cervical cancers.

 

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Screening tests for cervical cancer: The HPV test has replaced Pap smears as the first line screening test for cervical cancer

For many years Australian women have relied on Pap smears to help them identify cervical cancer before it occurs or in the early stages, which has in many cases allowed treatment that produced a cure. Pap smears involve gently scraping cells off the surface of the cervix and looking at them under the microscope to see if there are pre cancerous changes present. Thus, they only work if the test proceedure actually contacts the diseased area. One limitation of the Pap smear is that it can miss lesions higher up the cervical canal (mainly adenocarcinomas - see above) and this has meant that some cancers are not detected early.

Evidence has shown that testing for the presence of HPV (the virus that causes almost all cervical cancers) on the cervix is more successful overall at identifying women who are likely to develop cervical cancer. Initial results from screening has shown a reduction of the presence of HPV

Unlike the Pap smear, the test does not actually involve looking for precancerous (or cancercerous) cells. Rather it identifies the group of women who have high-risk types of HPV (16 & 18) and the other 14 intermediate risk types who are thus at increassed risk of developing cancerous change in their cervix; and this group can be looked at more closely to see whether that change has occurred. (Those women who do not have HPV present are at low risk.)

Women who test positive to the high-risk HPV types (HPV 16 & HPV 18) are refered to a gynaecologist for special colposcpy examination of the cervix.

 

HPV Testing - The new first line screening test for cervical cancer

What does HPV testing do?

It detects the presence of HPV virus in the cervix. As explained above, most women are exposed to HPV infection of their cervix during their lives. In most cases they are able to clear the infection fairly quickly (a few months) and they will not have a positive HPV test. With the additional protection offered by the HPV vaccination, the vast majority of women be able to fight off the virus before a significant infection occurs.

If a higer risk HPV infection is found (Tpye 16 or 18), the woman is referred to a gynaecologist for a special examination of the cervix called a coploscopy.

If one of the other 14 lesser risk types is found, the woman is referred back to their GP for further assessment of the cervix.  

How is the HPV test done? (It can be done by the patient without a speculum examination)

The test can involves inserting a small swab stick into the vagina and twisting it around. The est can be done by a doctor or by the patient. Patient samples have been found to be just as good as those done by cliniciansThe testing technique is similar to the PCR test used for Covid-19.             

At what age is it commenced and how often is it done?

It is commeced at age 25 years or two years after first sexual intercourse, which ever is later. As long as no abnormality is identified in any test, it is done every five years until the age of 70 to 74 years.

Who needs to have it done?

All women who have ever been sexually active (includig those with a same sex partner) need to be tested. As HPV vaccination does not provide complete protection to any woman, vaccinated women also require testing.

Will HPV testing indentify all cervical cancers?

Unfortunately a small number of cervical cancers are not caused by HPV infection and thus HPV testing will not pick up these cancers. These are mostly adenocarcinoma, with up to 10% of adenocarcinomas being thougt to be not caused by HPV. This means that up to 2% of cancers overall might not be due to HPV and thus HPV testing will miss these. (It is important to remember that Pap testing missed many more adenocarinomas than this.)

For this reason, all women who have symptoms that might indicate cervical cancer need to see their doctor about them as soon as they occur, irrespective of whether they are having screening testing. These symptoms include: abnormal vaginal bleeding and pain with sexual intercourse.

More detailed information about Pap smears appears at the end of this section.

 

Investigation of abnormal HPV screening trests - Colposcopy

Positive high risk HPV screening test isinvestigated by a gynaecologist using colposcopy. This involves using an instrument (a colposcope) that provides a magnified view of the surface of the cervix. Prior to viewing, areas of the cervix that are likely sources of the abnormal cells are identified by applying some iodine or acetic acid to the cervix. The operator can then carefully inspect these areas and take biopies (samples of tissue) of likely abnormal tissue. Inspection of these biopsies by a pathologist gives a more accurate assessment of the severity of the abnormality which in turn helps the doctor decide on the most appropriate treatment for the lesion.

