2010NCCN指南-宫颈癌检查

Continue NCCN Clinical Practice Guidelines in Oncology™ Cervical Cancer Screening V.1.2010 www.nccn.org Guidelines Index Cervical Cancer Screening TOC Discussion, References Practice Guidelines in Oncology – v.1.2010 Version 1.2010, 10/20/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Cervical Cancer ScreeningNCCN ® NCCN Cervical Cancer Screening Panel Members Edward E. Partridge, MD/Chair University of Alabama at Birmingham Comprehensive Cancer Center Nadeem Abu-Rustum, MD Memorial Sloan-Kettering Cancer Center Susan M. Campos, MD, MPH, MS Dana-Farber/Brigham and Women’s Cancer Center Patrick J. Fahey, MD The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute Benjamin E. Greer, MD Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance � � � † Þ Anna Giuliano, PhD & H. Lee Moffitt Cancer Center & Research Institute Diljeet K. Singh, MD, DrPH Robert H. Lurie Comprehensive Cancer Center of Northwestern University Karen Smith-McCune, MD, PhD UCSF Helen Diller Family Comprehensive Cancer Center Nelson Teng, MD, PhD Stanford Comprehensive Cancer Center Cornelia Liu Trimble, MD The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins Fidel Valea, MD Duke Comprehensive Cancer Center Sharon Wilczynski, MD, PhD City of Hope Comprehensive Cancer Center � � � � � � * Writing Committee member Gynecology oncology † Medical oncology Þ Internal medicine, including Family practice, Preventive management Pathology & Epidemiology � � Continue * NCCN Guidelines Panel Disclosures Howard W. Jones, III, MD Vanderbilt-Ingram Cancer Center Subodh M. Lele, MD UNMC Eppley Cancer Center at The Nebraska Medical Medical Center Richard W. Lieberman, MD University of Michigan Comprehensive Cancer Center Mark Morgan, MD Fox Chase Cancer Center Maria Enriqueta R. Nava, MD Roswell Park Cancer Institute R. Kevin Reynolds, MD University of Michigan Comprehensive Cancer Center Helen E. Rhodes, MD The University of Texas M. D. Anderson Cancer Center � � � � � � � Guidelines Index Cervical Cancer Screening TOC Discussion, References Practice Guidelines in Oncology – v.1.2010 Version 1.2010, 10/20/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Cervical Cancer ScreeningNCCN ® Table of Contents NCCN Cervical Cancer Screening Panel Members Summary of Guidelines Updates 21 y Follow-up of Screening Exam-Adult > 21 y (CERVS-6 Atypical Glandular Cells, Atypical Glandular Cells, Follow-up of Adenocarcinoma in Situ (CERVS-15 Atypical Glandular Cells, Follow-up of Endometrial Biopsy Findings (CERVS-16 Screening Guidelines for Early Detection of Cervical Cancer (CERVS-1 Initial Findings of Screening Exam (CERVS-3 Follow-up for HPV High Risk DNA Testing 30 y (CERVS-4 Follow-up of Screening Exam-Adolescents or Young Women (CERVS-5 Findings on Initial Screening/Pap Test, Colposcopy Findings, Cervical Biopsy Findings, Follow-up, Treatment (CERVS-7 Findings at Treatment, Follow-Up Post-Treatment for CIN (CERVS-11 Follow-up and Management (CERVS-12 Bethesda System 2001 (CERVS-A Colposcopy During Pregnancy (CERVS-B ) ) ) ) ) ) ) ) ) � � ) ) ) These guidelines are a statement of evidence and consensus of the authors regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult these guidelines is expected to use independent medical judgment in the context of individual clinical circumstances to determine any patient's care or treatment. The National Comprehensive Cancer Network makes no representations nor warranties of any kind whatsoever regarding their content, use, or application and disclaims any responsibility for their application or use in any way. These guidelines are copyrighted by National Comprehensive Cancer Network. All rights reserved. These guidelines and the illustrations herein may not be reproduced in any form without the express written permission of NCCN. ©2009. For help using these documents, please click here Discussion References Guidelines Index Print the Cervical Cancer Screening Guidelines Clinical Trials: Categories of Evidence and Consensus: NCCN The believes that the best management for any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. To find clinical trials online at NCCN member institutions, All recommendations are Category 2A unless otherwise specified. See NCCN click here: nccn.org/clinical_trials/physician.html