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The Latest Guidelines !
on Cervical
and Breast Cancer !
Screening!
!
!
Carolyn R. Zalameda-Castro, MD, FPOGS, FSGOP, FPSCPC!
!
Disclosures!
MSD speaker for Gardasil 9 

 
CECAP’s trainors’ training workshop
References
Introduction !
References
February 4, 2014 WORLD CANCER DAY CNN report
By the year 2030…!
New cancer cases are

predicted to rise from an
estimated
14 million annually in 2012
to
22 million within two
decades.!
References
Deaths from cancer are

predicted to rise from
8.2 million
to
13 million a year.!
References
>60% of the world's cancer

cases and about 70% of the
world's cancer deaths occur in
Africa, Asia, and Central and
South America
References
Introduction!
This alarming rise in cancer

burden calls for renewed focus
on PREVENTION and
EARLY DETECTION aside
from IMPROVING
TREATMENT.
References
Prevention!
References
Prevention!
References
Cancer Prevention Advocacy!
•  There is a need to appreciate that screening and early

detection programs are “an investment” rather than a
cost.
•  Part of the Cancer Prevention Advocacy is the

continued medical education of health providers on
the latest guidelines for cancer screening.
References
Cervical and Breast Cancer!
•  High burden of disease globally
•  Potential for prevention via screening
•  Potential for cure if diagnosed early
References
Local Setting!
In the Philippines,
breast cancer and
cervical cancer top the
list of the most common
cancers and most common
cancer-related deaths
among women.!
References
Cervical Cancer Screening
Guidelines!
References
Cervical Cancer Screening Guidelines!
I.  2012 ACS-ASCCP-ASCP Screening Guidelines for the Prevention and
Early Detection of Cervical Cancer and Updated Consensus Guidelines
for the Management of Abnormal Cervical Cancer Screening Tests
II.  2012 PSCPC Clinical Practice Guidelines
III.  2015 SGO and ASCCP Interim Clinical Guidelines on the Use of Primary
HPV testing
IV. 2016 ASCO Resource-Stratified Clinical Practice Guidelines on

Secondary Prevention of Cervical Cancer
References
I.  2012 ACS-ASCCP-ASCP Screening Guidelines for the Prevention
and Early Detection of Cervical Cancer and Updated Consensus
Guidelines for the Management of Abnormal Cervical Cancer
Screening Tests
HPV testing

References
References
Recommendations address:

1. Age-appropriate screening strategies, including the use of
cytology and HPV testing
2. Follow-up of women after screening (management of screen
positives and screening interval for screen negatives)
3. Age at which to exit screening
4. Screening strategies for women vaccinated against HPV 16/18
infections
5. Special
References
populations
!

When does screening for cervical cancer start?!

ü Screening starts at 21 years old
ü should NOT be done earlier regardless of the woman’s age at first

sexual contact or the presence of risk factors for the disease
ü Guidelines do not apply to special populations, i.e. History of

cervical cancer, DES exposure and immunocompromised.
References Saslow D, Solomon D, Lawson HW, Killackey M, Kulasingam SL, Cain J, Garcia FAR, Moriarty AT, Waxman AG, Wilbur DC, Wentzensen N,
Downs LS Jr, Spitzer M, Moscicki AB, Franco EL, Stoler MH, Schiffman M, Castle PE, Myers ER. American Cancer Society, Americal Society for
Colposcopy and Cervical Pathology and American Society for Clinical Pathology Screening Guidelines for the Prevention and Early Detection
of Cervical Cancer. Journal of Lower Genital Tract Disease Vol 16 Number 3, 2012, 1-‐29.
!
Why?

ü Cervical cancer is uncommon in young women and in the
adolescent age group.
ü Pre-invasive lesions in the cervix diagnosed in young women and

the adolescents have very high probability of spontaneously
resolving or regressing making screening in this age group
unnecessary and even harmful.
!
For young women, efforts should be focused on

primary prevention of the disease,
specifically through
vaccination against HPV, proper diet,
adequate exercise and good stress management.
!
How often should screening be done !

and what screening modality should be used? !

ü  ACS-ASCCP-ASCP screening guidelines advocate age-

appropriate screening schedule and screening modality
!
For women 21-29 years old:

ü  cervical cytology alone at 3-year interval
ü  cytology is sufficient
§  HPV testing, whether as a component of co-testing or as stand-
alone screening test, offer NO ADDED BENEFIT
§  a lot of HPV infections and HPV-derived lesions in this age
group have high propensity to resolve on their own.
!

