Cervical Cancer Screening (Clinical)

Overview

Cervical cancer Cervical cancer Cervical cancer, or invasive cervical carcinoma (ICC), is the 3rd most common cancer in women in the world, with > 50% of the cases being fatal. In the United States, ICC is the 13th most common cancer and the cause of < 3% of all cancer deaths due to the slow progression of precursor lesions and, more importantly, effective cancer screening. Cervical Cancer^[6,12]

• Cancer of the uterine cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy
• Major histologic types:
  • Squamous cell carcinoma Squamous cell carcinoma Cutaneous squamous cell carcinoma (cSCC) is caused by malignant proliferation of atypical keratinocytes. This condition is the 2nd most common skin malignancy and usually affects sun-exposed areas of fair-skinned patients. The cancer presents as a firm, erythematous, keratotic plaque or papule. Squamous Cell Carcinoma (SCC): approximately 80% of cervical cancers
  • Adenocarcinoma: 15%
  • Adenosquamous carcinoma: 3%–5%
• Associated with human papillomavirus Human papillomavirus Human papillomavirus (HPV) is a nonenveloped, circular, double-stranded DNA virus belonging to the Papillomaviridae family. Humans are the only reservoir, and transmission occurs through close skin-to-skin or sexual contact. Human papillomaviruses infect basal epithelial cells and can affect cell-regulatory proteins to result in cell proliferation. Papillomavirus (HPV) ( HPV HPV Human papillomavirus (HPV) is a nonenveloped, circular, double-stranded DNA virus belonging to the Papillomaviridae family. Humans are the only reservoir, and transmission occurs through close skin-to-skin or sexual contact. Human papillomaviruses infect basal epithelial cells and can affect cell-regulatory proteins to result in cell proliferation. Papillomavirus (HPV)):
  • Detected in 99.7% of cervical cancers
  • Subtypes HPV 16 HPV 16 A type of alphapapillomavirus usually associated with genital warts; and laryngeal neoplasms. Papillomavirus (HPV) and 18 found in > 70% of cervical cancers^[6]

Epidemiology^[1,6,12]

• More than 80% of new cases worldwide are from less developed countries.
• Worldwide:
  • 2020 estimates:
    • > 600,000 diagnosed with cervical cancer Cervical cancer Cervical cancer, or invasive cervical carcinoma (ICC), is the 3rd most common cancer in women in the world, with > 50% of the cases being fatal. In the United States, ICC is the 13th most common cancer and the cause of < 3% of all cancer deaths due to the slow progression of precursor lesions and, more importantly, effective cancer screening. Cervical Cancer
    • > 340,000 died due to cervical cancer Cervical cancer Cervical cancer, or invasive cervical carcinoma (ICC), is the 3rd most common cancer in women in the world, with > 50% of the cases being fatal. In the United States, ICC is the 13th most common cancer and the cause of < 3% of all cancer deaths due to the slow progression of precursor lesions and, more importantly, effective cancer screening. Cervical Cancer
  • Most common cause of cancer in 23 developing countries, primarily in sub-Saharan Africa, South America, and Southeast Asia ASIA Spinal Cord Injuries
• In the United States:
  • 14,000 new cases of invasive cervical cancer Cervical cancer Cervical cancer, or invasive cervical carcinoma (ICC), is the 3rd most common cancer in women in the world, with > 50% of the cases being fatal. In the United States, ICC is the 13th most common cancer and the cause of < 3% of all cancer deaths due to the slow progression of precursor lesions and, more importantly, effective cancer screening. Cervical Cancer are diagnosed annually.
  • Mean age at diagnosis: 50 years
  • 3rd most common gynecologic cancer diagnosed
  • 18th most common cause of cancer death overal

Risk factors^[12]