 

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Vaccination against Human Papilloma Virus

The initial vaccines (Gardisal) protected against four types of HPV and most importantly prevented women becoming infected with the two main types of HPV that cause cervical cancer; types 16 and 18. These two viruses are responsible for about 70% of cervical cancer. Unfortunately this vaccine will probably not help prevent the 30% of cervical cancer that is caused by other cancer-causing types of HPV and this means that, to adequately prevent cervical cancer, women will need to continue to have Pap smears (or from December 2017, the HPV test) irrespective of whether they have had the vaccination or not.

Professor Ian Frazer, the doctor who developed the HPV Vaccine and the 2006 Australian of the Year.

 

The new (current) HPV Vaccine - Gardisal 9

In 2018 a new vaccince, Gardisal 9, replaced the older vaccines, Gardisal and Cervarix. It protects against nine types of HPV and offers lifelong protection against 93% of cervical cancer; a significant improvement on the 70% protection previously offered.

It needs to be emphasised that those women who have had the previous vaccive are still well protected against cervical cancer as long as they continue to have the HPV testing      .

Significantly, as well as preventing cervical cancer, the vaccine will also reduce (by roughly 50%) the incidence of high-grade abnormal Pap smears, which will of course mean that the social and financial costs of their investigation and treatment will also be avoided; as will the anxiety such diagnoses cause. (In 2004 in Australia, 14,500 women were diagnosed with high grade lesions.)

The vaccines are made up of virus-like particles that are non-infectious. (The vaccine does not include any attenuated viruses.) It targets the outer protein coat of the virus which the virus sheds after it enters a cervical cell. For this reason it is only effective against new infection.The vaccine is well tolerated, with the main problem being slight swelling and redness at the injection site.

The vaccines were initially administered as three injections over 6 months but now is given as two injections; and at present it is thought the vaccines will provide lifelong protection.

To help reduce the sread of the virus the vaccine is offered to both girls and boys. 

Has the vaccine worked: It's ealy days but a recent review (in 2019) of 200,000 screening tests for HPV, the test which has replaced the Pap smear, showed that the peak rate of infection with the more serious Type 16 and Type 18 HPV viruses (that occurred at roughly age 25 years) dropped from about 20% to 2%; a 90% decrease in the infection rate. This is a wonderful result and should translate into a dramatic drop in the rate of cervical cancer amongst these women as they get older.

Other vaccine benefits

Target age group for the vaccine

The vaccines give the best chance of protection if given before a woman becomes sexually active and currently they are provided free to all girls and boys aged 12 to 13. Everyone, both males and females, should consider having the vaccine BEFORE they become sexually active.

The reason for this is that, as mentioned above, the vaccine targets the outer protein shell of the virus and once the virus comes in contact with and enters cervical cells it sheds this coat and incorporates its DNA into the cells DNA. Once this has occurred, it is 'invisible' to immunological defence mechanisms that the vaccine helps the body produce. Thus the infected cells go undetected and have the potential to develop into cancer cells. The vaccine only targets new virus infections before they enter the cell and it is thus necessary for the vaccine to be administered before such infection occurs (i.e. before the young woman starts having sexual intercourse).

Another factor in timing of administration is that the optimum response to the vaccine occurs in teenagers aged less than 16 years.

The vaccines may also help protect older women, but this benefit is less . It is thought that the number who would benefit in the over 25 age group would be between 20% and 50%. The reasons for this reduced likelihood of benefit are that many women in this older age group:

Women over 25 years of age who have previously had limited sexual contacts or who are not in a long term relationship are more likely to gain protection against contracting HPV by having the vaccination. Also, there is a high incidence of partnership breakup in western countries including Australia and women leaving longer term relationships are likely to have new sexual partners and may benefit from vaccination. Women interested in having the vaccine should discuss this issue with their GP. There is very little likelihood of harm in having the vaccination    .

