Cervical
cancer is the most easily detected and, if caught early,
the most easily cured of all the cancers of the female reproductive
system.
What
Is a Colposcopy?
A colposcope, a kind
of large microscope, is placed at the entrance of your vagina
to give a magnified view of the area of your cervix where
the cells were taken from that were not normal. During a colposcopy
the cells of the cervix may be stained with a solution so
it will be easier to tell which ones are not normal. Some
cells may be removed for more lab tests.
A cone biopsy is
where the entire layer of cells that are abnormal on the pap
smear is removed by a scalpel or by a laser beam. You are
not awake during this procedure. If cancerous cells are discovered,
treatment is given for cervical cancer.
There is some debate
now among the medical community as to how often should women
have Pap smears. Some doctors say every year for the first
three years after you become sexually active, others says
after 3 years of negative (normal) results, every two years
is fine. We believe it is wise to have a pap smear every year,
but discuss this with your health care provider.
Pap
Smears and Cervical Cancer: What Every Woman Should Know
by Craig L. Bissinger, MD - (Updated
8/20/2002)
How much
do you know about the prevention of cervical cancer? Did you
know, for example, that although it was once the number one
killer of American women, it is now considered preventable
by using a simple test? Of the 16,000 newly diagnosed cases
and 4,800 women who will die of cervical cancer this year,
almost all of them could have been prevented with a pap smear.
As a physician,
I find it extremely gratifying to see women taking care of
their health. It's hard to believe that there are still millions
of women who fail to keep up with annual check-ups. Prevention
of disease, with an annual pap smear, is the most effective
medicine possible against cervical cancer. To understand why
a pap smear is the first line of defense against cervical
cancer, it is important to know a few basic points about the
test itself.
What
Is a Pap Smear?
A
pap smear is a test in which a ‘smear’ of bodily
secretions, especially from the cervix, is taken from the
body, and examined to detect any abnormal cells.
The cervix
is composed of two types of cells. The majority of the cells
are flat cells called squamous cells. They encircle the entire
cervix with the exception of an area in the center, which
is composed of mucus-secreting cells known as columnar cells.
The two types of cells come together at an area known as the
squamo-columnar junction. I retrieve a sample from this spot
because the cells are actively growing and any changes in
the cells can be found in here.
The
Procedure
When I
do a pap smear, I use an instrument called a speculum to inspect
the vagina. The instrument resembles a duck’s beak with
two portions that can be drawn apart to view the vagina and
cervix. After carefully inserting the speculum into the vagina,
I open and position it so that I can see the cervix (the tip
of the uterus). With both a small wooden spatula and a brush,
I scrape the surface of the cervix to obtain a sample of skin.
It is a quick and relatively painless process. Women often
describe the feeling as an ‘internal pinch’ when
the brush touches the cervix. After I've obtained the sample,
I rub the cells onto a glass slide and then I ‘fix’
the sample to the slide with a spray.
Human
Papilloma Virus
The two
cell types, squamous and columnar cells, are constantly reproducing
and creating new cells. This process of cell division progresses
normally until something triggers a change. In almost all
cases, the changes are caused by a virus known as human papilloma
virus (HPV), also known as genital
warts. The virus is introduced through sexual intercourse
and has the unique ability to infect the dividing cells of
the cervix. Once inside the cell, HPV inserts itself into
the DNA of the cervical cells and alters their ability to
produce new cells. A simple way to understand the role of
HPV is to imagine the virus as a foreman on a production line.
The foreman has given new instructions to the workers to alter
the way a part is made. In the case of HPV,
defective cells are' the new parts', and they will in turn
produce more and more defective cells. Over the course of
many years, the cells tend to become cancerous. This process
takes a long time, and an annual pap smear can detect some
of these changes early on.
What
Happens in the Lab?
The specimen
is sent to a laboratory where it is treated with special stains
to highlight the cells for study. A specially trained technician
will examine the slide to determine if it is normal. The results
are then given to the physician who performed the pap smear.
In order to maintain a high level of quality, 10% of all the
slides are reviewed at the laboratory. In addition, many labs
have physicians known as pathologists who review a select
sample of the slides, especially the abnormal ones, to ensure
the accuracy of the tests.
Pap
Smear Accuracy
Even in
the best labs, the pap smear is only 80% accurate. This means
that some abnormalities will not be detected or a test may
be interpreted as having a problem where none exists. This
can lead to a great deal of confusion and anxiety for the
patient. Fortunately, the cell changes responsible for cervical
cancer take many years to develop and with repeated pap smears,
the chance of missing an abnormality is very remote. Still,
the idea that an abnormality might be undetected causes much
concern among my patients. I use a little math to ease their
fears. Each year you have a 20% (which is 0.2) chance of a
falsely normal pap smear. If we did a pap yearly for three
years, your risk of missing an abnormality would be 0.2 x
0.2 x 0.2, which equals 0.008 or 0.8%. This is less than one
percent! This is a comforting percentage for my patients,
and another reason why annual pap smears are so important.