• HPV-related:
  • Early onset of sexual activity
  • Multiple sexual partners
  • Multiparity ≥ 3 full-term births 
  • Early age (< 20 years of age) at 1st birth 
  • History of vulvar or vaginal squamous intraepithelial neoplasia or cancer
  • Immunosuppression
  • Human immunodeficiency Immunodeficiency Chédiak-Higashi Syndrome virus Virus Viruses are infectious, obligate intracellular parasites composed of a nucleic acid core surrounded by a protein capsid. Viruses can be either naked (non-enveloped) or enveloped. The classification of viruses is complex and based on many factors, including type and structure of the nucleoid and capsid, the presence of an envelope, the replication cycle, and the host range. Virology ( HIV HIV Anti-HIV Drugs) infection
  • Co-infection with Chlamydia trachomatis Chlamydia trachomatis Type species of Chlamydia causing a variety of ocular and urogenital diseases. Chlamydia or herpes simplex Herpes Simplex A group of acute infections caused by herpes simplex virus type 1 or type 2 that is characterized by the development of one or more small fluid-filled vesicles with a raised erythematous base on the skin or mucous membrane. It occurs as a primary infection or recurs due to a reactivation of a latent infection. Congenital TORCH Infections virus Virus Viruses are infectious, obligate intracellular parasites composed of a nucleic acid core surrounded by a protein capsid. Viruses can be either naked (non-enveloped) or enveloped. The classification of viruses is complex and based on many factors, including type and structure of the nucleoid and capsid, the presence of an envelope, the replication cycle, and the host range. Virology
• Non-HPV related:
  • Low socioeconomic status
  • African American race
  • Use of oral contraceptives
  • Cigarette smoking Smoking Willful or deliberate act of inhaling and exhaling smoke from burning substances or agents held by hand. Interstitial Lung Diseases (associated with squamous cell carcinoma Squamous cell carcinoma Cutaneous squamous cell carcinoma (cSCC) is caused by malignant proliferation of atypical keratinocytes. This condition is the 2nd most common skin malignancy and usually affects sun-exposed areas of fair-skinned patients. The cancer presents as a firm, erythematous, keratotic plaque or papule. Squamous Cell Carcinoma (SCC))
  • Family history Family History Adult Health Maintenance
  • Negative risk factor: circumcised male partners

Screening Rationale

• Screening Screening Preoperative Care is recommended because:^[11]
  • Women 21‒65 years of age are at risk for cervical cancer Cervical cancer Cervical cancer, or invasive cervical carcinoma (ICC), is the 3rd most common cancer in women in the world, with > 50% of the cases being fatal. In the United States, ICC is the 13th most common cancer and the cause of < 3% of all cancer deaths due to the slow progression of precursor lesions and, more importantly, effective cancer screening. Cervical Cancer due to potential exposure to high-risk human papillomavirus Human papillomavirus Human papillomavirus (HPV) is a nonenveloped, circular, double-stranded DNA virus belonging to the Papillomaviridae family. Humans are the only reservoir, and transmission occurs through close skin-to-skin or sexual contact. Human papillomaviruses infect basal epithelial cells and can affect cell-regulatory proteins to result in cell proliferation. Papillomavirus (HPV) (hrHPV) through sexual intercourse.
  • A 75% decline in the incidence Incidence The number of new cases of a given disease during a given period in a specified population. It also is used for the rate at which new events occur in a defined population. It is differentiated from prevalence, which refers to all cases in the population at a given time. Measures of Disease Frequency and mortality Mortality All deaths reported in a given population. Measures of Health Status of cervical cancer Cervical cancer Cervical cancer, or invasive cervical carcinoma (ICC), is the 3rd most common cancer in women in the world, with > 50% of the cases being fatal. In the United States, ICC is the 13th most common cancer and the cause of < 3% of all cancer deaths due to the slow progression of precursor lesions and, more importantly, effective cancer screening. Cervical Cancer occurred in the past 50 years due to screening Screening Preoperative Care.
  • Most cases of cervical cancer Cervical cancer Cervical cancer, or invasive cervical carcinoma (ICC), is the 3rd most common cancer in women in the world, with > 50% of the cases being fatal. In the United States, ICC is the 13th most common cancer and the cause of < 3% of all cancer deaths due to the slow progression of precursor lesions and, more importantly, effective cancer screening. Cervical Cancer are found in women who have not been adequately screened.
  • Cervical cancer Cervical cancer Cervical cancer, or invasive cervical carcinoma (ICC), is the 3rd most common cancer in women in the world, with > 50% of the cases being fatal. In the United States, ICC is the 13th most common cancer and the cause of < 3% of all cancer deaths due to the slow progression of precursor lesions and, more importantly, effective cancer screening. Cervical Cancer usually does not cause symptoms.
• Screening Screening Preoperative Care is not recommended earlier than age 21 because:^[3]
  • Cancerous and precancerous Precancerous Pathological conditions that tend eventually to become malignant. Barrett Esophagus lesions are rare before the age of 21.
  • The progression from hrHPV infection → precancerous Precancerous Pathological conditions that tend eventually to become malignant. Barrett Esophagus lesions (cervical intraepithelial neoplasia ( CIN CIN An increased tendency to acquire chromosome aberrations when various processes involved in chromosome replication, repair, or segregation are dysfunctional. Colorectal Cancer)) → invasive cancer takes many years
  • Many precancerous Precancerous Pathological conditions that tend eventually to become malignant. Barrett Esophagus lesions and HPV HPV Human papillomavirus (HPV) is a nonenveloped, circular, double-stranded DNA virus belonging to the Papillomaviridae family. Humans are the only reservoir, and transmission occurs through close skin-to-skin or sexual contact. Human papillomaviruses infect basal epithelial cells and can affect cell-regulatory proteins to result in cell proliferation. Papillomavirus (HPV) infections Infections Invasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases. Chronic Granulomatous Disease will regress.
  • May lead to more harm from psychological distress and unnecessary procedures

