Family Medicine Resident, PGY 2, Oklahoma State University Center for Health Sciences, 2345 Southwest Blvd, Tulsa, OK 74137, USAUnited States
Assistant Professor of Family Medicine, Oklahoma State University Center for Health Sci- ences, 2345 Southwest Blvd, Tulsa, OK 74137, USAUnited States
Also available as PDF (figures and tables appear in the PDF).
A case presentation about an individual treated at Oklahoma State University Medical Center with high-grade metastatic squamous cell carcinoma of the cervix that was high-risk HPV and p16/Ki-67 positive. The clinical presentation, laboratory data, imaging, and subsequent therapy are reported as well as highlights of screening guidelines for cervical pathology.
Keywords: Cervical squamous cell carcinoma; Human papillomavirus; P16; Ki-67; Cervical screening guidelines; Cervical female that did not meet the current screening guidelines
This case brings forward an important discussion about screening for cervical cancer and highlights the necessity of regular screening in this population. Current recommendations from the ACS, the USPSTF, and ACOG suggest that this patient have cytology performed every three years and that HPV co-testing should be performed in women once they become 30 years of age.2 The current guidelines take into account increased risk of unnecessary procedures such as colposcopy, and likelihood that women under 30 years of age have the potential to clear the infection. However, in 2015, the Society of Gynecologic Oncology and the ASCCP suggested screening women for HPV starting at the age 25.3 Also this year, the FDA approved the Cobas HPV test for the age of 25 or older. While the interim guidelines were given and testing is available, these recommendations are not consistent across all organizations and are not widely known; therefore they are not likely being used by all
last Pap smear but failed to have routine examination and did not meet criteria for HPV testing. Had guidelines recommended cotesting in a younger population, closer screening may have been warranted and early discover may have been possible.
One of the markers not currently being utilized to help screen for cervical cancer is p16/Ki-67. Protein p16 is overexpressed in cervical and/or HPV associated cancers. At the time of diagnosis of metastatic cancer, this patient was positive for HPV p16 and Ki-67. A study that looked at the dual stained cytology of p16/Ki-67 showed these markers have superior sensitivity with noninferior specificity with that of Pap cytology when screening for CIN2.4 However, this testing currently is not FDA approved for routine screening.
It is unclear if this patient’s outcome would have been different if routine screening had been performed according to the guidelines at that time. It falls upon the physician to stay current on screening recommendations to improve the chances of earlier detection of cervical cancer. Early recognition of this particular cancer is critical to institute the proper therapy and improve prognosis. In the future, the testing and guidelines may evolve to include testing for HPV at an age younger than 30 or other innovations that include screening with a precursor p16/ Ki-67.
Authors have no conflicts to declare.
No consent is required for our article publication.
Authors would like to thank Andrea McEachern, DO, Clinical Associate Professor for Family Medicine at Oklahoma State University Center for Health Sciences for her editorial contribution.