SUMMARY:

ASCCP has 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. 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)

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