Your Pap Smear Was Abnormal: Now What?

Routine Pap smears (also known as Pap tests) are an important part of protecting your health because they can help prevent cervical cancer or find it early. But learning your results are abnormal can cause some anxiety, and you may find yourself wondering what comes next. Join Dr. Sarah Feldman, a gynecologic oncologist at Brigham and Women’s Hospital, as she breaks down what abnormal results mean, what happens after, and why it’s important to follow up on an abnormal Pap smear.

1. Your Pap smear was abnormal-now what? Sarah Feldman MD MPH Medical Director Ambulatory Gynecologic Oncology Brigham and Women’s Hospital Harvard Medical School

2. Disclosures I write chapters on cervical cancer screening and colposcopy for Uptodate I have several grants from the NCI to study how best to screen for and manage patients with abnormal screening results I sit on multiple national and international committees aimed at preventing cervical cancer This slide deck was prepared in collaboration with Kelly Welch from Team Maureen. Team Maureen has been working to end cervical cancer through education since 2007. For more information on Team Maureen, visit TeamMaureen.org

3. Goals To explain the why, how and what of cervical cancer prevention To discuss “Pap screening” and other ways to prevent cervical cancer To suggest what to do after an abnormal Pap test, including questions to ask your health care provider

4. Cervical cancer Cervical cancer is a cancer that affects the cervix or opening to the uterus in women. It usually affects women in their 30s and 40s, but 20% of cases occur in women over the age of 65. Historically, cervical cancer was prevented by having an annual “Pap Smear.”

5. Cervical cancer is PREVENTABLE Prevention relies on a two piece approach Vaccination Screening with management of abnormal results

6. What is screening? Screening refers to testing all healthy people with a cervix with no symptoms and a history of normal tests between the ages of 21 and 65 Once a patient has an abnormal test result, they no longer undergo “screening.” In order to prevent cancer abnormal result needs further evaluation, and then if there is a precancer (also known as a high grade lesion) they need treatment and more frequent testing known as “surveillance.” Women who are immunosuppressed or have a history of abnormal results or cancer will get more frequent testing.

7. New knowledge has improved screening for cervical cancer… Cervical cancer is caused by persistent infection with a high risk HPV virus. Ultimately persistent active infection (more than 2 years) with a hrHPV virus will cause changes at the cellular level that can be detected by a Pap test (an improved version of the historic “Pap smear.”)

8. What is HPV? HPV is a sexually transmitted infection and can (rarely) cause cancers of the cervix, vagina, vulva, anus, throat/base of tongue, and penis. It is transmitted through sexual skin to skin contact. In most cases HPV infection ‘clears’ without knowing you ever had it. There are 5 FDA approved HPV tests in the US. These HPV tests are not all used for the same purpose. Some tests may be used alone (without a Pap) and some need a Pap to determine next steps-ask your doctor which type you’re getting

9. Cervical Cancer Screening 2023- the modern “Pap smear” Many clinicians still refer to all screening as a Pap smear, but you are likely getting one of these tests: A Pap test (similar to a Pap smear) but more accurate An HPV test which screens for 14 types of HPV. The HPV test can be done by itself (called “Primary HPV testing”) or as a co-test (done at the same time as a Pap test). If an HPV test is positive, then a Pap test is needed to determine if there are abnormal cells present. The HPV test is the most reliable test (for your risk of developing a precancer) especially if it is either repeatedly positive or negative over time.

10. What are possible results of screening?

11. If my HPV test is positive what does that mean? Most unvaccinated people get HPV at some point (80%), but most infections clear and do not cause any precancerous changes A positive HPV test means you have an active infection of the cells which can, if it persists over time (years) cause cervical cancer A negative test does not mean that you have not ever been infected with HPV, but rather that the infection is not active and therefore your risk of developing cancer or precancer is lower. A negative test is very reassuring. Some patients (especially older women) may have dormant infections that then reactivate- does not require a new sexual exposure Some HPV types are more aggressive than others

12. What about my partner? If you tell your partner, it’s helpful to mention that: Most unvaccinated people have HPV. Especially in older people, a positive HPV test could just be an old infection that has reactivated, not a new infection. If you have HPV and are in an intimate relationship of any kind, your partner probably has it as well. Encourage your partner to keep up with screenings too: Dental exams Cervical exams Regular wellness appointments

13. Who needs colposcopy? Most patients with an abnormal Pap test, or a normal Pap but repeated positive HPV tests will need a colposcopy Ask your doctor about your particular case You can also access this website and put your information in: www.cervicalrisk.com Most abnormal results will require colposcopy and biopsy.

14. What is colposcopy/biopsy? Colposcopy is when a clinician looks at your cervix (and vagina and sometimes vulva) with magnification. It allows a clinician to see the cells in better detail to determine where to biopsy. A biopsy is a piece of tissue that is sent to a lab and a diagnosis is made (such as normal, low grade (not precancer) or high grade (precancer). Most of the time you will have at least one biopsy at the time of the colposcopy.

15. What to expect at colposcopy? (and will it hurt?)

16. Results and next steps

17. Need for ongoing surveillance All patients with abnormal screening results, whether or not treatment is needed, will start a more frequent surveillance testing regimen. After an abnormal result, you are no longer considered a routine screening patient. Treatment is often a LEEP---or removal of the abnormal cells. After evaluation and/or treatment you will be advised as to whether you need to return in 6months, one year, or 3 years depending on your prior and current results and age. Keep a record of any abnormal Pap, HPV tests, biopsies or treatments and make sure any future clinicians know your results as they affect how often you should be tested.

18. Questions to ask your doctor: AFTER

19. Thank you!