Strategies for Screening

Screening Screening Preoperative Care strategies can be done independently or concurrently (co-testing).

• Cervical cytology Cervical cytology A procedure in which ectocervical and endocervical cells are collected to evaluate the transformation zone (area at risk for cervical cancer). Cervical Cancer Screening:^[1,13]
  • Ectocervical and endocervical cells are collected to evaluate the transformation zone Transformation zone Diagnostic Procedures in Gynecology (area at risk for cervical cancer Cervical cancer Cervical cancer, or invasive cervical carcinoma (ICC), is the 3rd most common cancer in women in the world, with > 50% of the cases being fatal. In the United States, ICC is the 13th most common cancer and the cause of < 3% of all cancer deaths due to the slow progression of precursor lesions and, more importantly, effective cancer screening. Cervical Cancer).
  • The procedure is performed with either:
    • An endocervical brush and ectocervical spatula
    • A cervical broom Cervical broom Diagnostic Procedures in Gynecology (collects both endocervical and ectocervical cells simultaneously)
  • Preparation methods:
    • Conventional Papanicolaou (Pap) smear: Ectocervical spatula is smeared and the brush rolled onto a slide, with fixative applied immediately
    • Liquid-based thin layer cytology: Collection device is placed and swirled in the liquid fixative solution, which is then processed by the laboratory.
• HPV testing HPV testing Cervical Cancer Screening:^[1,6,13]
  • Identifies hrHPV subtypes
    • Most are nucleic acid amplification Nucleic acid amplification Laboratory techniques that involve the in-vitro synthesis of many copies of DNA or RNA from one original template. Septic Arthritis tests (NAATs)^[1,6]
    • Tests vary as to which subtypes they can detect, though all detect the 13 most common types, including 16 and 18.
    • Genotyping Genotyping Methods used to determine individuals’ specific alleles or snps (single nucleotide polymorphisms). Polymerase Chain Reaction (PCR) refers to testing for an individual type, typically 16 and 18, +/– 45.
  • Samples are collected from the endocervix Endocervix Uterus, Cervix, and Fallopian Tubes: Anatomy.
  • If liquid-based cytology is performed, the same cytology specimen can be used.

Cervical Cancer Screening for Average-Risk Individuals

The following recommendations are for average-risk individuals.^[1-7] This group includes individuals who are fully vaccinated against HPV HPV Human papillomavirus (HPV) is a nonenveloped, circular, double-stranded DNA virus belonging to the Papillomaviridae family. Humans are the only reservoir, and transmission occurs through close skin-to-skin or sexual contact. Human papillomaviruses infect basal epithelial cells and can affect cell-regulatory proteins to result in cell proliferation. Papillomavirus (HPV).