The
Lab Results
After your
pap smear is examined at the lab, your physician will receive
a report describing the results of your pap smear as either
satisfactory or unsatisfactory. On the report, there will
be comments about the type of cells seen: A recommendation
of follow-up care will be accompany the results. Listed below
are the possible diagnoses:
Normal:
The cells appear normal and a follow-up pap should be done
the following year.
Unsatisfactory
pap smear: I tell my patients that an unsatisfactory pap
smear is a "do over". It means that there was a
problem with the preparation or staining of the slide, or
there was an interpretation error, or there were not enough
cells retrieved for proper evaluation.
Inflammation:
This means that there are no changes in the cervical cells
that would indicate cancer, but there are inflammatory changes
in the cells environment.
Benign
changes: These are changes within the cervical cells themselves
that have not yet progressed to be cancerous. This should
be followed regularly, I would recommend a re-check in one
year.
Atypical
squamous (glandular) cells of undetermined significance (ASCUS
or ASGUS): This diagnosis is the most confusing to patients.
Basically it means that the person at the lab who evaluated
the slide felt that some of the cells were slightly abnormal
but not abnormal enough to warrant more aggressive evaluation.
This may occur in situations associated with mild infections
in the vagina or during the postpartum (after delivery of
a baby) or menopausal time periods. * Pap
smears should be repeated 3 to 6 months after this diagnosis.
If the follow-up smear is normal, you should resume yearly
pap smear testing. If the repeat test is still ‘ASCUS’,
you should have a colposcopy (described below)...
Low-grade
squamous intraepithelial lesion (LGSIL): This result requires
further testing by means of a colposcopy. A low-grade squamous
intraepithelial lesion represents the mildest cervical change,
though 15% of these abnormalities will progress toward cancer
(Don't worry. It will take more than 5 years to get there).
Many physicians recommend treating these lesions by destroying
the abnormal cells. 60% of these lesions will disappear on
their own without treatment, and there are some doctors who
prefer to follow patients in this group with repeated pap
smears and colposcopy instead of treatment.
You may
wonder why many physicians treat these patients if most of
them will heal on their own. A doctor's internal monologue
goes something like this: “Forty percent need therapy,
but which ones? Should I wait and find out? What happens if
my patient fails to follow-up or moves away?” Without
answers to these questions, many doctors prefer to offer treatment
when a patient is diagnosed with a low-grade squamous intraepithelial
lesion.
High-grade
squamous intraepithelial lesion (HGSIL): This result also
requires further testing by colposcopy and represents a pre-malignant
condition, which must be treated aggressively by destroying
the abnormal cells. There is no question about this diagnosis.
Failure to treat will lead to cancer in many patients.
Cervical
Cancer: This is a rare diagnosis, and the patient
should be referred to a gynecological oncologist for management
and treatment.
Other
Types of Cervical Testing
In some cases, I recommend an additional test called a colposcopy
(pronounced coal-pa-scoe-pee).
Colposcopy
In a colposcopy, as with a pap smear, your doctor will use
a speculum to see the cervix. The cervix is cleaned with a
vinegar solution. Using a special set of ‘binoculars’
mounted on a stand (colposcope), the doctor shines light on
the cervix and takes a biopsy (sample of cells for study)
of all areas that look suspicious. In addition, some of the
cells on the uterine wall will be gently scraped off and sent
to the lab. This is done to check for any abnormal cells that
may not be obvious.
At the
time of the colposcopy, I can usually predict the diagnosis
based on the appearance of the cervix, which is a tremendous
relief to the patient. When the biopsy results return from
the lab, I compare those results with my own findings at the
time of the actual colposcopy procedure. The biopsy results
and procedural findings should be consistent. If they are
not, I perform additional tests.
LEEP
A loop electrical excision procedure of the transformation
zone, referred to as LEEP, is another diagnostic procedure
that has become very popular. It involves using a live, electric
wire loop to scoop out a small piece of tissue from the squamo-columnar
junction. A sample of the cells on the uterine wall is also
scraped during this procedure. Both samples are then sent
to a lab for analysis. This test requires local anesthesia,
given as an injection similar to a shot of novocaine at the
dentist, but takes only seconds to perform. You should expect
to have a watery discharge for up to 2 weeks following this
procedure, which is normal.
Cone
Biopsy
In any cervical/uterine test, the physician must be able to
see the entire cervical opening to make a proper evaluation.
In certain circumstances this is not possible and further
testing is needed. In the case that a physician cannot see
or evaluate the cervix properly, a cone biopsy is recommended.
This procedure
typically involves a trip to the operating room and many physicians
will request that you have some sedation or general anesthesia
when doing this type of procedure. There are some doctors,
however, who will use a local anesthesia for a cone biopsy.