ü  Inclusion of HPV testing in the screening of women 21-29 years
may actually lead to more harm
§  Overtreatment
§  unnecessary treatment expense
§  treatment-related reproductive complications
§  undue anxiety to the patient and her family
!

ü  co-testing is the preferred screening

ü  cytology alone every 3 years is acceptable
!
Why co-testing?

ü  addition of HPV DNA testing to cervical cytology increases the
detection of prevalent CIN3
§  This translates to lower incidence of CIN3 and cervical
cancer during the next round of screening
ü  There is increase detection of cervical adenocarcinoma and its

precursor lesions
§  Cytology alone has been ineffective in identifying women
with adenocarcinoma of the cervix.
!
When do we STOP screening

for cervical cancer?!
ü Screening is discontinued at age 65 years
§  with adequate negative prior screening results
§  No CIN2+ in the last 20 years
ü Screening “should not resume for any reason, even if a woman

reports having a new sexual partner”.
!
When do we STOP screening

for cervical cancer?!
ü After hysterectomy with removal of cervix and no history of
CIN 2+
ü Continuing screening for the purpose of screening for vaginal

malignancies is not cost-effective and has not been proven to be of any
benefit due to the rarity of the condition
!
When do we NOT stop

screening for cervical cancer?!
ü If with history of CIN 2, CIN 3 or AIS
ü Continue “routine screening” for at least 20 years, even if this extends

past age 65 years.
!

Do we need to screen women who have already been

vaccinated against HPV?!

ü  No researches to support either discontinuation of or a change in
the manner of screening of women who have already received
vaccination against HPV
ü  follow the age-specific screening recommendations as
discussed for the general population
!
MANAGEMENT OF
ABNORMAL SCREENING TESTS
!
•  Occurs for ≤ 1% across all preparation types
•  Unreliable for detecting epithelial abnormalities
•  Conventional pap tests

Obscuring blood
Inflammation
Other processes
•  Liquid-based cytology
Insufficient squamous cells
!
•  Has adequate cellularity for interpretation but lacks endocervical or
metaplastic cells!
•  Raises concern for missed disease!
•  Occurs in 10-20%, higher in older women!
•  Risk for CIN 3+ over time comparable with women with a satisfactory EC/
TZ component!
•  Not associated with an increased incidence of cervical disease!

Women ≥ Age 30 who are Cytology Negative but HPV Positive
•  Despite negative cytology, women with oncogenic HPV are at

higher risk for later CIN 3+ than women with negative HPV tests!
•  Persistent HPV increases risk further!
•  Most HPV infections are cleared allowing observation for clearance!
Women ≥ Age 30 who are Cytology Negative but HPV Positive
ASCUS CYTOLOGY – HPV NEGATIVE!
ACS-ASCCP-ASCP recommendations on the management of

abnormal screening results:
HPV NEGATIVE ASCUS Cytology

ü  Risk for development of cervical cancer following an HPV negative-
ASCUS cytology result is very low and just comparable to the risk of a
negative co-testing result.
ü  No additional intervention other than age-appropriate routine
screening is warranted for patients with HPV negative-ASCUS result
ASCUS CYTOLOGY – HPV POSITIVE!


HPV POSITIVE ASCUS Cytology

ü  immediate referral to COLPOSCOPY as the risk of CIN3 or more
severe lesion is quite high with these combinations
LSIL+ LESIONS!


Regardless of HPV status LSIL or greater on cytology

ü  immediate referral to COLPOSCOPY as the risk of CIN3 or more
severe lesion is quite high with these combinations
References
HPV testing

References
2012 PSCPC Clinical Practice Guidelines!
References
ü initiation of cervical cancer screening at the age of 21

years (consistent with international recommendation)
References Philippine Society for Cervical Pathology and Colposcopy Clinical Practice Guidelines on Cervical Cancer Screening. September 2012.