NCCN Categories of Evidence and Consensus Guidelines Index Cervical Cancer Screening TOC Discussion, References Practice Guidelines in Oncology – v.1.2010 Version 1.2010, 10/20/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Cervical Cancer ScreeningNCCN ® Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. UPDATES SUMMARY OF GUIDELINES UPDATES CERVS-1 CERVS-2 CERVS-3 CERVS-4 CERVS-6 CERVS-11 CERVS-B CERVS-10 � � � � � � � � � � � � When to discontinue screening, second sub bullet was modified, “Women who have a history of cervical cancer ...” Screening interval, first bullet was modified, “unless they have a history ...” Screening interval, third bullet was modified from, “Until more data are available, women who test positive for HPV DNA should continue screening at the discretion of their health care provider” to “Women whose cytology is negative but test positive for HPV High Risk DNA should have screening as shown on CERVS-4.” Footnote b, “HPV HR DNA tests detect whether any of the 14 high-risk types of HPV are present, although the tests do not indicate which types are present” is new to the page. Visible/suspicious lesion on cervix, after biopsy, “If invasive cancer, see NCCN Cervical Cancer Guidelines” and “If no cancer, consider CKC” were added. Cervical cytology/Pap test positive for invasive cancer, after biopsy visible lesion; diagnostic excision if no visible lesion, “If cancer, see NCCN Cervical Cancer Guidelines” and “If CIN I- III, see CERVS-11” were added. Follow-up for “Cervical cytology/Pap test negative and HPV High Risk DNA positive 30 y” algorithm was added to the guidelines. Footnote j, “In women with ACS-US who are HPV HR positive, the NCCN and ASCCP do not recommend using the HPV 16/18 specific DNA test (ie, HPV genotyping) to screen for who should proceed to colposcopy” is new to the page. Footnote k, “For colposcopy for ASC-US or LSIL, see CERVS-7 and for ASC-H or HSIL, see CERVS-9. If appropriate, see Colposcopy During Pregnancy (CERVS-B)” is new to the page. Unsatisfactory colposcopy was separated into HSIL and ASC-H. After ASC-H, “perform ECC” and follow-up findings and management were added. CIN II, III with positive margins, reexcision, “especially if invasion is suspected” replaced “not recommended unless both endocervical and ectocervical margins are positive” and follow- up of reexcision results “If CIN, see Follow-up Therapy for CIN” and “If invasive cancer, see NCCN Cervical Cancer Guidelines” were added for clarification. Third bullet was clarified as, “Colposcopically directed cervical biopsy during pregnancy should be limited to patients where high-grade neoplasia or invasive cancer is suspected.” or diagnosis of CIN III of CIN III based on cytology (ie, ASC-H, HSIL, AGC) � Summary of changes in the 1.2010 version of the Cervical Cancer Screening Guidelines from the 1.2009 version include: Guidelines Index Cervical Cancer Screening TOC Discussion, References Practice Guidelines in Oncology – v.1.2010 Version 1.2010, 10/20/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Cervical Cancer ScreeningNCCN ® Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. SCREENING GUIDELINES FOR EARLY DETECTION OF CERVICAL CANCER When to start screening When to discontinue screening � � � � � � � Cervical cancer screening should begin approximately 3 years after the onset of vaginal intercourse. Screening should begin no later than 21 years of age. It is critical that adolescents who may not need a cervical cytology test obtain appropriate preventive health care, including assessment of health risks, contraception and prevention counseling, screening and treatment of sexually transmitted diseases. The need for cervical cancer screening should not be the basis for the onset of gynecologic care. Women at age 70 and older with an intact cervix who have had three or more documented, consecutive, technically satisfactory negative cervical cytology tests, and no abnormal/positive cytology test, within the 10 year period prior to age 70 may elect to cease cervical cancer screening. Screening is recommended for women who have not been previously screened, women for whom information about previous screening is unavailable, and when past screening is unlikely. Women who have a history