Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Describe the new ASCCP ‘risk based’ strategy to determine whether a woman needs further treatment following an abnormal cervical cancer screening result
2. Discuss the major changes in the new ASCCP consensus management guidelines following an abnormal cervical cancer screening test report

Estimated time to complete activity: 0.25 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.

The PIM planners and others have nothing to disclose. The OBG Project planners and others have nothing to disclose.

Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from through , participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.

Read Disclaimer & Fine Print

SUMMARY:

ASCCP released new guidance (April 2020) to inform assessment and treatment of abnormal cervical cancer screening results. The overarching theme reflects a ‘risk-based’ strategy, rather than rigid focus on a particular result. Risk tables have been generated to assist the clinician and guide practice (Egemen et al. Journal of Lower Genital Tract Disease, 2020). This is a consensus document with input from ACOG, ACS, SGO and multiple other professional organizations, including those affiliated with laboratory medicine. (In October 2020, ACOG released a practice advisory supporting the new ASCCP guidance and withdrew its previous practice bulletin on cervical cancer screening management. )

The executive summary states

New data indicate that a patient’s risk of developing cervical precancer or cancer can be estimated using current screening test results and previous screening test and biopsy results, while considering personal factors such as age and immunosuppression

For a given current results and history combination, the immediate CIN 3+ risk is examined

If this risk is 4% or greater, immediate management via colposcopy or treatment is indicated

If the immediate risk is less than 4%, the 5-year CIN 3+ risk is examined to determine whether patients should return in 1, 3, or 5 years

Routine screening applies only to asymptomatic individuals who do not require surveillance for prior abnormal screening results

Key Changes to Watch for in the New Guidelines

• Recommendations (colposcopy and treatment vs surveillance) are based on risk for CIN 3+
  • Risk determined by prior history as well as screen results
  • Risk tables also address ‘unknown history’ scenario
• Deferral of colposcopy: Low risk for CIN 3+ (risk defined by tables)
  • Repeat HPV testing or cotesting at 1 year
  • At the 1-year follow-up test, referral to colposcopy if still abnormal
• Expansion of expedited treatment category (biopsy not needed prior to therapy), for example, in nonpregnant patients ≥25 years, expedited treatment is
  • Preferred: CIN 3+ risk is ≥60%
  • Preferred: HPV 16–positive HSIL cytology and never or rarely screened patients with HPV-positive HSIL regardless of HPV genotype
  • Acceptable: CIN 3+ risk is between 25% and 60%
  • Shared decision making is important in the context of “impact on pregnancy outcomes”
• Excisional treatment
  • Preferred over ablation for HSIL (CIN 2 or CIN 3) in the US
  • Recommended for AIS
• CIN 1
  • Observation is preferred vs treatment
  • Treatment acceptable with persistent CIN 1 results >2 years
• Lower Anogenital Squamous Terminology (LAST)/World Health Organization (WHO) recommendations for reporting histologic HSIL
  • Include HSIL (CIN 2) and HSIL (CIN 3) (i.e., include CIN 2 and 3 qualifiers)
• Reflex cytology
  • Should be performed on all positive HPV tests, regardless of genotype
  • If HPV 16 and 18 testing is positive but additional laboratory testing of the same sample is not feasible, proceed directly to colposcopy
• Surveillance recommendations following histologic HSIL, CIN 2, CIN 3, or AIS
  • Continue surveillance with HPV testing or cotesting at 3-year intervals for at least 25 years (recommended)
  • >25 years is acceptable “for as long as the patient’s life expectancy and ability to be screened are not significantly compromised by serious health issues”
• HPV assays
  • The ASCCP consensus document states the following in reference to HPV tests

Human papilloma virus assays that are Food and Drug Administration (FDA)-approved for screening should be used for management according to their regulatory approval in the United States

Note: All HPV testing in this document refers to testing for high-risk HPV types only

For all management indications, HPV mRNA and HPV DNA tests without FDA approval for primary screening alone should only be used as a cotest with cytology, unless sufficient, exceptionally rigorous data are available to support primary HPV testing in management

Learn More – Primary Sources:

2019 ASCCP Risk-Based Management Consensus Guidelines for Abnormal Cervical Cancer Screening Tests and Cancer Precursors

Risk Estimates Supporting the 2019 ASCCP Risk-Based Management Consensus Guidelines (Egemen et al. Journal of Lower Genital Tract Disease, 2020)

ACOG Practice Advisory: Updated Guidelines for Management of Cervical Cancer Screening Abnormalities

ASCCP Management Web App

Related ObG Topics:

Guidance Update: Professional Organizations Align on Cervical Cancer Screening

Cervical Cancer Screening Guidelines: The Role of Pap and HPV

ASCCP: Clinicians Routinely Exposed to HPV Should Receive Vaccine