Abnormal Cervical Cancer Screening Test and Cancer Precursors

If CIN 2 or CIN 3 but no glandular lesion is identified histologically for patients with cytology atypical glandular, endocervical, or endometrial cells not otherwise specified, management should be according to the 2019 guidelines for the lesion diagnosed. ( C, II )

For patients with atypical glandular or endocervical cells “favor neoplasia” or endocervical AIS cytology, if invasive disease is not identified during initial colposcopic workup, a diagnostic excisional procedure is recommended. The diagnostic excisional procedure used in this setting should provide an intact specimen with interpretable margins. ( B, II )

Endocervical sampling above the excisional bed is preferred. ( B, II )

Treatment is preferred if histologic HSIL cannot be specified (e.g., reported as histologic HSIL or histologic HSIL [CIN 2,3]). ( C, III )

In all nonpregnant patients with a diagnosis of histologic HSIL (CIN 3), treatment is recommended and observation is unacceptable. ( A, II )

When treatment of histologic HSIL is planned, excisional treatment is preferred, and treatment with ablation is acceptable. ( B, I )

For patients with a diagnosis of histologic HSIL (CIN 2) whose concerns about the effects of treatment on a future pregnancy outweigh their concerns about cancer, either observation or treatment is acceptable provided the squamocolumnar junction is visible and CIN 2+ or ungraded CIN is not identified on endocervical sampling. ( C, II )

When CIN 2+ is not identified histologically after an ASC-H or HSIL cytology result, it is acceptable to review the cytologic, histologic, and colposcopic findings. If the review yields a revised interpretation, management should follow guidelines for the revised diagnosis. ( C, III )

For patients 25 years or older with histologic LSIL (CIN 1) who is diagnosed at consecutive visits for at least 2 years, observation is preferred, ( B, II )

For patients 25 years or older with histologic LSIL (CIN 1) who is diagnosed at consecutive visits for at least 2 years, observation is preferred (BII) but treatment is acceptable. ( C, III )

If treatment is selected and the entire squamocolumnar junction and all lesions were fully visualized during colposcopic examination, either excision or ablation treatments are acceptable. ( C, II )

A diagnostic excisional procedure is recommended for all patients with a diagnosis of AIS on cervical biopsy to rule out invasive adenocarcinoma, even when definitive hysterectomy is planned. Excisional procedures should optimally remove an intact specimen to facilitate accurate interpretation of margin status. Although there is no preference for cold knife conization versus LEEP, intentional disruption of the specimen by performance of a LEEP followed by a “top hat” endocervical excision to achieve the desired specimen length is unacceptable. An excisional specimen length of at least 10 mm is preferred, and this can be increased to 18 to 20 mm for patients who are not concerned about the effect of treatment on future pregnancy. These dimensions are preferred regardless of whether hysterectomy is planned.

After the initial diagnostic procedure, hysterectomy is the preferred management for all patients who have a histologic diagnosis of AIS, although fertility-sparing management for appropriately selected patients is acceptable. For patients with confirmed AIS with negative margins on the excisional specimen, simple hysterectomy is preferred. For patients with confirmed AIS with positive margins on the excisional specimen, re-excision to achieve negative margins is preferred, even if hysterectomy is planned. For patients with AIS and persistent positive margins for whom additional excisional procedures are not feasible, either a simple or modified radical hysterectomy is acceptable. After hysterectomy, surveillance per the ASCCP surveillance guidelines for treated CIN 2+ is recommended.