ü Recommended screening for women 21 – 65 years
of age:
Ø Annual screening using conventional cytology
Ø Biennial screening with liquid based cytology

v due to the disease burden and low sensitivity of cytology
in the local setting

ü advocate continuation of screening in women 65 years

and older
Ø due to the high rate of cervical cancer in women
greater than 65 years old in our country
Ø annually with conventional cytology

Ø biennially with liquid based cytology
Ø every 5 years if co-testing with HPV DNA test

Popula'on ACS/ASCCP/ASCP Screening PSCPC 2012 Recommenda'on
Recommenda'on
<21 years No screening No screening
(Screening should begin approximately 3 years
a8er the onset of vaginal intercourse, but not
earlier than 21 years old.)
21-‐29 years Cytology alone every 3 years •  Due to the disease burden and low sensiBvity
of cytology in the local seCng, either annual
screening using conven0onal cytology or
biennial screening with liquid based
cytology is recommended.
30-‐65 years HPV and Cytology “co-‐tes'ng” every 5 years •  Due to the disease burden in the local seCng,
(preferred) either annual screening using
conven0onal cytology or biennial
Cytology alone every 3 years (acceptable) screening with liquid based cytology is
recommended.
Popula'on ACS/ASCCP/ASCP Screening PSCPC 2012 Recommenda'on
Recommenda'on
A8er hysterectomy No screening Screening for vaginal cancer in women
(applies to women without a who had total hysterectomy for benign
cervix and without a history of condiBons, except premalignant cervical
CIN 2 or a more severe diagnosis lesions, is not recommended.
in the past 20 years or cervical
cancer ever)
HPV-‐vaccinated Follow age-‐specific recommendaBons

III.  2015 SGO and ASCCP Interim Clinical Guidelines on the

Use of Primary HPV testing

References
2015 SGO and ASCCP Interim Clinical Guidelines !
on the Use of Primary HPV testing!

ü HPV testing alone as a primary screening
modality for cervical cancer in women 25 years and
above.
ü They recommend screening every 3 years if initial

result is negative.
References Huh WK, Ault KA, Chelmow D, et al. Use of primary high-‐risk human papillomavirus testing for cervical cancer screening: interim clinical guidance. Obstet Gynecol 2015;125:330.
Committee on Practice Bulletins—Gynecology. Practice Bulletin No. 168: Cervical Cancer Screening and Prevention. Obstet Gynecol 2016; 128:e111.
FDA approves ]irst human papillomavirus test for primary cervical cancer screening. http://www.fda.gov/newsevents/newsroom/pressannouncements/ucm394773.htm
(Accessed on November 24, 2014).
2015 SGO and ASCCP Interim Clinical Guidelines !
on the Use of Primary HPV testing!

ü supported by ACOG with their guidelines released in 2016
ü ACOG further recommended discontinuation of screening at age

65 years if previous screening results are all negative
ü US FDA has approved COBAS HPV test for primary screening in
women 25 years and older
References Huh WK, Ault KA, Chelmow D, et al. Use of primary high-‐risk human papillomavirus testing for cervical cancer screening: interim clinical guidance. Obstet Gynecol 2015;125:330.
Committee on Practice Bulletins—Gynecology. Practice Bulletin No. 168: Cervical Cancer Screening and Prevention. Obstet Gynecol 2016; 128:e111.
FDA approves ]irst human papillomavirus test for primary cervical cancer screening. http://www.fda.gov/newsevents/newsroom/pressannouncements/ucm394773.htm
(Accessed on November 24, 2014).
III.  2015 SGO and ASCCP Interim Clinical Guidelines on the

Use of Primary HPV testing

References
2016 ASCO Resource-Stratified CPG!
References
•  large disparities in incidence of and mortality

resulting from cervical cancer regionally and
globally
•  disparities in the provision of mass screening and primary
prevention
•  different regions of the world, both among and within countries,

differ
References with respect to access to prevention and treatment
•  85% of incident cervical cancers occur in less developed

regions (LMICs) around the world
•  87% of deaths resulting from cervical cancer occur in these

less-developed regions
•  Some of the regions in the world with the highest mortality

rates include the WHO Southeast Asia and Western Pacific
regions, followed by India and Africa
References
4-Tiered Resource Settings for Secondary Prevention!
References
This clinical practice guideline addresses the following clinical
questions:
(1) What is the best method(s) for screening for each resource stratum?
(2) What is the best triage strategy for women with positive results or other
abnormal (eg, discordant HPV/cytology) results?
(3) What are the best management strategies for women with precursors of cervical
cancer?
(4) What screening strategy should be recommended for women who have received
HPV
References vaccination?
In MAXIMAL-resource settings, mass screening

