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Cervical Cancer Screening In Vietnamese Women

 

Cau Van Vo, MD., FACOG.
 

Epidemiology

Approximately 13,000 new cases of Cervical Cancer and 4,600 deaths occur annually in the United States. The death rate from Cervical Cancer is about 3.0 per 100,000 women. This is the third most gynecologic cancer death in the United States.
The incidence of Cervical Cancer is 9.2 per 100,000 women. The cervical cancer incidence has decreased by 77% in the past 50 years. The mortality from cervical cancer has been decreased by as much as 74% since the innovation of the Papanicolaou test (Pap test) in 1940.

Incidence of Invasive Cervical Cancer

The incidence of cervical cancer by rate:

-White                                                                                8.1 per 100,000 women
-Black                                                                                11.0 per 100,000 women
-Asian/Pacific Islander                                                  10.3 per 100,000 women
However, the Vietnamese women have the highest rate of this cancer compared to others in the United States. In fact, the number of new annual cases in Vietnamese women is five times that of white women based on the statistics of the National Cancer Institute.
-American Indian/Alaskan National                             6.4 per 100,000 women
-Hispanic                                                                           14.4 per 100,000 women

Risk Factors

* Risk factors associated with precancerous changes and cancer of cervix

-High risk human papilomavirus infection (HPV)
-Multiple sexual partners
-Sexual activity starting at an early age
-Parity
-Human immunodeficiency virus infection (HIV)
-Immune status
-Smoking
-History of other sexual transmitted diseases
-Oral contraceptive use more than 12 years
-Low socioeconomic status
-Poor diet, e.g., vitamin deficiency
-Use of immunosuppressant drugs
-In-utero exposure to Diethylstilbestrol (DES).1938-1971

* Other risk factors

-20% of women in the United States do not undergo regular cervical cytology screening (Pap smear).
-Approximately 50% of the women who develop invasive cervical cancer have never had cytology screening; another 10% have not had screening within 5 years.
-False negative due to incorrect sampling, fixation or interpretation.

* Additional specific risk factors in Vietnamese women
-Because of the culture, it must be more than 20% of women who do not have regular pelvic exam and Pap smears.
-First pregnancy at early age
-Multiparity
-Many low socioeconomic families
-Poorer diet, e.g., vitamin deficiency
-Higher risk of vaginal and cervical infection
-Higher risk of HPV infection
-More risk of in-utero exposure to DES.

Etiology

A 1995 study in the Journal of the National Cancer Institute (JNCI) reported finding genetic material of oncogenic HPV in 93% of invasive cervical cancer.
Human papilloma virus has been found to be associated with cervical cancer in 85% and this invasive cervical cancer contain high-risk HPV (types 16, 18, 31, 33, 35, etc.). (Clinical gynecologic oncology review. Tung v.Dinh, E. Hannigan).
The cervical cancer begins as an infection of HPV over 99%. It was reported in the draft of a bilingual booklet to educate the Vietnamese women prepared by the National Cancer Institute in 2005.
It is now clearly established that HPV is the cause of the majority of the common invasive cervical cancer.
Another 1 to 15% cervical cancers appear not to be related to HPV infection. Their etiologies may link to the risk factors mentioned above or may not be known.

Disease course

The progression to invasive cervical cancer is an important factor in the determination of cervical cytology screening. Over the last decade, it becomes clear that the beginning of infection with HPV is necessary for the development of high-grade lesions and cervical cancer. However, until 2001, it has been well established that cervical infection with high-risk HPV causes the majority of invasive cervical cancer.
A new guideline for HPV DNA testing was approved by FDA in February 2003. Cervical cancer arises form the early precancerous lesions, which may progress to high-grade, preinvasive stages and finally invasive cervical cancer. They also may regress to normal cells without any treatment.
Within 2 years, the mild dysplasia progress to moderate or worse at about 11.1% and to severe or worse at about 2.1%. The moderate dysplasia progress to severe or worse at about 16.3%.
It may also however, within 2 years, regress spontaneously from mild dysplasia to normal Pap smear about 44.3% and from moderate dysplasia to normal Pap smear
about 33.0%.

