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Difficulty: MediumPreventive Care and Screening

A 68-year-old woman presents to the clinic for an annual health maintenance examination. She feels well and has no new symptoms. Her past medical history is notable for a total abdominal hysterectomy and bilateral salpingo-oophorectomy at age 62. The surgical pathology at that time revealed cervical intraepithelial neoplasia (CIN) 3 with negative surgical margins. She has not undergone any further gynecologic evaluation since her postoperative period. She has never smoked and consumes alcohol occasionally. Her family history is noncontributory. Screening mammography performed 1 year ago was negative for malignancy. A screening colonoscopy and a dual-energy x-ray absorptiometry (DXA) scan performed at age 65 were both normal. Vital signs and physical examination today are unremarkable. Which of the following is the most appropriate next step in preventive screening for this patient?

  1. Cytology and high-risk human papillomavirus testing of the vaginal cuffAnswer
  2. B
    Reassurance that no routine cancer screening is currently indicated
  3. C
    Annual fecal immunochemical testing
  4. D
    Repeat dual-energy x-ray absorptiometry scan
  5. E
    Serum CA-125 measurement and pelvic ultrasonography

Answer

The correct answer is cytology and high-risk human papillomavirus testing of the vaginal cuff.
According to the United States Preventive Services Task Force (USPSTF) and the American Society for Colposcopy and Cervical Pathology (ASCCP), routine cervical cancer screening can be discontinued in women over age 65 who have had adequate prior screening, and in women of any age who have undergone a total hysterectomy for benign disease. However, a critical exception exists for women with a history of cervical intraepithelial neoplasia (CIN) grade 2, CIN 3, or cervical cancer. These patients remain at elevated risk for vaginal intraepithelial neoplasia and must continue to receive routine screening of the vaginal cuff for at least 20 years after the spontaneous regression or appropriate management of the disease. Because this patient was treated for CIN 3 at age 62, she must continue screening until age 82. Since she has had no screening in the 6 years following her surgery, cytology and high-risk HPV testing of the vaginal cuff is the most appropriate next step.

Step-by-Step Solution

1
Evaluate the patient's age and surgical history against general cervical cancer screening guidelines.
The patient is 68 years old and had a total hysterectomy. Generally, screening ceases at age 65 or after removal of the cervix for benign indications.
To determine if standard age or surgical cutoffs apply.
2
Assess the specific indication for the patient's hysterectomy.
The hysterectomy was performed for high-grade cervical dysplasia (CIN 3).
Surgical indication dictates whether exceptions to the standard cessation rules apply.
3
Apply the exception guidelines for high-grade cervical dysplasia.
Patients treated for CIN 2, CIN 3, or cervical cancer must continue screening for 20 years post-treatment, utilizing the vaginal cuff if the cervix was removed.
CIN 3 carries a long-term risk of recurrence or progression at the vaginal apex.
4
Review the status of other preventive screenings (colon, breast, bone density).
Mammogram is up to date (due every 2 years). Colonoscopy is up to date (due in 10 years). DXA is up to date (due in 10-15 years for normal results).
To rule out other competing indications for immediate preventive interventions.

Key Concept

Cervical cancer screening must continue for 20 years following treatment for CIN 2, CIN 3, or cervical cancer, even if this extends screening beyond age 65 or follows a total hysterectomy.
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Topics

Preventive Care and Screening

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