For patients of reproductive age who desire future pregnancy, fertility-sparing management with an excisional procedure is acceptable provided that negative margins have been achieved on the excisional specimen, and the patient is willing and able to adhere to surveillance recommendations. If negative margins cannot be achieved after maximal excisional attempts, fertility-sparing management is not recommended. For patients who undergo fertility-sparing management, surveillance with cotesting and endocervical sampling is recommended every 6 months for at least 3 years, then annually for at least 2 years, or until hysterectomy is performed. For patients who have consistently negative cotesting and endocervical sampling results for 5 years, extending the surveillance interval to every 3 years starting in the sixth year of surveillance is acceptable. Small retrospective studies have shown HPV test results to be the best predictor for recurrent disease. Therefore, for patients who have consistently negative cotesting and endocervical sampling results, continued surveillance is acceptable after completion of childbearing. For patients who have had positive HPV test results or abnormal cytology/histologic results during surveillance, hysterectomy at the completion of childbearing is preferred. 

Surveillance with cervical cytology alone is acceptable only if testing with HPV or cotesting is not feasible. ( C, III )

Cytology is recommended at 6-month intervals when 1-year intervals are recommended for HPV or cotesting, and annually when 3-year intervals are recommended for HPV or cotesting. ( A, II )

Cytology should be used for patients younger than 25 years, with transition to HPV-based testing at 25 years or older. ( A, II )

If HPV-based tests are positive, colposcopy and appropriate biopsies should be performed. ( A, II )

Follow-up at 6 months with colposcopy and ECC is acceptable. ( B, III )

After the initial intensive surveillance period, continued surveillance at 3-year intervals is recommended for at least 25 years after treatment of high-grade histology (histologic HSIL, CIN 2, CIN 3, or AIS) or high-grade cytology (HSIL or persistent ASC-H) even if this is beyond the age of 65 years. ( B, II )

When patients with a history of treated high-grade histology or cytology reach the age of 65 years, if they have completed the initial 25-year surveillance period, continued surveillance at 3-year intervals is acceptable and may continue as long as the patient is in reasonably good health. ( B, III )

In patients younger than 25 years with low-grade cytology screening results of LSIL, ASC-US HPV-positive, or ASC-US without HPV testing, repeat cytology alone at 1 and 2 years after the initial abnormal result is recommended. ( B, II )

In patients younger than 25 years with histologic HSIL (CIN 2), observation is preferred, and treatment is acceptable. ( B, II )

Endocervical curettage, endometrial biopsy, and treatment without biopsy are unacceptable during pregnancy. ( E, III )

A diagnostic excisional procedure or repeat biopsy is recommended only if cancer is suspected based on cytology, colposcopy, or histology. ( B, II )

If histologic HSIL (CIN 2 or CIN 3) is diagnosed at the first colposcopy examination during pregnancy, surveillance colposcopy and testing (diagnostic cytology/HPV depending on age) is preferred every 12 to 24 weeks, but deferring colposcopy to the postpartum period is acceptable. ( B, II )

Repeat biopsy is recommended if invasion is suspected or the appearance of the lesion worsens. ( B, II )

Treatment of histologic HSIL (CIN 2 or CIN 3) during pregnancy is not recommended. ( D, II )

If AIS is diagnosed during pregnancy, referral to a gynecologic oncologist is preferred, but management by a gynecologist skilled in the colposcopic diagnosis and treatment of AIS is acceptable. ( C, III )

In patients diagnosed with histologic HSIL (CIN2 or CIN3) during pregnancy, if a lesion is detected at postpartum colposcopy, an excisional treatment procedure or full diagnostic evaluation (cervical cytology, HPV, and biopsy) is acceptable. ( B, II )

In the absence of a lesion on colposcopy, a full diagnostic evaluation is recommended; expedited treatment is not recommended. ( B, II )

Among patients who have undergone hysterectomy but either have no previous diagnosis of CIN 2+ within the previous 25 years or have completed the 25 year surveillance period, screening is generally not recommended. However, if performed, abnormal vaginal screening test results should be managed according to published recommendations. ( B, III )

If surveillance testing is recommended for either a history of abnormal screening results or treatment for precancer, discontinuing surveillance is unacceptable if the patient is in reasonably good health and testing is feasible. ( D, II )

Discontinuation of surveillance is recommended for patients with a limited life expectancy. ( E, III )