of cervical cancer or diagnosis of CIN III, in utero exposure to diethylstilbestrol (DES), and/or who are immunocompromised (including HIV+) should continue cervical cancer screening for as long as they are in reasonably good health and do not have a life-limiting chronic condition. Women over the age of 70 should discuss their need for cervical cancer screening with their health care provider based on their individual circumstances, including the potential benefits, harms, and limitations of screening, and make informed decisions about whether to continue screening. Women with comorbid or life-threatening illnesses may forego cervical cancer screening. � � CERVS-1 Screening Guidelines continued (See CERVS-2) From Saslow D, Runowicz C, Solomon D, et al., American cancer society guideline for the early detection of cervical neoplasia and cancer. CA: A Cancer Journal for Clinicians 52(6):342-362. Adapted from Lippincott, Williams & Wilkins.2002; Guidelines Index Cervical Cancer Screening TOC Discussion, References Practice Guidelines in Oncology – v.1.2010 Version 1.2010, 10/20/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Cervical Cancer ScreeningNCCN ® Hysterectomy Screening interval OR � � � � � � � � � � � � Screening with vaginal cytology tests after total hysterectomy (with removal of the cervix) for benign gynecologic disease is not indicated. Efforts should be made to confirm and/or document via physical exam and review of the pathology report (when available) that the cervix was completely removed. Women who have had a subtotal hysterectomy should continue cervical cancer screening as per current guidelines. Patients with a history of cervical intraepithelial neoplasia (CIN) II-III, or for whom it is not possible to document the absence of CIN II-III prior to or as the indication for the hysterectomy, should be screened until three documented, consecutive, technically satisfactory negative vaginal cytology tests, and no abnormal/positive cytology tests, within a 10 year period are achieved. Women with a history of in utero exposure and/or with a history of cervical carcinoma should continue screening after hysterectomy for as long as they are in reasonably good health and do not have a life-limiting chronic condition. After initiation of screening, cervical screening should be performed annually with conventional cervical cytology smears every 2 years using liquid-based cytology; at or after age 30, women who have had 3 consecutive, technically satisfactory negative cytology results may be screened every 2-3 years (unless they have a history of CIN III, in utero DES exposure, are HIV+, or are immunocompromised). Human papillomavirus (HPV) high risk DNA testing for primary cervical cancer screening has recently been approved by the FDA for women 30 y of age. It is reasonable to consider that for women age 30 and over, as an alternative to annual cervical cytology testing alone, cervical screening may be performed every 3 years using conventional or liquid-based cytology combined with a test for DNA for high-risk HPV types. Frequency of combined cytology and HPV High Risk DNA testing should NOT be more often than every 3 years, if both tests are negative. Counseling and education related to HPV infection is a critical need. Women who received HPV vaccination should continue cervical cancer screening according to the guidelines. diethylstilbestrol (DES) Women whose cytology is negative but test positive for HPV High Risk DNA should have screening as shown on .a,b CERVS-4 Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. SCREENING GUIDELINES FOR EARLY DETECTION OF CERVICAL CANCER From Saslow D, Runowicz C, Solomon D, et al., American cancer society guideline for the early detection of cervical neoplasia and cancer. CA: A Cancer Journal for Clinicians 52(6):342-362. Adapted from Lippincott, Williams & Wilkins.2002; CERVS-2 See Initial Findings of Screening Exam (CERVS-3) aFDA approved HPV DNA testing for high-risk virus types. It is not useful to test for low-risk virus types. HPV HR DNA tests detect whether any of the 14 high-risk types of HPV are present, although the tests do not indicate which types are present.b Guidelines Index Cervical Cancer Screening TOC Discussion, References Practice Guidelines