The procedure involves cutting out a central portion of the
cervix (which includes the squamo-columnar junction) and sending
it to the lab. This can be done with a knife, a laser, or
with the LEEP method. The tissue sample actually looks like
an ice cream cone, hence the name. Because it involves cutting
out a larger piece of tissue, cone biopsy is considered more
likely to find any abnormal tissue. The surgery takes 20 to
40 minutes to complete. Post-operatively, there is little
pain. Most of my patients who have had a cone performed say
it feels like menstrual pain and is easily relieved with Ibuprofen.
A cone
biopsy should be performed if:
The diagnosis is unclear from a previous colposcopy
biopsy.
The entire cervix cannot be visualized by colposcopy.
Abnormal cells are found along the uterine wall.
There is suspicion of cervical cancer.
Treatment
The basic job of any cervical treatment is to destroy abnormal
cells. Once abnormal cells are destroyed, the cervix has a
chance to regenerate healthy cells. Biopsy results usually
take between 2 and 7 days to come back. Before diagnosis,
I like to outline for my patients how I will manage their
treatment in the case that they need treatment. I explain
to my patients that any of the available cervical treatments
will cure between 90% and 95% of patients.
Cryosurgery
Cryosurgery has been a “treatment work horse” for
many years. It involves a process of freezing the cervix and
destroying the entire junction between the squamous and columnar
cells. It is a quick, office-based procedure and causes minimal
discomfort. In general, a few Advil or Tylenol in advance
of the procedure will suffice as pain medication. After the
procedure, patients will experience watery discharge for up
to 2 weeks.
Laser
Surgery
Laser treatment was an appealing option in the past and still
has a role in certain circumstances if your doctor is comfortable
using it. Treatment using a laser involves the use of high
energy to vaporize an abnormal area. It takes longer than
cryosurgery and is more uncomfortable. Sometimes local anesthesia
is used to make the procedure more comfortable. Patients will
experience watery discharge for up to 2 weeks.
Electrocautery
Electrocautery uses electrical energy to burn away abnormal
cervical tissue. It is a quick procedure, which typically
requires local anesthesia to perform. As with all these procedures,
a watery discharge should be expected for up to 2 weeks.
Cone
Biopsy
The cone biopsy was described above, but it is both a diagnostic
and a therapeutic treatment. If the cone biopsy is found to
have removed all abnormal cells when examined in the lab (has
clean margins) it will have successfully treated as well as
diagnosed the problem. In many patients, it is just as effective
as hysterectomy for pre-cancers of the cervix.
Follow-Up
Following treatment, I suggest that patients have pap smears
every 3 months for a full year to make sure that any recurrence
of abnormal cells are promptly found. In the second year after
treatment, I extend the interval between tests to 6 months.
Thereafter, yearly pap smears are recommended. In the event
that a recurrent abnormal pap smearis obtained, you should
start from scratch and again go through the process of colposcopy,
biopsy, and treatment.
Conclusion
The pap smear is an excellent screening test to help prevent
and detect cervical cancer. With these routine tests, you
can help make cervical cancer a thing of the past. The time
you have taken here to learn about this important health topic
is well spent. It is up to each of us to take charge of our
own health. Don't be afraid to ask your doctor questions.
Be assertive. Nobody is as interested in your health as you!
Good luck
and good health to you.
Craig L.
Bissinger, MD
© 2002
Healthology, Inc.
To our Cervical Cancer
article...
For more on Genital Warts
and HPV and the Gardacil®
Vaccine.
For
more up-to-date information, check out these resources.
You can
find out more about Pap tests by contacting the
National
Women's Health Information Center (NWHIC) at
1-800-994-9662
or the following organizations:
Cancer
Information Service, NCI, NIH, HHS
Phone Number: (800) 422-6237
Internet Address: http://cis.nci.nih.gov
American
College of Obstetricians and Gynecologists (ACOG) Resource
Center
Phone Number: (800) 762-2264 x 192 (for publications requests
only)
Internet Address: http://www.acog.org
American
Cancer Society
Phone Number: 1-800-227-2345
Internet Address: http://www.cancer.org
National
Cervical Cancer Coalition (NCCC)
Phone Number: (800) 685-5531
Internet Address: http://www.nccc-online.org
Planned
Parenthood Federation of America
Phone Number: (800) 230-7526
Centers for Disease Control
National Breast and Cervical Cancer Early Detection Program
Phone Number: (888) 842-6355
Internet Address: http://www.cdc.gov/cancer/nbccedp
A wooden
spatula (thinner than a tongue depressor) is wiped across
the cervix, and the smear is transferred to a glass slide.
Also a very long wand, much like a mascara wand is used to
gently scrape the inside of the cervix. This doesn't hurt;
some women say they feel a little twinge, but it only lasts
a second. This wand is also smeared on the slide and sprayed
with a solution to "fix" it to the slide. The slide
is then sent to a laboratory to be examined by a medical person
who specializes in "reading" pap smears. The results
should be available in a few days.