• United States Preventive Services Task Force (USPSTF)^[1] recommendations (which are endorsed by the American Society for Colposcopy Colposcopy The examination, therapy or surgery of the cervix and vagina by means of a specially designed endoscope introduced vaginally. Cervical Cancer Screening and Cervical Pathology (ASCCP),^[4,5] the American College of Obstetricians and Gynecologists (ACOG),^[7] and the Society of Gynecologic Oncology^[7]):
  • No screening Screening Preoperative Care prior to the age of 21, regardless of sexual history 
  • For ages 21‒29: cytology alone every 3 years:
    • Primary hrHPV testing every 5 years can be considered for patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship 25‒29^[7]
  • For ages 30‒65, options are:
    • Cervical cytology Cervical cytology A procedure in which ectocervical and endocervical cells are collected to evaluate the transformation zone (area at risk for cervical cancer). Cervical Cancer Screening alone every 3 years
    • hrHPV every 5 years
    • Cytology with hrHPV co-testing every 5 years 
  • For ages > 65:
    • No further screening Screening Preoperative Care if patient has average risk AND adequate prior screening Screening Preoperative Care over the past 10 years (see below)
    • Screening Screening Preoperative Care may be appropriate if prior screening Screening Preoperative Care has been inadequate or if screening Screening Preoperative Care history is unknown.
  • Differences from the American Cancer Society (ACS) recommendations:^[7]
    • Access to primary screening Screening Preoperative Care with hrHPV testing alone is still frequently unavailable in the US.
    • Raising the initial age of screening Screening Preoperative Care to 25 (as ACS did) is under consideration.
    • Concern exists that raising the initial age of screening Screening Preoperative Care and/or changing the preferred method of screening Screening Preoperative Care may exacerbate underscreening in those 25‒29 years old and health equity concerns.
• Updated American Cancer Society recommendations (2020):^[2,3]
  • No screening Screening Preoperative Care prior to the age of 25, regardless of sexual history
  • Screen individuals ages 25‒65
  • Preferred test: primary HPV testing HPV testing Cervical Cancer Screening (approved testing that is adequate for screening Screening Preoperative Care by itself) every 5 years
  • If primary HPV testing HPV testing Cervical Cancer Screening cannot be done:
    • Co-testing with HPV HPV Human papillomavirus (HPV) is a nonenveloped, circular, double-stranded DNA virus belonging to the Papillomaviridae family. Humans are the only reservoir, and transmission occurs through close skin-to-skin or sexual contact. Human papillomaviruses infect basal epithelial cells and can affect cell-regulatory proteins to result in cell proliferation. Papillomavirus (HPV) and cervical cytology Cervical cytology A procedure in which ectocervical and endocervical cells are collected to evaluate the transformation zone (area at risk for cervical cancer). Cervical Cancer Screening every 5 years
    • Cervical cytology Cervical cytology A procedure in which ectocervical and endocervical cells are collected to evaluate the transformation zone (area at risk for cervical cancer). Cervical Cancer Screening alone every 3 years 
  • Screening Screening Preoperative Care ends at age 65 for average-risk individuals with adequate negative screening Screening Preoperative Care.
  • Rationale for the above:
    • Low incidence Incidence The number of new cases of a given disease during a given period in a specified population. It also is used for the rate at which new events occur in a defined population. It is differentiated from prevalence, which refers to all cases in the population at a given time. Measures of Disease Frequency of cervical cancer Cervical cancer Cervical cancer, or invasive cervical carcinoma (ICC), is the 3rd most common cancer in women in the world, with > 50% of the cases being fatal. In the United States, ICC is the 13th most common cancer and the cause of < 3% of all cancer deaths due to the slow progression of precursor lesions and, more importantly, effective cancer screening. Cervical Cancer in those < 24 years of age
    • HPV testing HPV testing Cervical Cancer Screening is more specific.
    • About 70% of adolescents have received at least 1 dose of the HPV HPV Human papillomavirus (HPV) is a nonenveloped, circular, double-stranded DNA virus belonging to the Papillomaviridae family. Humans are the only reservoir, and transmission occurs through close skin-to-skin or sexual contact. Human papillomaviruses infect basal epithelial cells and can affect cell-regulatory proteins to result in cell proliferation. Papillomavirus (HPV) vaccine Vaccine Suspensions of killed or attenuated microorganisms (bacteria, viruses, fungi, protozoa), antigenic proteins, synthetic constructs, or other bio-molecular derivatives, administered for the prevention, amelioration, or treatment of infectious and other diseases. Vaccination.
• World Health Organization recommendations:^[6]
  • Screening Screening Preoperative Care ages:
    • Individuals 30‒50 years of age should be screened/prioritized.
    • Screening Screening Preoperative Care may continue in individuals 50‒65 if resources are available, prioritizing those who have never been screened.
  • Screening Screening Preoperative Care is recommended with hrHPV testing every 5‒10 years.
• Adequate negative prior screening Screening Preoperative Care is defined as 1 of the following:^[1,3,7]
  • 3 consecutive negative cytology results, with the last result within the past 3 years
  • 2 consecutive negative co-test results within the past 10 years, with the most recent test within the past 5 years
  • 2 consecutive negative primary HPV HPV Human papillomavirus (HPV) is a nonenveloped, circular, double-stranded DNA virus belonging to the Papillomaviridae family. Humans are the only reservoir, and transmission occurs through close skin-to-skin or sexual contact. Human papillomaviruses infect basal epithelial cells and can affect cell-regulatory proteins to result in cell proliferation. Papillomavirus (HPV) test results within the past 10 years, with the most recent test within the past 5 years