in Oncology – v.1.2010 Version 1.2010, 10/20/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Cervical Cancer ScreeningNCCN ® Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. c d e Referral to specialist with oncological expertise for complex clinical situations should be strongly considered. Examples of complex clinical situations include: Atypical glandular cells Adenocarcinoma in-situ � � Cervical cytology/Pap test results should be reported using the Bethesda System. . Conventional Pap test or thin-layer technology is an acceptable method for primary screening. See The Bethesda System 2001 (CERVS-A) CERVS-3 INITIAL FINDINGS OF SCREENING EXAMc �Visible/suspicious lesion on cervix �Cervical cytology/Pap test negative for intraepithelial lesion or malignancy d,e �Cervical cytology/Pap test unsatisfactoryd,e � High-grade squamous intraepithelial lesions (HSIL) � Atypical glandular cells (AGC)c See Screening Findings Adolescents or Young Women 21 y (CERVS-5)� See AGC Follow-Up and Management (CERVS-12) Suspicion of high-grade dysplasia (ASC-H) � Atypical squamous cells (ASC) Undetermined significance (ASC-US) � Low-grade squamous intraepithelial lesions (LSIL) �Cervical cytology/Pap test positive for invasive cancerd,e c See Screening Findings Adult > 21 y (CERVS-6) �Cervical cytology/Pap test positive ford,e epithelial abnormalities: �Cervical cytology/Pap test negative and HPV High Risk DNA positive 30 y d,e � See Follow-up for HPV High Risk DNA testing (CERVS-4)� 30 y � � Pregnancy Persistent/recurrent dysplasia with desire for fertility preservation FOLLOW-UP Biopsy Screening frequency based on screening guidelines See Screening for Early Detection of Cervical Cancer (CERVS-1) � � Repeat cervical cytology/Pap test should be done within 6-12 weeks. Treat infection if present and indicated Biopsy visible lesion; diagnostic excision if no visible lesion � � If cancer, If CIN I- III, see NCCN Cervical Cancer Guidelines see CERVS-11 � � If invasive cancer, If no cancer, consider CKC see NCCN Cervical Cancer Guidelines Guidelines Index Cervical Cancer Screening TOC Discussion, References Practice Guidelines in Oncology – v.1.2010 Version 1.2010, 10/20/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Cervical Cancer ScreeningNCCN ® Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. HPV DNA specific test for 16/18 genotypeh Colposcopyg CERVS-4 HPV High Risk (HR) DNA positive and Cytology/Pap test negative b Positive HPV 16/18 specific DNA test Negative HPV 16/18 specific DNA test Resume routine screening per guidelines in 3 y ( )See CERVS-2 Repeat both tests at 12 mo Cytology/Pap test HPV HR DNA test � � and Both tests negative Colposcopyg HPV HR test positive and Cytology/Pap test negative HPV HR test positive or negative and Cytology/Pap test positive See CERVS-3 b h HPV HR DNA tests detect whether any of the 14 high-risk types of HPV are present, although the tests do not indicate which types are present. The HPV 16/18 DNA diagnostic test is a separate test that detects whether HPV 16 or HPV 18 are present. f g Because HPV genotyping (ie specific HPV DNA 16/18) does not detect other high risk HPV types, (eg, HPV 31 and 45), proceeding directly to colposcopy is an option. Follow appropriate colposcopy findings pathway (i.e. satisfactory or unsatisfactory). If appropriate, only see Colposcopy During Pregnancy (CERVS-B) MANAGEMENTFOLLOW-UP FOR HPV HIGH RISK (HR) DNA TESTINGf Colposcopyf,g or FOLLOW-UP FOR HPV HIGH RISK DNA TESTING � 30 y SCREENING FINDINGS (Cytology negative) Guidelines Index Cervical Cancer Screening TOC Discussion, References Practice Guidelines in Oncology – v.1.2010 Version 1.2010, 10/20/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Cervical Cancer ScreeningNCCN ® gFollow appropriate colposcopy findings pathway (i.e. satisfactory or unsatisfactory). If appropriate, . HPV DNA testing is not recommended in adolescent or young women 21 y.i � see Colposcopy During Pregnancy (CERVS-B) CIN= Cervical intraepithelial neoplasia ECC= Endocervical curettage LEEP= Loop electrosurgical excision procedure CKC= Cold-knife conization Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. SCREENING FINDINGS SCREENING FOLLOW-UP FOLLOW-UP FINDINGS ASC-US or LSIL i i Repeat cervical cytology/Pap test