The vaccine is safe with very few side effects. The most common is some soreness around the vaccination site and very occasionally allergic reactions occur. Vaccination in pregnancy is not recommended but is unlikely to cause problems should a women who is unaware she is pregnant get vaccinated.

All vaccinated women need to continue to have HPV screening

It is important to remember that the vaccine does not give any woman 100% protection against cervical cancer and HPV screening still needs to be done at least every 5 years in any woman who has had sexual intercourse and is 25 years of age or older. As mentioned above, one problem with women over 25 having the vaccination is that there is a considerable risk that they have already been infected with HPV prior to vaccination and thus the vaccine gives them no protection against the type of HPV they have. Should they then decide to have HPV screening less regularly because they think they are well protected, they will put themselves at significantly increased risk of getting cervical cancer.

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Further information

National Cervical Screening Program
http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/content/cervical-screening-1

 

 

 

 

 

 

 

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Old information on traditional Pap smears

Pap smears

A Pap smear test is the examination of cells scraped off the surface of the cervix using a wooden or plastic spatula and/or a small brush. This tissue is taken randomly as it is usually not possible for the doctor performing the procedure to visually detect abnormal tissue. The specimen should contain cells from the surface of the cervix and the cervical canal that leads up into the uterus.

These cells are placed on a glass slide and then examined under a microscope to see if any have abnormalities. These abnormalities can vary in severity from a mildly atypical appearance to actual cancer. While in some women taking a Pap smear can be slightly uncomfortable, it is not usually painful. (Women should discuss the actual procedure with their doctor.)

In pre-menopausal women, the best time to collect a specimen is probably mid-way between menstrual periods, although getting a good quality sample of cervical cells is far more important than when in the menstrual cycle the smear is taken. Contact bleeding with the procedure is relatively common and does not increase the likelihood that cancer is present.  It is best to avoid having a smear when an infection such as ‘thrush’ is present. Also, the use of douches and vaginal creams should be avoided in the two days prior to having a smear.
The vast majority of male GPs, while being extremely competent at performing Pap smears, understand that some women prefer a female doctor to perform the procedure.

Who should have Pap smears?

Pap smears done as advised by health authorities reduce rates of squamous cell cervical cancer by up to 90 per cent and therefore are recommended for all women who have been sexually active. They should commence at the age of 18 or within 24 months of first sexual intercourse, which ever comes later. (About 35 per cent of women show evidence of HPV infection within two years of becoming sexually active.) It is considered safe for women to stop having pap smears at age 70 if they have had two normal smears in the past five years and have no symptoms.

A woman who has had a total hysterectomy does not need pap smears when all the following apply;

Otherwise, Pap smears may still be necessary. (Women should discuss the need for a Pap smear with their doctor.)   

Pap smears are a screening test

Routine Pap smears are a screening test. This means that they are used to assess women who do not have symptoms that suggest cervical cancer might be present. These symptoms include abnormal vaginal bleeding and pain with sexual intercourse, abnormal vaginal dischage and abnormal vaginal bleeding, and pelvic pain. It is important for women with such symptoms to have them investigated when they occur. A negative last Pap smear does not mean that cervical cancer cannot occur. Cancers can very occasionally devekop quickly between smear tests and tests are never perfect; there will always be the possibility that some abnormalities will missed. It is not appropriate to wait till the next smear to investigate the cause of such symptoms.

Monitoring Pap smear programs
To help increase compliance with this optimum Pap smear regimen, there are now national and state programs to monitor women participating in Pap smear screening. They incorporate promotional schemes, registries and recall systems for women who have had previous smears.