Cervical Cancer Screening for Special Populations

High-risk individuals^[1,3,6,7]

Certain conditions have a high risk for cervical cancer Cervical cancer Cervical cancer, or invasive cervical carcinoma (ICC), is the 3rd most common cancer in women in the world, with > 50% of the cases being fatal. In the United States, ICC is the 13th most common cancer and the cause of < 3% of all cancer deaths due to the slow progression of precursor lesions and, more importantly, effective cancer screening. Cervical Cancer, so screening Screening Preoperative Care must be individualized and more frequent:

• HIV HIV Anti-HIV Drugs infection: Screening Screening Preoperative Care may start at the time of HIV HIV Anti-HIV Drugs diagnosis, but no sooner than 21 years of age, regardless of sexual history.
  • Note: The WHO recommends initiating screening Screening Preoperative Care at age 25, regardless of age of HIV HIV Anti-HIV Drugs diagnosis^[6]
• Immunocompromised immunocompromised A human or animal whose immunologic mechanism is deficient because of an immunodeficiency disorder or other disease or as the result of the administration of immunosuppressive drugs or radiation. Gastroenteritis: Screening Screening Preoperative Care may start at 21 years of age, regardless of sexual history.
• In utero exposure to diethylstilbestrol Diethylstilbestrol A synthetic nonsteroidal estrogen used in the treatment of menopausal and postmenopausal disorders. It was also used formerly as a growth promoter in animals. According to the fourth annual report on carcinogens, diethylstilbestrol has been listed as a known carcinogen. Noncontraceptive Estrogen and Progestins (last used in the 1970s, so most relevant in women born prior to 1980)
• Previous treatment of a high-grade precancerous Precancerous Pathological conditions that tend eventually to become malignant. Barrett Esophagus lesion or cervical cancer Cervical cancer Cervical cancer, or invasive cervical carcinoma (ICC), is the 3rd most common cancer in women in the world, with > 50% of the cases being fatal. In the United States, ICC is the 13th most common cancer and the cause of < 3% of all cancer deaths due to the slow progression of precursor lesions and, more importantly, effective cancer screening. Cervical Cancer within the past 25 years

Prior hysterectomy^[1,7]

