The following statement(s) is/are true about human papillomavirus (HPV) infection:

• a)
  

  It can cause lesions in domestic rabbits so they provide a good research model

  
  
• b)
  

  There are less than 40 types of HPV

  
  
• c)
  

  Most women will have HPV infection at some time in their lives

  
  
• d)
  

  Genital warts may be pre-malignant and may cause cervical cancer

  
  
• e)
  

  HPV types mutate from low to high risk

With regard to HPV vaccines:

• a)
  

  They are available against types 6, 11, 16 and 18.

  
  
• b)
  

  They must be given before the onset of sexual activity.

  
  
• c)
  

  There is a small risk that the vaccines can cause cervical cancer.

  
  
• d)
  

  Although they do prevent genital warts, they are not very effective against development of pre-malignant cervical lesions.

  
  
• e)
  

  Women who have been vaccinated may be withdrawn from cervical screening programmes.

When counselling about HPV vaccination, the following statement(s) is/are true:

• a)
  

  You will not develop cervical cancer if you only ever have one sexual partner.

  
  
• b)
  

  There will never be a need to vaccinate boys or men.

  
  
• c)
  

  The vaccine has been tested in thousands of women, and no serious side-effects have been found.

  
  
• d)
  

  The vaccine is safe for people with egg allergy.

  
  
• e)
  

  The vaccine can help abnormal smears return to normal.

Alternative methods of screening for cervical neoplasia include:

• a)
  

  Cervicography.

  
  
• b)
  

  Test for the consistency of the ectocervix.

  
  
• c)
  

  Low current electric conductivity of the cervix.

  
  
• d)
  

  Methylene blue staining of the cervix.

  
  
• e)
  

  Acetic acid application to the cervix with visual inspection.

With respect to a screening test’s characteristics, the following is/are true:

• a)
  

  A high sensitivity of the test will increase the true negatives

  
  
• b)
  

  A low sensitivity of the test will increase the false negatives

  
  
• c)
  

  A high specificity will increase the true positives

  
  
• d)
  

  A low specificity will increase the false positives

  
  
• e)
  

  A decreasing sensitivity only slightly affects the predictive value of a positive test.

With respect to the influence of disease prevalence in screening:

• a)
  

  It is of no importance.

  
  
• b)
  

  If the disease is common, more false–positive cases will be identified.

  
  
• c)
  

  If the disease is common, more false–negative cases will be identified.

  
  
• d)
  

  If the disease is rare, more false–positive cases will be identified.

  
  
• e)
  

  If the disease is rare, more false–negative cases will be identified.

To justify a screening programme, which of the following should be asked:

• a)
  

  Is the disease to be screened for an important health problem?

  
  
• b)
  

  Is the natural history of the disease known?

  
  
• c)
  

  Is there an effective treatment?

  
  
• d)
  

  Is the screening test valid and reliable?

  
  
• e)
  

  Is there capacity to confirm and treat everyone diagnosed?

Which of the following statement(s) is/are true concerning cytology-based population screening programmes to prevent cervical cancer?

• a)
  

  Frequent screening is more effective than comprehensive population coverage.

  
  
• b)
  

  Women who are HIV positive should be screened annually.

  
  
• c)
  

  Women who have multiple sexual partners should be screened more frequently.

  
  
• d)
  

  They are of limited value in the prevention of adenocarcinoma of the cervix.

  
  
• e)
  

  They have high sensitivity and high specificity.

Which of the following statement(s) is/are true of liquid-based cervical cytology?

• a)
  

  It is easier to carry out in the clinical setting than conventional cytology.

  
  
• b)
  

  It results in improved sensitivity for detection of cervical intraepithelial neoplasia.

  
  
• c)
  

  It results in fewer inadequate samples.

  
  
• d)
  

  Specimen adequacy is easily assessed.

  
  
• e)
  

  It improves laboratory productivity.

In a 29-year old woman presenting for the first time with borderline nuclear changes in squamous cells (atypical squamous cells in the Bethesda system), which of the following is/are correct management options?

• a)
  

  Immediate referral for colposcopy.

  
  
• b)
  

  Repeat test in 6 months.

  
  
• c)
  

  Repeat and if negative return to routine screening.

  
  
• d)
  

  Test for high risk human papillomavirus and if positive refer to colposcopy.

  
  
• e)
  

  Test for high risk human papillomavirus and if negative repeat test in 6 months.

Which of the following is/are true of automated screening?

• a)
  

  It is only possible on liquid-based cytology specimens.

  
  
• b)
  

  It is less sensitive but more specific than conventional cytology for the detection of high grade cervical intraepithelial neoplasia.

  
  
• c)
  

  Laboratory staff will lose their interpretative skills.

  
  
• d)
  

  It will increase laboratory productivity.