Older women still need smears
As stated previously, the Pap smear participation rate is lowest in older women and unfortunately this is the age group in which most cervical cancer occurs. A history of previously normal smears does not mean that the woman can safely stop having Pap smears and older women who choose not to have smears regularly put themselves at significantly increased risk of cervical cancer

Newer methods of examining cervical cells taken during Pap smears

Over the past few years, newer laboratory techniques aimed at more accurate diagnosis of cervical cancer have been developed. These tests are done in addition to the normal Pap smear test (i.e. the specimen is examined twice) and are paid for by the patient.

1. Different slide preparation (ThinPrep / Autocyte tests)

With this method, a conventional slide for the routine Pap smear is made and the remaining cells are placed in a liquid medium. The slide subsequently prepared from this liquid medium enables the pathologist to have a clear view of just the cervical cells. This provides a slight advantage over normal smears as normal smears are sometimes difficult to read due the presence of thick mucous or blood. Problems with reading conventional smears mean that about one to two per cent of conventional smears need to be repeated. The use of these types of smears may be helpful in reducing this incidence in women with previous ‘inadequate’ smears or in women who have excessive mucous, blood or discharge present when the smear is being taken that may make a conventional smear difficult to read. While there is some argument at present as to whether this benefit is significant, a back-up slide may prevent the woman needing to return for a repeat test. The extra cost is about $40. The choice is often left up to the patient.
With regard to cervical cancer detection, there is no convincing evidence that these newer techniques are better at detecting high-grade lesions. They do detect a few more low-grade lesions but most of these will resolve without the need for treatment.
At present these tests are read manually and a newer test that uses computer reading will probably be available in Australia soon. Whether it has more definite advantages time will tell.

Please remember, it is having smears that is important; not the type of smear. Eighty-five per cent of cervical cancers in Australia occur in women who do not have regular second-yearly smears.

2. Retesting conventional smears by computer (PAPNET and Autopap tests)

These techniques use computer-assisted microscopes to look for abnormal cells and they have been shown to pick up a few more abnormalities. Due to their expense, these tests are mostly used for laboratory quality control. That is, they are generally not available to women having Pap smears.

What does a normal Pap smear mean?

Pap smears are not perfect. Abnormalities can be missed and this is one of the reasons why Pap Smears need to be done every two years. (Overall, about 10 per cent of abnormal cervical lesions are missed by Pap smears, the rate being higher in women under 40 years of age. Luckily most will either be picked up at the next smear or be mild abnormalities and go away naturally.)

A normal Pap smear means that the woman has a very low risk of either having cancer or developing cancer in the next few years. It does not indicate that the woman has no risk of developing cervical cancer. Women with symptoms such as bleeding or pain with sexual intercourse or bleeding between periods or after menopause cannot assume that they have no cause for concern because their last Pap smear was normal. They should consult their general practitioner to make sure there is no serious cause.

Pap smears occasionally need to be repeated due to difficulty in interpreting the cells taken. This occurs in about two per cent of smears and is usually due to too few cells being present, the presence of blood and mucous making the cells difficult to see properly, or the cells being slightly inflamed for some other reason. If an 'inadequate' Pap smear does need to be repeated, it is best to wait about two to three months to allow the cervix to ‘grow back’ to normal.

Not all cancers are picked up by Pap smears. This is mostly a problem in glandualar cell cancer or adenocarcinomas (see above). Patients need to be aware of this fact and, even if their last Pap smear was normal, they should report any sysptoms that might suggest cervical cancer might be present. These include pain or bleeding after sexual intercourse, any unusual vaginal dischage or abnormal vaginal bleeding.

What does an abnormal Pap smear mean?

Pap smears are not just normal or abnormal. There is a range of ‘abnormality’, varying from mild changes to actual cancer. Abnormal smears are divided into two main groups; low-grade and high-grade lesions. Each year about two million Australian women have a Pap smear and about 100,000 of these smears will reveal a low grade abnormality and about 20,000 will reveal a high grade abnormality. These two abnormal groups require quite different management as discussed below.