should be available to the entire target population
and should aim to cover at least 80% of women age
25 to 70 years.
References
MAXIMAL Resource Key Recommendations
Settings
Primary Screening HPV DNA testing
Age range and frequency of 25-65 years, every 5 years
screening
Exiting screening ≥ 65 years with consistent negative results during the past
15 years
Triage HPV genotyping and/or cytology
After triage • Women with negative triage results should receive follow-
up in 12 months
• Women with abnormal of positive results from triage
should receive colposcopy
Treatment of women with •  LEEP (if high level of quality assurance) or ablation (if medical
References
precursor lesions contraindication to LEEP)
• 12 months post-treatment follow-up
ENHANCED- resource settings refer to

most programs in urban areas of middle-
income countries. !
References
ENHANCED Resource Key Recommendations
Settings
Age range and frequency of 30-65 years, if two consecutive negative tests at 5-years intervals,
screening then every 10 years
Exiting screening ≥ 65 years with consistent negative results during the past
15 years
After triage • Women with negative triage results should receive follow-
up in 12 months
• Women with abnormal of positive results from triage
should receive colposcopy
Treatment of women with •  LEEP (if high level of quality assurance) or ablation (if medical
References
Limited-resource settings often

correspond to rural areas in
middle-income countries.!
References
LIMITED Resource Key Recommendations
Settings
Age range and frequency of 30-49 years, every 10 years
screening
Exiting screening ≤ 49 years, resource-dependent

After triage • Women with negative triage results should receive follow-up in 12
months
• women with abnormal results from triage should receive
colposcopy, if available, or visual assessment for treatment, if
colposcopy is not available.
Treatment of women with • LEEP (if high level of quality assurance) or ablation (if medical
References
•  In BASIC settings, there is no mass

screening and no culture of screening.!
•  VIA may be used, with the goal of moving to

population-based screening with HPV
testing at the earliest opportunity. !
References
BASIC Resource Settings Key Recommendations
Primary Screening HPV DNA testing or VIA
Age range and frequency of 30-49 years, one to three times per lifetime
screening
Exiting screening ≤ 49 years, resource-dependent
Triage • (+) HPV DNA result è VIA
• If (+) VIA as primary screening è advise treatment
After triage • Women with negative triage results should receive follow-up in
12 months
• women with abnormal results from triage should receive
treatment
Treatment of women with • Cryotherapy or LEEP
precursor lesions
References
Philippine Department of Health
References
Philippine Department of Health
•  The Philippine Department of Health and PhilHealth had announced

the target screening of age of 25-55 years old using primarily Visual
Inspection with Acetic Acid (VIA) in the Single Visit Approach (SVA),
especially at the community primary health centers.
•  The pap smear will continue to be used in facilities in hospitals where

these laboratories are in place and has capabilities for its
maintenance.
References
References
Breast Cancer Screening
Guidelines
References
Breast Cancer!
ü tops the list of the most common cancer type
ü the most common cause of cancer-related deaths among women

worldwide
ü In the US, breast cancer is most commonly diagnosed following

an abnormal screening result
References UpToDate
Breast Cancer!
ü one of the few cancer types with an efficient and effective

screening modality
ü Its screening ably detects women most likely to develop

breast cancer for whom early intervention can be instituted
ü Early treatment of the disease can greatly reduce mortality

rate
References UpToDate
Screening Modalities for Breast Cancer!
Mammography
•  preferred screening modality and that has been shown to decrease mortality. This
modality may also miss up to 20 percent of underlying breast cancers.
Ultrasound
•  not recommended for average-risk women
•  has not been evaluated as a screening strategy in reducing mortality from breast
cancer in average-risk women and in women with dense breast
•  may be prudent to mention to women with dense breasts regarding ultrasound as an

adjunctive
References UpToDate imaging modality to mammography
Magnetic Resonance Imaging (MRI)
•  not recommended for average-risk women. MRI with

mammography is performed in high-risk patients.
•  higher sensitivity and finds smaller tumors compared

to mammography.
Tomosynthesis
•  a 3D mammography that is used as an adjunct to

standard mammography.
•  usedUpToDate
References in screening
women with dense breast tissue
and in high-risk women
Clinical Breast Examination (CBE)
•  not suggested as part of screening of average-

risk women but it is an important tool for
evaluating women with breast complaints or
abnormalities.
•  yearly breast examination of the Health