Mean transition time from mild to severe is approximately 5.8 years and from moderate to severe is approximately 3.1 years. Mean transition time from severe to invasive cancer is about 10 years.
However, there have been few cases, well documented, in Vietnamese women that the progression from normal Pap smear to invasive cancer was in 2 to 3 years. Among them, there was one case of small cell carcinoma. Etiology is completely unknown. Some countries have recently identified a higher incidence of cervical cancer diagnosed in younger women in their 20s and 30s, including adenocarcinoma and adenosquamous carcinoma.

Revised Bethesda System Classification 2001

Satisfactory or unsatisfactory slides
Negative for intraepithelial lesion or malignancy including other findings:
-Vaginal infectious organisms
-Other non-neoplastic findings
Other: endometrial cells (> 40 years of age)
Epithelial cell abnormalities
Squamous cell:
-Atypical squamous cells (ASC):
-ASC of undetermined significance (ASC-US)
-ASC cannot rule out HSIL (ASC-H)
-Low grade SIL (HPV/CIN I)
-High grade SIL:
-CIN II, CIN III
-With features suspicious for invasion
-Squamous cell carcinoma.
Glandular cell:
-Atypical Glandular cells (AGC):
-Atypical endocervical, endometrial and glandular cells (NOS)
-Atypical endocervical and glandular cells, favor neoplastic
-Endocervical adenocarcinoma in situ
-Adenocarcinoma.
Other malignant neoplasms

Guideline : American Cancer Society : American College of OBGYN
Initial screening : Age 21 or 3 years after intercourse : Age 21 or 3 years after vaginal sex.
Interval : Every year for conventional Pap test
: Every 2 y for liquid-based cytology
: Every 2-3 y after age 30 with 3 consecutive normals.		 : Every year for either liquid-base cytology or conventional Pap smear
: Every 2-3 y after age 30 with 3 Consecutive normals
: Yearly cervical cytology alone remain an acceptable strategy after age 30.
Discontinuation : Age 70 if 3 consecutive normals and  there were no positive tests in the last 10 years. : No age limit
 

Pap smears should continue at least yearly in women with a history of in-utero DES exposure, HIV infection or immunosuppressant status.

Continue screening if the patient is in reasonably good health without a life-limiting condition and cervical cytology was never performed.

Continue screening if the previous cytology report is not available or there is a history of dysplasia, cervical cancer or HIV

 

Suggestion of Cervical cancer screening in Vietnamese women.

Vietnamese women have the highest invasive cervical cancer rate in the United States of America. It is 5 times higher than white women. There are many factors; however, the main reason is still lack of regular gynecologic exam and annual cytologic screening. In our culture, women are not used to talking about sexual activities in public and letting other people see their intimate parts. That is the reason why many women are embarrassed to see their doctor for a pelvic exam and a Pap smear. Many Vietnamese women also believe as long as they do not have any symptoms they would have been healthy.
Because many Vietnamese American women do not get regular cervical cancer screening, they have a higher risk of getting invasive cervical cancer.
For that reason, I would recommend following the Cervical Cancer Screening Guidelines of the American College of Obstetricians and Gynecologists with few additional suggestions that address the specific risk factors in Vietnamese women.
As a member of the review team for the English-Vietnamese bilingual booklet on Cervical Cancer Risk and Pap tests for Vietnamese women, I have the privilege to recommend to the National Cancer Institute the guidelines of Cervical Cancer Screening, which serve for the highest risk Vietnamese population.

Following are the guidelines recommended:
 
Initial screening

: Every woman should begin to have regular screening at least by
the time she is 21 years old or 3 years after onset of vaginal
intercourse, whichever comes first.
   
