Management of Abnormal Cervical Cancer Screening Test Results and Cervical Cancer Precursors

Publication Date: December 2, 2013

Recommendations and Conclusions

The following recommendations are based on good and consistent scientific evidence.

  • For women with ASC-US cytology test results, reflex HPV testing is preferred.
  • For women with HPV-positive ASC-US, whether from reflex HPV testing or co-testing, colposcopy is recommended.
  • For women with LSIL cytology test results and no HPV test or a positive HPV test result, colposcopy is recommended.
  • For women with a histologic diagnosis of CIN 2, CIN 3, or CIN 2,3 and adequate colposcopic exami- nation, both excision and ablation are acceptable treatment modalities, except in pregnant women and young women.
(A)
574

The following recommendations are based on limited and inconsistent scientific evidence.

  • For women 30 years of age and older with HPV-positive but cytology-negative co-test results, repeat co-testing at 1 year is acceptable. For women with HPV-negative ASC-US, whether from reflex HPV testing or co-testing, repeat co-testing at 3 years is recommended.
  • When colposcopy does not identify CIN in women with HPV-positive ASC-US, co-testing at 12 months is recommended. If the co-test result is HPV- negative and cytology negative, return for age-appropriate testing in 3 years is recommended.
  • For women aged 21–24 years with ASC-US cytology test results, cytology testing alone at 12-month intervals is preferred, but reflex HPV testing is acceptable.
  • For women aged 65 years and older, HPV-negative ASC-US test results should be considered abnormal when considering discontinuation of screening.
  • For women aged 21–24 years with LSIL cytology test results, follow-up with cytology testing at 12-month intervals is recommended. Colposcopy is not recommended.
  • For pregnant women with LSIL, colposcopy is preferred.
  • For women with ASC-H cytology test results, colposcopy is recommended regardless of HPV result. Reflex HPV testing is not recommended.
  • For women with HSIL cytology test results, immediate LEEP or colposcopy is acceptable, except in special populations.
  • A diagnostic excisional procedure is recommended for women with HSIL cytology test results when the colposcopic examination is inadequate, except during pregnancy.
  • For women aged 21–24 years with ASC-H or HSIL test results, colposcopy is recommended. Immediate treatment (ie, see-and-treat) is unacceptable.
  • For women with all subcategories of AGC and AIS except atypical endometrial cells, colposcopy with endocervical sampling is recommended regardless of HPV test result. Endometrial sampling is recommended in conjunction with colposcopy and endo- cervical sampling in women 35 years of age and older with all subcategories of AGC and AIS. Endometrial sampling is also recommended for women younger than 35 years with clinical indications that suggest they may be at risk of endometrial neoplasia.
  • No further evaluation is recommended for asymptomatic premenopausal women with benign endome- trial cells, endometrial stromal cells, or histiocytes. For postmenopausal women with benign endometrial cells, endometrial assessment is recommended regard- less of symptoms.
  • For women aged 25 years and older with CIN 1 or no lesion preceded by “lesser abnormalities,” co-testing at 1 year is recommended. If both the HPV test and cytology test results are negative, then age-appropriate retesting 3 years later is recommended. If all test results are negative, then return to routine screening is recommended. If any test result is abnormal, then colposcopy is recommended. If CIN persists for at least 2 years, either continued follow-up or treatment is acceptable.
  • When CIN 1 is detected on endocervical sampling after lesser abnormalities but no CIN 2+ is detected colposcopically directed biopsies, management should follow ASCCP management guidelines for CIN 1, with the addition of repeat endocervical sampling in12 months.
  • For women aged 21–24 years with CIN 1 after an ASC-US or LSIL cytology test result, repeat cytology testing at 12-month intervals is recommended. Follow-up with HPV testing is unacceptable.
  • Regardless of antecedent cytology test results, treat- ment of CIN 1 in women aged 21–24 years is not recommended.
  • Treatment of pregnant women for CIN 1 is unacceptable.
  • Hysterectomy is unacceptable as primary therapy for CIN 2, CIN 3, or CIN 2,3.
  • For women treated for CIN 2, CIN 3, or CIN 2,3, co-testing at 12 months and 24 months is recommended. If both co-test results are negative, retesting in 3 years is recommended. If any test result is abnormal, colposcopy with endocervical sampling is recommended. If all test results are negative, routine screening is recommended for at least 20 years, even if this extends screening beyond 65 years of age.
(B)
574

The following recommendations are based primarily on consensus and expert opinion.

  • For women with an unsatisfactory cytology test result and no, unknown, or a negative HPV test result, repeat cytology testing in 2–4 months is recommended.
  • For women aged 21–29 years with negative cytology test results and absent or an insufficient endocervical–transformation zone component, routine screening is recommended. For women aged 30 years and older with cytology test results reported as negative and with an absent or insufficient endocervical–transformation zone component and no or unknown HPV test result, HPV testing is preferred.
  • Acceptable options for the management of post-menopausal women with LSIL and no HPV test include obtaining HPV testing, repeat cytology testing at 6 months and 12 months, and colposcopy.
  • For women aged 21–24 years with HSIL cytology test results, when CIN 2+ is not identified on histology testing, observation for up to 24 months using both colposcopy and cytology testing at 6-month intervals is recommended, provided the colposcopic examination is adequate and endocervical assessment is negative or CIN 1.
  • When CIN 2+ is not identified on histologic testing, either a diagnostic excisional procedure or observation with co-testing at 12 months and 24 months is recommended, provided in the latter case that the colposcopic examination is adequate and the endocervical sampling is negative. In this circumstance, it is acceptable to review the cytologic, histologic, and colposcopic findings.
  • For women aged 21–24 years with CIN 1 or no lesions after an ASC-H or HSIL cytology test result, observation for up to 24 months using both colposcopy and cytology testing at 6-month intervals is recommended, provided the colposcopic examination is adequate and endocervical assessment is negative.
  • If CIN 2, CIN 3, or CIN 2,3 is identified at the margins of a diagnostic excisional procedure or in an endocervical sample obtained immediately after the procedure, reassessment using cytology testing with endocervical sampling at 4–6 months after treatment is preferred.
  • For young women with a histologic diagnosis of CIN 2,3 not otherwise specified, either treatment or observation for up to 12 months using both colposcopy and cytology testing at 6-month intervals is acceptable, provided the colposcopy finding is adequate. When a histologic diagnosis of CIN 2 is specified for a young woman, observation is preferred but treatment is acceptable. Hysterectomy is preferred for women who have completed child-bearing and have a histologic diagnosis of AIS on a specimen from a diagnostic excisional procedure.
(C)
574

Recommendation Grading

Disclaimer

Overview

Title

Management of Abnormal Cervical Cancer Screening Test Results and Cervical Cancer Precursors

Authoring Organization

Publication Month/Year

December 2, 2013

Document Type

Consensus

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Female, Adolescent, Adult, Infant

Health Care Settings

Ambulatory, Laboratory services

Intended Users

Physician, nurse, nurse practitioner, physician assistant

Scope

Assessment and screening

Diseases/Conditions (MeSH)

D002583 - Uterine Cervical Neoplasms

Keywords

cervical cancer, HPV, HPV test, HPV infections