Provider from 40 years old or earlier if with family
history is advised.
•  CBE may be an appropriate screening method for

women age 50 to 60 in low resource setting
where
References
imaging modalities for screening are
lacking.
Breast Self-Examination (BSE)
•  studies have shown no benefit plus higher

rate of biopsy with benign results
•  an adjunct to mammography
•  a way to empower and raise awareness

among women at risk rather than a
screening method as WHO recommends
References
Breast Cancer Screening Guidelines!
ü Recommendations for screening of breast cancer take into

account the risk that the patient has for developing the disease
ü Clinical risk assessment for breast cancer considers the
presence or absence of major risk factors:
Ø Personal history of ovarian, tubal, peritoneal or breast
cancer
Ø Family history of breast, ovarian, tubal and peritoneal cancer
Ø Genetic predisposition, i.e., BRCA status
Ø Radiation therapy to the chest between age 10-30 years
References UpToDate
ü Risk Classification
Ø Average risk
Ø Moderate risk
Ø High risk
ü This risk stratification estimates the lifetime risk of developing breast

cancer, and NOT according to the risk of death from it.
References Breast cancer risk in American women. National Cancer Institute Web site. https://www.cancer.gov/types/breast/risk-‐ fact-‐sheet. (Accessed
on January 05, 2017).
Risk stratification for breast cancer

Risk stratification Average Risk Moderate Risk High Risk
Lifetime risk of <15%
15-20% >20%
developing
breast cancer
Risk factors present None
family history of •  Personal history of breast
breast, ovarian or cancer
peritoneal •  Confirmed or suspected genetic

cancer* mutation, e.g. BRCA 1 or 2
•  Previous radiotherapy to the
chest between 10-30 years of
age
References

!
*use of additional risk prediction tools needed to accurately determine if patient is truly of moderate risk for the disease
ü Screening recommendations is dependent on age because

incidence of breast cancer is dependent on age.
Ø The risk rises in women 40 years and above.
ü The accuracy of mammography is also dependent on age, having

higher sensitivity and specificity in older women.
References Breast cancer risk in American women. National Cancer Institute Web site. https://www.cancer.gov/types/breast/risk-‐ fact-‐sheet. (Accessed
on January 05, 2017).
Recommendations for Routine Mammographic
Screening in Women at Average Risk!
Group (year) Frequency of Initiation of Screening
screening (years) 40 to 49 years of age 50 to 69 years of age >70 years of age
US Preventive Services Task 2 years *Individualize Yes Yes, up to 74 years
Force (2016) of age
American College of 1-2 years *Individualize Yes Yes, up to 74 years
Physicians (2015) of age
American Cancer Society 1 year for age 45 Yes, start at 45 years Yes +Yes
(2015) to 54 of age
2 years for age
>55 years
American College of 1 year Yes Yes Yes
Obstericians and
Gynecologists (2011)
American Academy of 2 years *Individualize Yes Yes, up to 74 years
Family Physicians (2009)
References of age
*Women should be counseled about the harms and benefits of mammography; individualized decision is based on risk and patient preference.
+ If patient is in good health and life expectancy > 10 years.
Age-related Screening Approach for Average Risk Women

Age Group
Recommendations
<40 y/o No screening recommended1
•  incidence of breast cancer is low

•  very low positive predictive value of mammography in young women
(1.3% only)2

1 UpToDate
References 2 Yankaskas BC, Haneuse S, Kapp JM, et al. Performance of ]irst mammography examination in women younger than 40 years. J Natl Cancer Inst 2010; 102:692.
3 American College of Obstetricians-‐Gynecologists. Practice bulletin no. 122: Breast cancer screening. Obstet Gynecol 2011; 118:372.
4 Oef]inger KC, Fontham ET, Etzioni R, et al. Breast Cancer Screening for Women at Average Risk: 2015 Guideline Update From the American Cancer Society. JAMA
2015; 314:1599.