• Screening Screening Preoperative Care is still recommended in women:
  • With history of subtotal hysterectomy ( cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy intact; typically called a supracervical hysterectomy)
  • With history of cervical intraepithelial neoplasia ( CIN CIN An increased tendency to acquire chromosome aberrations when various processes involved in chromosome replication, repair, or segregation are dysfunctional. Colorectal Cancer), even after hysterectomy
• No screening Screening Preoperative Care is recommended in women who meet both of the following criteria:
  • History of a total hysterectomy (which includes removal of the cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy) for a benign Benign Fibroadenoma disease
  • No history of a high-grade precancerous Precancerous Pathological conditions that tend eventually to become malignant. Barrett Esophagus lesion ( CIN CIN An increased tendency to acquire chromosome aberrations when various processes involved in chromosome replication, repair, or segregation are dysfunctional. Colorectal Cancer grade 2 or 3) or cervical cancer Cervical cancer Cervical cancer, or invasive cervical carcinoma (ICC), is the 3rd most common cancer in women in the world, with > 50% of the cases being fatal. In the United States, ICC is the 13th most common cancer and the cause of < 3% of all cancer deaths due to the slow progression of precursor lesions and, more importantly, effective cancer screening. Cervical Cancer

Individuals > 65 years of age^[1,3,7]

• Screening Screening Preoperative Care may be indicated in older women with inadequate screening Screening Preoperative Care.
  • Those at risk for inadequate screening Screening Preoperative Care:
    • Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with limited access to care
    • Women from racial or ethnic minority groups
    • Immigrant women from countries where screening Screening Preoperative Care is not available 
  • Duration of screening Screening Preoperative Care is based on:
    • A life expectancy Life expectancy Based on known statistical data, the number of years which any person of a given age may reasonably expected to live. Population Pyramids of ≥ 10 years
    • An informed decision-making discussion with the patient
  • Screening Screening Preoperative Care should continue until “adequate negative screening Screening Preoperative Care criteria” above are met MET Preoperative Care.
• Continued screening Screening Preoperative Care is recommended for at least 25 years after a precancerous Precancerous Pathological conditions that tend eventually to become malignant. Barrett Esophagus lesion regresses or is treated, even if screening Screening Preoperative Care goes past the age of 65, including situation in which:
  • The lesion regresses or is treated
  • The patient has undergone total hysterectomy 

Cervical cytology (i.e., Pap test)

Results ( Bethesda system Bethesda system A standardized reporting of results of PAP test, which includes the specimen adequacy, general categorization of findings, and results Cervical Cancer Screening)^[14]

The Bethesda system Bethesda system A standardized reporting of results of PAP test, which includes the specimen adequacy, general categorization of findings, and results Cervical Cancer Screening is a standardized reporting of results, which includes the specimen adequacy, general categorization Categorization Types of Variables of findings, and results.

Specimen adequacy (critical for quality Quality Activities and programs intended to assure or improve the quality of care in either a defined medical setting or a program. The concept includes the assessment or evaluation of the quality of care; identification of problems or shortcomings in the delivery of care; designing activities to overcome these deficiencies; and follow-up monitoring to ensure effectiveness of corrective steps. Quality Measurement and Improvement assurance):^[14]

• Requires at least 5,000 well-visualized squamous cells on a liquid preparation or 8,000‒12,000 well-visualized squamous cells on a traditional Pap smear Pap smear Cytological preparation of cells collected from a mucosal surface and stained with Papanicolaou stain. Cervical Cancer Screening
• Presence of the endocervical transformation zone Transformation zone Diagnostic Procedures in Gynecology:
  • The area of squamous metaplasia Metaplasia A condition in which there is a change of one adult cell type to another similar adult cell type. Cellular Adaptation between the squamocolumnar junction Squamocolumnar junction Esophagus: Anatomy separating squamous ectocervical cells from glandular endocervical cells
  • Requires at least 10 well-preserved endocervical or squamous metaplastic cells
• Absent or minimal obscuring or interfering factors (a specimen is unsatisfactory for evaluation when > 75% of the cells are obscured); factors include:
  • Blood
  • Inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body’s defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation
  • Some lubricants

Types of squamous cell epithelial cell abnormalities:

• Negative for intraepithelial lesion or malignancy Malignancy Hemothorax (NILM): no cellular evidence of neoplasia
• Atypical squamous cells (ASC):
  • Some cells seen are not normal but do not meet the requirements to be precancerous Precancerous Pathological conditions that tend eventually to become malignant. Barrett Esophagus. 
  • May be precancerous Precancerous Pathological conditions that tend eventually to become malignant. Barrett Esophagus or associated with infection, irritation, or intercourse
  • Categories:
    • ASC of undetermined significance (ASC-US): abnormal cells, but no squamous intraepithelial lesions (SIL)
    • ASC cannot exclude high-grade SILs (HSIL): equivocal findings, but may be a sign of HSIL
• Squamous intraepithelial lesion (SIL):
  • Premalignant findings for invasive squamous cell carcinoma Squamous cell carcinoma Cutaneous squamous cell carcinoma (cSCC) is caused by malignant proliferation of atypical keratinocytes. This condition is the 2nd most common skin malignancy and usually affects sun-exposed areas of fair-skinned patients. The cancer presents as a firm, erythematous, keratotic plaque or papule. Squamous Cell Carcinoma (SCC)
  • Low-grade squamous intraepithelial lesion (LSIL):
    • Low-grade dysplasia corresponding to CIN CIN An increased tendency to acquire chromosome aberrations when various processes involved in chromosome replication, repair, or segregation are dysfunctional. Colorectal Cancer 1 (cervical intraepithelial neoplasia type 1 Type 1 Spinal Muscular Atrophy) 
    • Early, mild changes in the size or shape of cells
    • May regress on its own
  • High-grade squamous intraepithelial lesion (HSIL):
    • Moderate or high-grade dysplasia (corresponding to CIN CIN An increased tendency to acquire chromosome aberrations when various processes involved in chromosome replication, repair, or segregation are dysfunctional. Colorectal Cancer 2, CIN CIN An increased tendency to acquire chromosome aberrations when various processes involved in chromosome replication, repair, or segregation are dysfunctional. Colorectal Cancer 3, or carcinoma in situ)
    • Increased risk of progression to invasive carcinoma (compared with LSIL changes)
• Squamous cell carcinoma Squamous cell carcinoma Cutaneous squamous cell carcinoma (cSCC) is caused by malignant proliferation of atypical keratinocytes. This condition is the 2nd most common skin malignancy and usually affects sun-exposed areas of fair-skinned patients. The cancer presents as a firm, erythematous, keratotic plaque or papule. Squamous Cell Carcinoma (SCC): cancer

Glandular cell abnormalities (categorized as endocervical, endometrial, or not otherwise specified):

• Atypical endocervical, endometrial, or glandular cells (AGC): endometrial or cervical cell changes abnormal, requiring closer evaluation
• AGC, favor neoplastic: show features that suggest, but are not sufficient for, a diagnosis of adenocarcinoma
• Endocervical adenocarcinoma in situ ( AIS AIS Scoliosis): premalignant lesion of invasive adenocarcinoma
• Adenocarcinoma: cancer

Other possible findings reported on cervical cytology Cervical cytology A procedure in which ectocervical and endocervical cells are collected to evaluate the transformation zone (area at risk for cervical cancer). Cervical Cancer Screening reports:

• Organisms:
  • Trichomonas Trichomonas A genus of parasitic flagellate eukaryotes distinguished by the presence of four anterior flagella, an undulating membrane, and a trailing flagellum. Nitroimidazoles vaginalis
  • Fungal elements (consistent with Candida Candida Candida is a genus of dimorphic, opportunistic fungi. Candida albicans is part of the normal human flora and is the most common cause of candidiasis. The clinical presentation varies and can include localized mucocutaneous infections (e.g., oropharyngeal, esophageal, intertriginous, and vulvovaginal candidiasis) and invasive disease (e.g., candidemia, intraabdominal abscess, pericarditis, and meningitis). Candida/Candidiasis)
  • Cellular changes consistent with herpes simplex Herpes Simplex A group of acute infections caused by herpes simplex virus type 1 or type 2 that is characterized by the development of one or more small fluid-filled vesicles with a raised erythematous base on the skin or mucous membrane. It occurs as a primary infection or recurs due to a reactivation of a latent infection. Congenital TORCH Infections virus Virus Viruses are infectious, obligate intracellular parasites composed of a nucleic acid core surrounded by a protein capsid. Viruses can be either naked (non-enveloped) or enveloped. The classification of viruses is complex and based on many factors, including type and structure of the nucleoid and capsid, the presence of an envelope, the replication cycle, and the host range. Virology or cytomegalovirus Cytomegalovirus CMV is a ubiquitous double-stranded DNA virus belonging to the Herpesviridae family. CMV infections can be transmitted in bodily fluids, such as blood, saliva, urine, semen, and breast milk. The initial infection is usually asymptomatic in the immunocompetent host, or it can present with symptoms of mononucleosis. Cytomegalovirus
  • Bacterial vaginosis Bacterial vaginosis Polymicrobial, nonspecific vaginitis associated with positive cultures of gardnerella vaginalis and other anaerobic organisms and a decrease in lactobacilli. It remains unclear whether the initial pathogenic event is caused by the growth of anaerobes or a primary decrease in lactobacilli. Vulvovaginitis
  • Bacteria Bacteria Bacteria are prokaryotic single-celled microorganisms that are metabolically active and divide by binary fission. Some of these organisms play a significant role in the pathogenesis of diseases. Bacteriology consistent with Actinomyces Actinomyces Actinomyces is an anaerobic, gram-positive, branching, filamentous rod. Actinomyces israelii is the most common species involved in human disease. The organism is commonly found as part of the normal flora in the oral cavity, gastrointestinal tract, and reproductive tract. Actinomyces/Actinomycosis
• Other nonneoplastic findings may be included:
  • Reactive cellular changes
  • Glandular cells status post-hysterectomy
  • Atrophy Atrophy Decrease in the size of a cell, tissue, organ, or multiple organs, associated with a variety of pathological conditions such as abnormal cellular changes, ischemia, malnutrition, or hormonal changes. Cellular Adaptation
  • Inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body’s defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation

Billing and Coding

Screening Screening Preoperative Care Encounter Codes:

These codes are used to document a routine visit for cervical cancer Cervical cancer Cervical cancer, or invasive cervical carcinoma (ICC), is the 3rd most common cancer in women in the world, with > 50% of the cases being fatal. In the United States, ICC is the 13th most common cancer and the cause of < 3% of all cancer deaths due to the slow progression of precursor lesions and, more importantly, effective cancer screening. Cervical Cancer screening Screening Preoperative Care in an asymptomatic patient, establishing the medical necessity for the screening Screening Preoperative Care tests.

Screening Screening Preoperative Care & Diagnostic Procedures:

These CPT codes represent the core procedures in cervical cancer Cervical cancer Cervical cancer, or invasive cervical carcinoma (ICC), is the 3rd most common cancer in women in the world, with > 50% of the cases being fatal. In the United States, ICC is the 13th most common cancer and the cause of < 3% of all cancer deaths due to the slow progression of precursor lesions and, more importantly, effective cancer screening. Cervical Cancer screening Screening Preoperative Care and evaluation: the Pap test to collect cervical cells, HPV testing HPV testing Cervical Cancer Screening, and a colposcopy Colposcopy The examination, therapy or surgery of the cervix and vagina by means of a specially designed endoscope introduced vaginally. Cervical Cancer Screening with biopsy Biopsy Removal and pathologic examination of specimens from the living body. Ewing Sarcoma to examine the cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy under magnification if screening Screening Preoperative Care is abnormal.

Abnormal Findings Codes:

These codes are used to document the results of abnormal screening Screening Preoperative Care tests, such as Atypical Squamous Cells of Undetermined Significance (ASC-US) or the pathologic diagnosis of cervical dysplasia ( CIN CIN An increased tendency to acquire chromosome aberrations when various processes involved in chromosome replication, repair, or segregation are dysfunctional. Colorectal Cancer) from a biopsy Biopsy Removal and pathologic examination of specimens from the living body. Ewing Sarcoma.

Treatment Procedures:

This code is for a Loop Electrosurgical Excision Procedure Loop Electrosurgical Excision Procedure Diagnostic Procedures in Gynecology ( LEEP LEEP Diagnostic Procedures in Gynecology), the most common treatment for high-grade cervical dysplasia ( CIN CIN An increased tendency to acquire chromosome aberrations when various processes involved in chromosome replication, repair, or segregation are dysfunctional. Colorectal Cancer II/III), where a thin, low-voltage electrified wire loop is used to remove the abnormal tissue.