Since its introduction in the 1940s, the Pap smear has been the standard method of cytologic screening of the cervix. Although the false-negative rate of screening Pap smears in the general population reportedly has been as high as 20 to 45 percent, annual screening could lower that rate. The American College of Obstetricians and Gynecologists (ACOG), the American Academy of Family Physicians and the U.S. Preventive Services Task Force recommend that all women receive screening Pap smears at the onset of sexual activity or at 18 years of age, because strong evidence supports the theory that routine screening with Pap smears will lower the rate of cervical cancer. Once three normal annual Pap smears are documented, the interval for continued surveillance with screening Pap smears may be lengthened at the discretion of the physician and the patient. Inadequately screened populations, such as women more than 65 years of age, and indigent women, account for 25 percent of the cases of cervical cancer and 41 percent of deaths resulting from the disease. Sixty percent of women who are diagnosed with invasive cervical cancer have not had a Pap smear in the past five years. Women who present for medical care should have initial screening, as well as ongoing surveillance, for the presence of cervical neoplasia.
Pap smears that suggest invasive disease require further evaluation by colposcopy, colposcopic-directed biopsy and endocervical curettage. Colposcopy offers direct visualization of the cervix with an opportunity to biopsy sites of abnormality.
Although colposcopy requires additional training to properly differentiate between normal and abnormal epithelium and additional expense to set up the proper equipment to perform the procedure, family physicians can and do perform the procedure as a part of their outpatient practice.
|International Federation of Gynecologists and Obstetricians Staging System for Cervical Cancer
|| Carcinoma in situ, intraepithelial neoplasia.
|| Carcinoma strictly confined to the cervix.
|| Invasive cancer identified only microscopically. All gross lesions, even with superficial invasion, are stage Ib cancers. Invasion is limited to measured invasion of stroma <=5 mm in depth and <=7 mm in width.
|| Measured invasion of stroma <=3 mm in depth and <=7 mm in width.
|| Measured invasion of stroma >3 mm and <=5 mm in depth and <=7mm in width.
|| Clinical lesions confined to the cervix or preclinical lesions greater than Ia.
|| Clinical lesions <= 4cm in size.
|| Clinical lesions > 4cm in size.
|| Carcinoma extends beyond the cervix but not to the pelvic wall; carcinoma involves the vagina but not as far as the lower one third.
|| No obvious parametrial involvement.
|| Obvious parametrial involvement.
|| Carcinoma has extended to the pelvic wall; on rectal examination no cancer- free space is found between the tumor and the pelvic wall; the tumor involves the lower one third of the vagina; all cases with a hydronephrosis or nonfunctioning kidney should be included, unless they are known to be related to another cause.
|| No extension to the pelvic wall, but involvement of the lower one third of the vagina.
|| Extension to the pelvic wall and hydronephrosis or nonfunctioning kidney, or both.
|| Carcinoma has extended beyond the true pelvis or has clinically involved the mucosa of the bladder or rectum.
|| Spread to adjacent organs.
|| Spread to distant organs.