Age Group
Recommendations
<40 y/o No screening recommended1
•  incidence of breast cancer is low

•  very low positive predictive value of mammography in young women
(1.3% only)2
40-49 y/o Screening mammography every 2 years1,3

• should be a shared decision-making between the patient and the
physician
• expert guidelines have varying recommendations on when to initiate
breast cancer screening
• ACS recommends annual screening for women 45-55 years of age,
References
1
2
UpToDate then every 2 years thereafter 4
Yankaskas BC, Haneuse S, Kapp JM, et al. Performance of ]irst mammography examination in women younger than 40 years. J Natl Cancer Inst 2010; 102:692.
3 American College of Obstetricians-‐Gynecologists. Practice bulletin no. 122: Breast cancer screening. Obstet Gynecol 2011; 118:372.
4 Oef]inger KC, Fontham ET, Etzioni R, et al. Breast Cancer Screening for Women at Average Risk: 2015 Guideline Update From the American Cancer Society. JAMA
2015; 314:1599.
screening (years) 40 to 49 years of 50 to 69 years of age >70 years of age
age
US Preventive Services Task 2 years *Individualize Yes Yes, up to 74 years
Force (2016) of age
American College of 1-2 years *Individualize Yes Yes, up to 74 years
Physicians (2015) of age
American Cancer Society 1 year for age 45 Yes, start at 45 Yes +Yes
(2015) to 54 years of age
2 years for age
>55 years
Obstericians and
American Academy of
References 2 years *Individualize Yes Yes, up to 74 years
Family
*Women Physicians
should (2009)
be counseled of age
about the harms and benefits of mammography; individualized decision is based on risk and patient preference.

Age Group
Recommendations
Screening mammography every 2 years 1,2
50-74 y/o
*systematic review of screening mammography studies showed
risk for breast cancer mortality in
evidence of decreased relative
women 50-59 years (RR 0.86, 95% CI) and an even greater risk

reduction in women 60-69 years (RR 0.67, 95% CI) 2
screening mammography for women in
• All expert groups advocate
this age group but with varying recommendations regarding
frequency of screening.1
≥ 75 y/o Offer screening mammography every 2 years only if life expectancy is at least 10
1 years
References 1 UpToDate
2 Nelson HD, Fu R, Cantor A, et al. Effectiveness of Breast Cancer Screening: Systematic Review and Meta-‐analysis to Update the 2009 U.S.
Preventive Services Task Force Recommendation. Ann Intern Med 2016; 164:244.
screening (years) 40 to 49 years of age 50 to 69 years of >70 years of age
age
US Preventive Services Task 2 years *Individualize Yes Yes, up to 74
Force (2016) years of age
American College of 1-2 years *Individualize Yes Yes, up to 74
Physicians (2015) years of age
American Cancer Society 1 year for age 45 Yes, start at 45 years Yes +Yes
(2015) to 54 of age
2 years for age
>55 years
Obstericians and
American Academy of
References 2 years *Individualize Yes Yes, up to 74
Family
*Women Physicians
should (2009)
be counseled years
about the harms and benefits of mammography; individualized decision is based on risk and patient of age
preference.

Age Group
Recommendations
Screening mammography every 2 years 1,2
50-74 y/o
*systematic review of screening mammography studies showed evidence of
cancer mortality in women 50-59 years (RR
decreased relative risk for breast
0.86, 95% CI) and an even greater risk reduction in women 60-69 years (RR
0.67, 95% CI) 2

• All expert groups advocate screening mammography for women in this age
group but with varying recommendations regarding frequency of screening.1
≥ 75 y/o
Offer screening mammography every 2 years only if life expectancy
is at least 10 years 1
References 1 UpToDate
2 Nelson HD, Fu R, Cantor A, et al. Effectiveness of Breast Cancer Screening: Systematic Review and Meta-‐analysis to Update the 2009 U.S.
Preventive Services Task Force Recommendation. Ann Intern Med 2016; 164:244.
Screening Approach for Moderate Risk Women
ü  women with family history of breast cancer especially in a first-degree relative
but with no known genetic mutation should have breast cancer screening at the
SAME starting age and SAME frequency as women with average risk
ü  Some authors recommend start of screening at an earlier age if the breast
cancer in the first-degree relative appeared during the premenopausal age.
Ø  No strong evidences to conclude that doing such would lead to a
reduction in mortality in these younger women.
References UpToDate
Screening Approach for Moderate Risk Women

ü Some experts suggest using screening mammography with supplemental
screening either with MRI or with sonomammography as the screening
modality for these women with moderate risk for breast cancer.
ü Decision to have these supplemental screening tests should be made

together with patient after weighing all the risks and benefits of the
procedures.
References UpToDate
Screening Approach for High Risk Women

