Twenty-nine-year-old “DM” is transferring care into your practice. They show you that their medical record from a previous provider, pulled up on their phone, includes an ASCUS cytology with reflex positive Human Papillomavirus (HPV) three months ago without follow-up. They pull up other records on their cell phone of a prior normal cytology test at age 26. “What do I do now? I’m worried that I have cancer.”
What do you do today?
Before 2012, cervical cancer screening and treatment guidelines focused on what to do next based on test results. Since then, large studies of longitudinal datasets of cervical screening tests and results have resulted in more precise estimation of risks based on age, current test results, and previous documented results. The 2019 ASCCP Risk Based Management Consensus Guidelines for management of abnormal cervical cancer screening focus on improving cervical cancer screening by identifying who is most at risk for high-grade dysplasia and avoiding overtreating people who are at lower risk.
Equal treatment for equal risks: Precision Medicine for the cervix
The 2019 guidelines accommodate the three currently available cervical screening strategies: primary human papillomavirus (HPV) screening, co-testing with HPV testing and cervical cytology, and cervical cytology alone. HPV testing is the cornerstone of this approach, but it is evolving to include other tests like HPV genotyping (testing for the highest-risk HPV types, 16 and 18, which are most likely to lead to cervical cancer). Eventually other tests may be included to help identify people at highest risk and avoid sending people at lower risk for follow-up colposcopy and biopsy tests. Especially in young people, low-grade cervical abnormalities often resolve on their own without additional tests or treatment. And in some but not all studies, treatment has been associated with complications such as preterm delivery.
Risks are based on CIN3, not cervical cancer
The 2019 ASCCP Risk Based Management Consensus Guidelines recommend follow-up testing and treatment when the immediate risk of at least Cervical Intraepithelial Neoplasia grade 3 (CIN3) or higher, a.k.a., high-risk dysplasia, is greater than 4%. CIN3+ was chosen as an endpoint instead of cancer because cancer is so uncommon in the United States, and progression from CIN3+ to cancer can be stopped with treatment. The risk level is based on cervical screening results over time and age, not just the last test results. Any person with a clinical situation having an immediate risk of CIN3 of over 4% receives the recommendation for colposcopy.
The 2019 ASCCP Risk-Based Management Consensus Guidelines are available for free online and through an app for a fee. The guidelines are updated regularly based on the latest in new technology by a multidisciplinary group including client and professional groups, such as Team Maureen, Cervivor, American College of Nurse-Midwives, American College of Obstetricians and Gynecologists, American Academy of Family Physicians, American Cancer Society, and the National Cancer Institute.
Using the ASCCP tool in the exam room
You can look at the 2019 ASCCP Risk Based Management Consensus Guidelines with your client to identify the next step based on their level or risk. You can do this in the article itself, but I find it is a little easier to use the online web or mobile apps (instructions are here).
For our clinical scenario with DM, you enter the latest HPV and cytology results followed by previous results:
ASCCP Management Guidelines App, version 1.6. Screenshots used with permission of ASCCP.
The app then provides a recommendation based on the immediate risk for CIN3, as well as references. The 2019 ASCCP Risk Based Management Consensus Guidelines also provide guidance about management of biopsies and additional follow-up after colposcopy.
For DM the risk of CIN3 or worse today is 4.4%. Since colposcopy is recommended for any person with results and age with an immediate risk of CIN3 or worse of over 4%, the next step for DM should be counseling and a colposcopy.
Counseling tips and additional resources for patients
When counseling patients about abnormal cytology or HPV results, here are a few things to keep in mind:
- HPV is the most common infection passed through sex. In fact, HPV is so common that almost everyone will get HPV at some point in their lives.
- Having HPV or abnormal cytology doesn’t mean that you will automatically get cancer, but it does mean that you will need additional testing and closer follow up.
- Some types of HPV are more likely to cause cancer in the cervix because of how they grow and change the cells. But the good news is that they grow very slowly, so the changes often happen over years.
- The best ways to prevent HPV infection is to get an HPV vaccine. Since HPV is passed by skin-to-skin contact, using condoms or internal condoms when having sex can decrease (but not eliminate) the risk of HPV infections.
There are good online tools for explaining more to DM, such as this Bedsider article, this online presentation designed to help avoid overtreatment for abnormal cervical screening, and this website by ASCO which discusses prevention of cervical cancer with an emphasis on HPV vaccination and screening. There are also free handouts here and here from the Journal of Midwifery and Women’s Health and here from the American Cancer Society.
The 2019 ASCCP Risk-Based Management Consensus Guidelines are an important tool for improving cervical cancer screening and follow-up by identifying who is most at risk for high-grade dysplasia and avoiding overtreating people at lower risk.