For women who choose to have regular second-yearly Pap smears, the chance of having an abnormal smear at some time is about 40 per cent. Obviously most of these abnormalities will be low grade and clear without the need for treatment.

A. Low-grade squamous cell abnormalities

Previously, low grade abnormalities have been divided into several sub-groups according to their perceived severity. (These included atypia, non-specific minor changes, HPV changes and mild dysplasia or CIN1.) As well as being a confusing classification, actually making such differentiations pathologically is not easy and this led to inconsistencies in the interpretation of Pap smears with low-grade abnormalities. It has also been shown that the prognosis of all the different types of low-grade lesions is very similar, with the vast majority (about 90%) being short-term changes due to a transient HPV cervical infection that will resolve without any treatment, leaving a normal cervix. (In the past, such lesions were all viewed as pre-cancerous, leading to unnecessary worry.) On average it takes about eight months for these lesions to disappear, but the period can be up to three years.
Thus, for the purposes of deciding on what further investigation a low-grade abnormality requires, it has been decided to group all low-grade abnormalities together and they are now all termed low-grade squamous epithelial lesions.

B. High-grade squamous cell abnormalities

This category of conditions is divided into three groups as follows. (It includes the CIN 2 and CIN 3 classifications.) All these lesions require further investigation with colposcopy.

  1. Possible high grade squamous epithelial lesions (THese lesions are show suspicious features of high grade lesions.)
  2. High grade squamous epithelial lesions (These are smears that show definite changes consistent with CIN2 and CIN3 lesions.)
  3. Cervical cancer – A Pap smear that identifies a cervical cancer requires immediate follow up by a gynaecologist, preferably one who specialises in cervical cancer if available.

All high-grade abnormalities require further investigation and treatment by a gynaecologist. A significant number of high-grade lesions develop into cancer, with the risk being greater in more advanced lesions, in larger sized lesions and in older women. This progression is usually (but not always) slow; it often takes eight to ten years. Thus, proper treatment of these abnormalities should prevent the future development of cervical cancer in most cases. However, Pap smears are not as accurate as colposcopy and a few women with high-grade lesions may actually have cancer. Thus, the initial investigation by colposcopy of all high-grade lesions should not be delayed.

Women who have had a high-grade abnormality need yearly smears
About a quarter of million women in Australia have had a high grade Pap smear abnormality at some time in the past. These women are at higher risk of developing cervical cancer and require different prevention programs. In the past this has been to have yearly smears for the rest of their lives, although there are other options now recommended and women who have had a high-grade abnormality need to discuss these with their gynaecologist.

All changes in glandular cells need investigation irrespective of whether they are low or high grade
As stated above, changes occurring in glandular cells (which may lead to adenocarcinoma of the cervix) are more difficult to identify by Pap smear and more difficult to treat. It is therefore important to have a high level of suspicion when dealing with abnormalities in this type of cell and all Pap smears that show changes in glandular cells need further investigation by a gynaecologist.

Pap smear classification for glandular cell abnormalities

Glandular cancers originating from glanduar cells are much less common that those resulting from squamous cells. However, as stated above, glandular cancers are unfortunately much harder for Pap smears to pick up. Pap smears indicating a glandular cell abnormality are divided into four groups as follows. Women with such abnormalities should be reviewed by a gynaecologist, with the urgency depending on the severity of the abnormality found.

A. Atypical endocercvical cells of uncertain significance or atypical glandular cells of uncertain significance: About 10% of women with this Pap smear result will have a high grade glandular pre-cancerous lesion and about 1% will have a cancerous lesion.

B. Possible high-grade glandular lesion: About 20% of women with this Pap smear result will have a high grade glandular pre-cancerous lesion and about 5% will have a cancerous lesion.

c. Endocervical ACIS: About 60% of women with this Pap smear result will have a high grade glandular pre-cancerous lesion and about 17% will have a cancerous lesion.

d. Adenocarcimona

 

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