ü  should be strongly counseled on the importance of proper screening and a
referral to specialists equipped to perform intense surveillance and early
intervention of the disease
ü  Screening modalities recommended is a combination of annual screening
mammogram alternating with breast MRI 6 months apart.
ü  Supplemental ultrasound may be an alternative for women who have no access
to MRI a long as the women undergoes screening at least every 6 months.
References UpToDate
Special Populations/Scenarios
•  Women with dense breast tissue- these women are associated with increased
risk of breast cancer. Digital mammography is preferred due to its greater
sensitivity.
•  Dense breast with no additional risk factors should not undergo supplemental
screening with other imaging modalities – no evidence of benefit.
•  Breast implants- screening mammography is used but additional views are

requested because implants may interfere with mammographic visualization.
References
Siu AL, U.S. Preventive Services Task Force. Screening for Breast Cancer: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med
2016; 164:279!
Local Breast Cancer Screening Guidelines!
•  Monthly self-breast-examination (SBE) and annual health

worker-breast-examination (HWBE) remain the mainstays of
early detection particularly in developing nations.
•  These should be a habit by the age of 30.
•  All suspicious masses should be biopsied, preferably using needle

aspiration biopsy.
Laudico A, Medina V, Mirasol-Lumague MR, Mapua C, Redaniel MT, Valenzuela F, Pukkala E. Philippine Cancer
Facts and Estimates 2010. Philippine Cancer Society, 2010.!
References
Local Breast Cancer Screening Guidelines!
“It had been shown in High Income Countries that mammographic

screening, combined with physician breast examination,
increased survival among women 50 years and older. However, the
WHO does not recommend mammography as a population-
screening method in developing countries because of the prohibitive
cost. Nevertheless, women 50 years and older are encouraged to
undergo annual mammography on their own.”
Laudico A, Medina V, Mirasol-Lumague MR, Mapua C, Redaniel MT, Valenzuela F, Pukkala E. Philippine Cancer
Facts and Estimates 2010. Philippine Cancer Society, 2010.!
References
Laudico A, Medina V, Mirasol-Lumague MR, Mapua C, Redaniel MT, Valenzuela F, Pukkala E. Philippine Cancer Facts and Estimates 2010. Philippine Cancer
Society, 2010. !
References
THANK YOU VERY MUCH
! &
!

GOOD ! DAY! J
!
Carolyn R. Zalameda-Castro, MD, FPOGS, FSGOP, FPSCPC!
!

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The Latest Guidelines !

MSD speaker for Gardasil 9

New cancer cases are

Deaths from cancer are

>60% of the world's cancer

This alarming rise in cancer

• There is a need to appreciate that screening and early

• Part of the Cancer Prevention Advocacy is the

• High burden of disease globally

• Potential for prevention via screening

• Potential for cure if diagnosed early

II. 2012 PSCPC Clinical Practice Guidelines

IV. 2016 ASCO Resource-Stratified Clinical Practice Guidelines on

II. 2012 PSCPC Clinical Practice Guidelines

IV. 2016 ASCO Resource-Stratified Clinical Practice Guidelines on

ü should NOT be done earlier regardless of the woman’s age at first

ü Guidelines do not apply to special populations, i.e. History of

ü Pre-invasive lesions in the cervix diagnosed in young women and

For young women, eﬀorts should be focused on

How often should screening be done !

ü ACS-ASCCP-ASCP screening guidelines advocate age-

For women 21-29 years old:

For women 21-29 years old:

For women 30-65 years old:

ü There is increase detection of cervical adenocarcinoma and its

When do we STOP screening

ü Screening “should not resume for any reason, even if a woman

When do we STOP screening

ü Continuing screening for the purpose of screening for vaginal

When do we NOT stop

ü If with history of CIN 2, CIN 3 or AIS

ü Continue “routine screening” for at least 20 years, even if this extends

• Occurs for ≤ 1% across all preparation types

• Unreliable for detecting epithelial abnormalities

• Conventional pap tests

• Raises concern for missed disease!

• Occurs in 10-20%, higher in older women!

• Not associated with an increased incidence of cervical disease!

• Despite negative cytology, women with oncogenic HPV are at

• Persistent HPV increases risk further!

• Most HPV infections are cleared allowing observation for clearance!