  
  
• e)
  

  It will be unnecessary in a progressively HPV-vaccinated population.

The following statement(s) is/are true about human papillomavirus (HPV) and cervical cancer.

• a)
  

  HPV16 and 18 account for around 70% of cervical cancer globally.

  
  
• b)
  

  Cervical intraepithelial neoplasia can be treated by HPV vaccination.

  
  
• c)
  

  Oncogenic HPVs are associated with a proportion of oro-pharangeal cancer.

  
  
• d)
  

  The incidence of cervical cancer in the developing world is expected to decrease in the next 5 years.

  
  
• e)
  

  The safety of HPV vaccination is still in doubt. It is associated with higher than expected occurrence of deaths in adolescents.

The following is/are true about HPV vaccination:

• a)
  

  The quadrivalent HPV vaccine has been approved by the US Food and Drug Adminstration for the primary prevention of anal cancer.

  
  
• b)
  

  Introducing HPV vaccination to a country with an effective cervical screening programme is not cost-effective.

  
  
• c)
  

  In the USA, a developed country, more than 80% of young women have been immunised with HPV vaccines.

  
  
• d)
  

  The World Health Organization does not recommend routine HPV vaccination to be included in national immunisation programmes in developing countries.

  
  
• e)
  

  In developed countries where teenagers are offered HPV vaccination, parents cannot override the teenager’s decision to have the vaccine.

Cervical cytology is widely used:

• a)
  

  Only in the developed world

  
  
• b)
  

  To triage women with high-risk HPV infection

  
  
• c)
  

  To prevent cervical cancer

  
  
• d)
  

  To determine whether a woman is infected with HPV 16

  
  
• e)
  

  To follow-up women treated for cervical lesions

HPV testing should be implemented in primary screening because:

• a)
  

  It is more specific than cytology

  
  
• b)
  

  It detects more high-grade disease than any other cervical screening technique

  
  
• c)
  

  It is an objective test

  
  
• d)
  

  It allows increasing the interval between screens

  
  
• e)
  

  Cytology does not work on vaccinated women

HPV vaccination will:

• a)
  

  Eliminate the need for cervical screening by 2020

  
  
• b)
  

  Have a substantial impact on the sensitivity of cytology

  
  
• c)
  

  Reduce the positive predictive value of HPV testing

  
  
• d)
  

  Have a greater (relative) impact on low-grade cytology than on high-grade cytology

  
  
• e)
  

  Have no impact unless screening continues for the foreseeable future

Following a positive HPV test:

• a)
  

  All women should be treated

  
  
• b)
  

  Women should be invited to screening five years later

  
  
• c)
  

  Women should be triaged with cytology or other test

  
  
• d)
  

  Women should have a second HPV test three months later

  
  
• e)
  

  Women positive for HPV16 and/or HPV18 should not be treated because they will be vaccinated

Excisional treatment is indicated

• a)
  

  In women with biopsy-proven cervical intraepithelial neoplasia (CIN)

  
  
• b)
  

  In women with Pap smears classified as low-grade squamous intraepithelial lesion (LSIL)

  
  
• c)
  

  In pregnant women with CIN2 and 3

  
  
• d)
  

  In women with biopsy-proven CIN1 and HSIL on cytology

  
  
• e)
  

  In women with frank invasive cancer

Regarding women with LSIL cytology results who are referred to colposcopy, the following is/are true:

• a)
  

  A management based on targeted punch biopsies with subsequent treatment of CIN2 and 3, and cytological surveillance of CIN1 or less, offers the best balance between benefits and harms.

  
  
• b)
  

  Management should not be based on targeted punch biopsies because punch biopsies miss a significant number of underlying CIN2 and 3.

  
  
• c)
  

  The most cost-efficient management is immediate loop excision under colposcopical guidance.

  
  
• d)
  

  A management based on human papillomavirus (HPV) testing with subsequent treatment of HPV 16/18 positive lesions and cytological surveillance of HPV 16/18 negative CIN offers the best balance between benefits and harms.

  
  
• e)
  

  Management should not be based on HPV testing because HPV testing misses a significant number of underlying CIN2 and 3.

Patients with biopsy-proven CIN3

• a)
  

  Should be treated with cryotherapy because this method is not associated with obstetrical complications in subsequent pregnancies.

  
  
• b)
  

  Should be treated with LLETZ or laser-conisation because these methods show the best balance of efficacy and complications.

  
  
• c)
  

  Should be treated with cold-knife conisation because this method allows for an optimal histopathological evaluation of specimen margins.

  
  
• d)
  

  Should be treated with LLETZ only when the lesion is located in a type III transformation zone.

  
  
• e)
  

  Should be treated with cryotherapy or laser vaporisation in pregnant women.

