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Zorluk: Çok zorPreventive Care and Screening

A 67-year-old woman comes to the clinic for a routine health maintenance examination. She has no acute symptoms and feels well. Her medical history is notable for hypertension, type 2 diabetes mellitus, and a total abdominal hysterectomy with bilateral salpingo-oophorectomy performed at age 52. A review of her surgical pathology report from that time confirms the procedure was a treatment for persistent cervical intraepithelial neoplasia grade 3 (CIN 3). She has no history of invasive cervical cancer. Her mother was diagnosed with ovarian cancer at age 65, and her father died of a myocardial infarction at age 70. The patient smoked 1.5 packs of cigarettes daily from age 20 to age 50 (a 45 pack-year history) but quit completely 17 years ago. She occasionally drinks wine.

Recent screening history is as follows:
- Screening mammogram 6 months ago: normal
- Screening colonoscopy 6 years ago: normal, no polyps
- Vaginal cuff cytology and HPV co-testing 6 years ago: negative
- Dual-energy x-ray absorptiometry (DEXA) 1 year ago: T-score of -1.5 at the lumbar spine

Her most recent comprehensive metabolic panel and lipid panel, obtained 6 months ago, were within normal limits. Her vaccinations are up to date.

Which of the following is the most appropriate next step in this patient's preventive care?

  1. A
    Low-dose computed tomography of the chest
  2. Vaginal cuff cytology and human papillomavirus co-testingCevap
  3. C
    Transvaginal ultrasonography and serum CA-125 measurement
  4. D
    Fecal immunochemical testing
  5. E
    Dual-energy x-ray absorptiometry

Cevap

The most appropriate next step is to perform vaginal cuff cytology and human papillomavirus co-testing.
The correct answer is vaginal cuff cytology and human papillomavirus (HPV) co-testing. According to current ASCCP guidelines, patients who have been treated for high-grade cervical dysplasia (CIN 2, CIN 3, or adenocarcinoma in situ) must continue routine screening for 25 years following treatment. This rule supersedes standard cessation criteria; it applies even if the patient has undergone a total hysterectomy and even if they pass the standard cessation age of 65. Because this patient was treated for CIN 3 at age 52, she requires continued screening of the vaginal cuff until age 77. As her last co-test was 6 years ago, she has surpassed the recommended 5-year interval and is currently overdue for screening.

Adım Adım Çözüm

1
Analyze the patient's cervical/vaginal screening history and surgical indications.
The patient had a total hysterectomy at age 52 for CIN 3. Her last screening was 6 years ago.
Identifying the reason for hysterectomy is critical, as benign indications allow for immediate cessation of screening, while high-grade dysplasia requires continued surveillance.
2
Apply the ASCCP guidelines for post-treatment surveillance of CIN 3.
The guidelines mandate continuing screening for 25 years after treatment for CIN 2, CIN 3, or adenocarcinoma in situ. This applies despite reaching age 65 and despite having a hysterectomy.
The 25-year rule overrides the standard age-based cessation. Since she was treated at age 52, she requires screening until age 77.
3
Determine the appropriate testing interval for her vaginal cuff screening.
The patient is overdue. Co-testing is recommended every 5 years, and her last test was 6 years ago.
This establishes that vaginal cuff cytology and HPV co-testing is the urgently indicated next step today.
4
Evaluate the patient's eligibility for lung cancer screening to rule out distractors.
Despite a 45 pack-year history, she quit 17 years ago. She is no longer eligible.
USPSTF guidelines strictly advise discontinuing low-dose CT screening once a person has not smoked for 15 years.

Anahtar Kavram

Patients treated for high-grade cervical dysplasia (CIN 2 or 3) must continue routine screening for 25 years post-treatment, even if they have undergone a hysterectomy and surpassed 65 years of age.
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Konular

Preventive Care and Screening

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