Interval

: Women should have annual cervical cytology screening until age
30.
The screening interval can be less frequent in women aged 30 years and older who have had three consecutive negative results. Screening every 2 to 3 years is acceptable, unless there is a history of HIV, Immunosuppression, or in-utero DES exposure. The problem we are facing now is the DES exposure of Vietnamese women. This medication was very popular in Vietnam from the decades 40s-70s. Any woman who had symptoms of threatened abortion might have received this medication and the patients did not know. For that reason, more frequent screening should be performed in Vietnamese women who were born in Vietnam. The second option that the ACOG suggests should be advocated
for this high-risk Vietnamese population. That is annual cervical cytology screening. Annual cervical cytology alone remains an acceptable strategy. In addition, the women need a complete annual gynecological exam to detect the ovarian, uterine and
breast cancer.
Unlike the ACS, ACOG does not recommend the screening guidelines based on either conventional Pap smear or liquid-based cytology.
The National Institutes of Health, ACS and the American Society for Colposcopy and Cervical Pathology sponsored a workshop in February 2003 to evaluate the use of high-risk HPV DNA testing in cervical cancer screening. It was recommended that a combination of HPV DNA testing and cytology screening be limited to women age 30 years and older. However, women with Pap smear classified as ASCUS, who have HPV DNA testing positive at any age, need a colposcopy and follow up accordingly.
   
Discontinuation

-The Vietnamese are a population that underutilizes cervical screening,
we should set the bar at the highest level for detection.
I would recommend no upper age limit to stop screening as suggested
by ACOG.
-ACS suggests stopping at age 70 if 3 consecutive normals and there
were no positive tests in the last 10 years. I do not think many
people in this population meet these criteria.
-Women with a history of in-utero DES exposure, HIV or
Immunosuppression should have a Pap smear yearly.
-Continue screening if the patient is in reasonably good health and
cervical cytology was never performed even if the patient is above 70.
-Continue screening if previous Pap results are not available or there is
a history of dysplasia or cervical cancer.
 

Screening after Hysterectomy:
     

For Benign Reasons:

-Continued screening depends on the history of previous Pap smears. Women with no history of HSIL may discontinue screening. If the patient has a history of HSIL, screening should continue until there are three consecutive negative Pap smears and at the same time the patient has had no abnormal Pap results in a 10 years period.
-Screening should continue if the women had a supracervical hysterectomy.
-We are still in a dilemma that many patients who had hysterectomy in Vietnam do not know the reasons of surgery. The decision of screening should be discussed between the patients and their doctor.
   

For Malignant reasons:

-Continue screening every 4 to 6 months in the first 2 years then every year later. These patients should be kept under surveillance indefinitely.
 

Management of Cervical Dysplasia

RX** Menopausal women who have cytological evidence of atrophy should be treated with intravaginal estrogen if there are no contraindications.

 

Conclusion.

Cervical cancer screening is a very effective method to detect the precancerous stage that is easily treatable and the deadly cervical cancer can be prevented. Remember, most deaths from cervical cancer occur among women who have never had a Pap test. Vietnamese American women are still influenced deeply by our culture. Many women are embarrassed and timid to see their Gynecologist. This is the main reason of the highest cervical cancer rate in the United States. However, there are still other high-risk factors such as DES exposure, first pregnancy at early age, multiparity…
In the Practice Bulletin, Cervical cytology Screening, August 2003, ACOG continues to support annual Pap testing when obstetricians and Gynecologists find it appropriate, even if the patients are 30 years of age or older. I would support this recommendation to the high-risk Vietnamese population.

Some studies show that the addition of HPV DNA testing to a cervical screening in women below 30 years of age will improve the sensitivity of detecting CIN I or greater about 95%. Even with this new combination of tests, some women will still develop invasive cancer. Improved screening technology is important, but encouraging every Vietnamese woman into a regular cervical cancer screening will still be the utmost important goal.

Instead, Obstetricians and Gynecologists should adopt the guidelines and explain the important of a Pap test. We need to redouble our efforts to educate the Vietnamese women the value of an annual exam for other health assessments such as detecting ovarian cancer, screening breast cancer and recto-colon cancer, not cervical cancer screening alone.

References

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