Colposcopy with immediate LLETZ (‘see and treat’) is evidence-based practice in

• a)
  

  Women with biopsy-proven CIN and satisfactory colposcopy.

  
  
• b)
  

  Women with atypical Pap results.

  
  
• c)
  

  Women with HSIL results and visible lesion on colposcopy.

  
  
• d)
  

  Women with positive HPV test results, normal cytology but signs of CIN3 on colposcopy.

  
  
• e)
  

  Women with biopsy-proven CIN3

Colposcopy in pregnancy:

• a)
  

  Increases the risk of preterm delivery and so should be deferred until the postpartum period.

  
  
• b)
  

  May result in early miscarriage.

  
  
• c)
  

  Is safe and necessary for the management of cervical intraepithelial neoplasia (CIN).

  
  
• d)
  

  Colposcopic-directed biopsies are mandatory in the management of CIN in pregnancy.

  
  
• e)
  

  CIN progresses due to the relative immune-suppression of pregnancy.

Antiretroviral therapy (ART) and human immunodeficiency virus (HIV)

• a)
  

  Reduces the risk of CIN in HIV-positive women

  
  
• b)
  

  Reduces the risk of cervical cancer in HIV-positive women

  
  
• c)
  

  Has no effect on the progression or regression of CIN.

  
  
• d)
  

  The effects remain unclear.

  
  
• e)
  

  Increases the risk of multifocal disease.

The Menopause:

• a)
  

  Is associated with a higher prevalence of human papillomavirus (HPV) infection than in younger women.

  
  
• b)
  

  The prevalence of HPV depends on the number of lifetime sexual partners.

  
  
• c)
  

  Is associated with a low rate of unsatisfactory colposcopy.

  
  
• d)
  

  CIN requires hysterectomy in postmenopausal women.

  
  
• e)
  

  Post-treatment cervical stenosis can be prevented by taking hormone-replacement therapy for 2–3 months.

Which of the following are true risk factors for developing cervical cancer or pre-cancer?

• a)
  

  Smoking

  
  
• b)
  

  Age

  
  
• c)
  

  Human papillomavirus infection (HPV)

  
  
• d)
  

  Family history of breast cancer

  
  
• e)
  

  Obesity

In terms of histological diagnosis of cervical intra-epithelial neoplasia (CIN), indicate which of the following statement(s) is/are true or false?

• a)
  

  CIN is a rare lesion

  
  
• b)
  

  High inter-observer reproducibility among pathologists is produced for CIN2 lesions.

  
  
• c)
  

  CIN3 lesions demonstrate abnormal cells in the full thickness epithelium

  
  
• d)
  

  p16 is a useful marker in the diagnosis of CIN.

  
  
• e)
  

  About 30% of CIN3 lesions progress to invasive cancer.

In relation to biomarkers and their utility for diagnosing CIN, which of the following statement(s) is/are true?

• a)
  

  Ki-67 is a proliferation marker specific for cervical cancer.

  
  
• b)
  

  p16 ^INK4a expression is strongly associated with expression of HPV E6 and E7 oncogenes.

  
  
• c)
  

  p16 ^INK4a only stains dysplastic cells.

  
  
• d)
  

  HPV DNA testing is the most specific biomarker test for detecting high-grade disease

  
  
• e)
  

  HPV genotyping of CIN lesions is useful as the risk of progression of CIN lesions is influenced by persistence of high-risk HPV types.

The following features during a colposcopic examination are important variables in diagnosing grade of cervical intraepithelial neoplasia (CIN):

• a)
  

  Degree of aceto-whiteness

  
  
• b)
  

  Presence of nabothian follicles

  
  
• c)
  

  Size of the lesion

  
  
• d)
  

  Presence of mosaic or punctuation

  
  
• e)
  

  Appearance of cervical mucus

Colposcopy as a diagnostic technique:

• a)
  

  Is generally better for low-grade abnormalities than high-grade abnormalities.

  
  
• b)
  

  Single colposcopic-directed biopsies are generally adequate for confirming grade of CIN.

  
  
• c)
  

  Can have adverse emotional effects on the woman.

  
  
• d)
  

  Can be omitted for those women presenting with high-grade cytological abnormality as they will all require treatment.

  
  
• e)
  

  Appropriate training is essential before independent practice.

Regarding the utility of detection of high-risk HPV DNA it is considered useful in the following circumstances

• a)
  

  As a primary screening tool alone

  
  
• b)
  

  As a primary screening tool in combination with cytology

  
  
• c)
  

  As a triage test to decide which minor cytological abnormalities need referral for colposcopy

  
  
• d)
  

  Ongoing management of women referred for colposcopy in whom no high-grade lesion is found

  
  
• e)
  

  For follow up of treatment as a test of cure