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Difficulty: MediumPreventive Care and Screening

During a scheduled wellness evaluation, a 68-year-old woman is seen in the outpatient clinic. She reports feeling well and has no new symptomatic complaints. Her active medical problems include essential hypertension and osteoarthritis, both of which are well-controlled. Her surgical history is notable for a total abdominal hysterectomy with bilateral salpingo-oophorectomy performed at age 65 for symptomatic uterine leiomyomas. Several years prior to that procedure, at age 57, she underwent a loop electrosurgical excision procedure for cervical intraepithelial neoplasia 3 (CIN 3) with clear margins. Subsequent follow-up testing prior to her hysterectomy was negative.

She has a 30-pack-year smoking history but successfully quit 18 years ago. She consumes alcohol rarely and exercises three times weekly. Recent preventive care includes a normal screening mammogram 6 months ago, a normal screening colonoscopy at age 62, and a normal dual-energy x-ray absorptiometry scan at age 65. Her immunizations, including recombinant zoster, pneumococcal, and seasonal influenza vaccines, are up to date. Vital signs today are within normal limits.

Which of the following screening recommendations is most appropriate for this patient at this visit?

  1. Cytologic evaluation of the vaginal cuffAnswer
  2. B
    Discontinuation of routine lower genital tract screening
  3. C
    Low-dose computed tomography of the chest
  4. D
    Screening abdominal ultrasonography
  5. E
    Repeat dual-energy x-ray absorptiometry

Answer

Cytologic evaluation of the vaginal cuff
This patient had a high-grade precancerous cervical lesion (CIN 3) treated at age 57. Current guidelines mandate that individuals with a history of CIN 2, CIN 3, or cervical cancer continue screening for 25 years following appropriate management. Although she underwent a total abdominal hysterectomy at age 65 for benign fibroids, her history of CIN 3 requires continued screening of the vaginal cuff (via cytology or human papillomavirus testing) until 25 years have passed since her treatment (i.e., until age 82 for this patient).

Step-by-Step Solution

1
Analyze the patient's gynecologic and surgical history.
The patient had a total hysterectomy (removal of uterus and cervix) at age 65, but has a history of high-grade cervical dysplasia (CIN 3) treated at age 57.
Prior history of dysplasia dictates the rules for discontinuing or maintaining lower genital tract screening.
2
Apply evidence-based screening guidelines for cervical cancer prevention.
Guidelines require 25 years of continued screening after treatment of CIN 2 or CIN 3. Because she lacks a cervix, this is accomplished via vaginal cuff screening.
This requirement persists even if the patient surpasses the standard cessation age of 65 or undergoes a hysterectomy.
3
Evaluate the patient's other risk factors against current preventive guidelines.
Her smoking cessation was >15 years ago (excluding her from LDCT), she is female (excluding AAA screening), and her prior DEXA was recent and normal (excluding repeat imaging).
Systematically eliminates alternative screening modalities that might otherwise act as strong distractors.

Key Concept

Patients with a history of CIN 2, CIN 3, or cervical cancer must continue routine lower genital tract screening for 25 years following appropriate management, even if they have surpassed age 65 or have undergone a total hysterectomy.
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Topics

Preventive Care and Screening

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