ACS-ASCCP-ASCP recommendations on the management of

ACS-ASCCP-ASCP recommendations on the management of

ACS-ASCCP-ASCP recommendations on the management of

II. 2012 PSCPC Clinical Practice Guidelines

IV. 2016 ASCO Resource-Stratified Clinical Practice Guidelines on

ü initiation of cervical cancer screening at the age of 21

ü advocate continuation of screening in women 65 years

Ø annually with conventional cytology

II. 2012 PSCPC Clinical Practice Guidelines

III. 2015 SGO and ASCCP Interim Clinical Guidelines on the

IV. 2016 ASCO Resource-Stratified Clinical Practice Guidelines on

ü They recommend screening every 3 years if initial

ü ACOG further recommended discontinuation of screening at age

II. 2012 PSCPC Clinical Practice Guidelines

III. 2015 SGO and ASCCP Interim Clinical Guidelines on the

IV. 2016 ASCO Resource-Stratified Clinical Practice Guidelines on

• large disparities in incidence of and mortality

• different regions of the world, both among and within countries,

• 85% of incident cervical cancers occur in less developed

• 87% of deaths resulting from cervical cancer occur in these

• Some of the regions in the world with the highest mortality

MSD speaker for Gardasil 9 

•  There is a need to appreciate that screening and early

•  Part of the Cancer Prevention Advocacy is the

•  High burden of disease globally

•  Potential for prevention via screening

•  Potential for cure if diagnosed early

II.  2012 PSCPC Clinical Practice Guidelines

II.  2012 PSCPC Clinical Practice Guidelines

ü should NOT be done earlier regardless of the woman’s age at first

ü Guidelines do not apply to special populations, i.e. History of

ü Pre-invasive lesions in the cervix diagnosed in young women and

ü  ACS-ASCCP-ASCP screening guidelines advocate age-

ü  There is increase detection of cervical adenocarcinoma and its

ü Screening “should not resume for any reason, even if a woman

ü Continuing screening for the purpose of screening for vaginal

ü If with history of CIN 2, CIN 3 or AIS

ü Continue “routine screening” for at least 20 years, even if this extends

•  Occurs for ≤ 1% across all preparation types

•  Unreliable for detecting epithelial abnormalities

•  Conventional pap tests

•  Raises concern for missed disease!

•  Occurs in 10-20%, higher in older women!

•  Not associated with an increased incidence of cervical disease!

•  Despite negative cytology, women with oncogenic HPV are at

•  Persistent HPV increases risk further!

•  Most HPV infections are cleared allowing observation for clearance!

II.  2012 PSCPC Clinical Practice Guidelines

ü initiation of cervical cancer screening at the age of 21

ü advocate continuation of screening in women 65 years

Ø annually with conventional cytology

II.  2012 PSCPC Clinical Practice Guidelines

III.  2015 SGO and ASCCP Interim Clinical Guidelines on the

ü They recommend screening every 3 years if initial

ü ACOG further recommended discontinuation of screening at age

II.  2012 PSCPC Clinical Practice Guidelines

III.  2015 SGO and ASCCP Interim Clinical Guidelines on the

•  large disparities in incidence of and mortality

•  different regions of the world, both among and within countries,

•  85% of incident cervical cancers occur in less developed

•  87% of deaths resulting from cervical cancer occur in these

•  Some of the regions in the world with the highest mortality

•  In BASIC settings, there is no mass

•  VIA may be used, with the goal of moving to

•  The Philippine Department of Health and PhilHealth had announced

•  The pap smear will continue to be used in facilities in hospitals where

ü tops the list of the most common cancer type

ü the most common cause of cancer-related deaths among women

ü In the US, breast cancer is most commonly diagnosed following

ü one of the few cancer types with an eﬃcient and eﬀective

ü Its screening ably detects women most likely to develop

ü Early treatment of the disease can greatly reduce mortality

•  not recommended for average-risk women

•  may be prudent to mention to women with dense breasts regarding ultrasound as an

•  not recommended for average-risk women. MRI with

•  higher sensitivity and finds smaller tumors compared

•  a 3D mammography that is used as an adjunct to

•  not suggested as part of screening of average-

•  yearly breast examination of the Health

•  CBE may be an appropriate screening method for

•  studies have shown no benefit plus higher

•  a way to empower and raise awareness

ü Recommendations for screening of breast cancer take into

ü This risk stratification estimates the lifetime risk of developing breast

ü Screening recommendations is dependent on age because

ü The accuracy of mammography is also dependent on age, having

ü Decision to have these supplemental screening tests should be made

•  Breast implants- screening mammography is used but additional views are

•  Monthly self-breast-examination (SBE) and annual health

•  These should be a habit by the age of 30.

•  All suspicious masses should be biopsied, preferably using needle