August 2009
Cytopathology Programs Review

Ann T. Moriarty, MD
Joel S. Bentz, MD
Teresa M. Darragh, MD

Cervical cancer screening in women less than 21 years of age has changed significantly with the introduction of the 2006 Consensus Guidelines for the Management of Women with Abnormal Cervical Screening Tests.¹ Women who are 20 years or younger are considered “adolescents.” HPV testing is not indicated in these women, and any HPV results should be ignored in managing the patient. Additionally, unless a Pap test demonstrates HSIL, colposcopy is not recommended. It has proved difficult to disseminate the information and to assess adherence to the guidelines.

To address these issues, the American Society for Colposcopy and Cervical Pathology sponsored an intersociety Practice Improvement in Cervical Screening and Management (PICSM) Committee meeting in Bethesda, Md., at the National Institutes of Health. The primary goal of the June 19–20 PICSM symposium was to bring together 40 to 50 experts in the fields of adolescent medicine, cervical cancer prevention, and treatment of HPV-associated conditions of the cervix and vulva who would review the data supporting current screening and management recommendations for adolescents and young women and develop a communication strategy to promote their dissemination and better adoption. At the meeting, group leaders reviewed the evidence, participants identified gaps in knowledge, and this was followed by open floor and small group discussions.

At the meeting’s conclusion, the participants identified the following three key messages:

• Adolescent (women age 20 years and under) cervical cancer prevention programs should focus on preventing HPV infection through universal HPV vaccination.
• Screening should start at age 21. Screening of adolescents (age 20 and under) is potentially harmful because it can lead to unnecessary evaluation and treatment.
• It is important for adolescents to have access to family planning as well as assessment of and treatment for sexually transmitted infections other than HPV.

These key messages relate to the scientific data that indicate that human papillomavirus is ubiquitous in women at the onset of sexual activity and the incidence of squamous cell carcinoma in this age group is nonexistent. Squamous cervical cancer develops after persistence of HPV and over time. Over-screening in this population leads to overtreatment and potential harm. Most squamous intraepithelial pathology in this age group will regress; premature eradication by biopsy or conization may lead to complications of premature rupture of membranes in pregnancy, premature birth, and other fertility problems. Instead of screening for cancer, efforts should be focused on preventing cervical cancer through vaccination. Adolescent women still need health care during early sexual activity. Family planning, contraceptive advice, screening for Chlamydia or other sexually acquired infections, and prenatal care are all important to adolescents, who need to be seen by their health care providers.

The purpose of the PICSM symposium was not to establish guidelines but to develop a strategy for disseminating those guidelines that are established based on the strength of scientific data. All of the participating organizations have been asked to bring the key messages home to their organizations and to develop a plan and a timeline specific for their organizations to disseminate the information. Pathologists will play a key role in disseminating information to and educating their clinical colleagues.

Reference

1. Wright TC, Massad LS, Dunton CJ, et al. 2006 consensus guidelines for the manage­ment of women with abnormal cervical screening tests. J Lower Gen Tr Dis. 2007;11:201–222.