Cytopathology and More | Managing abnormal screening results: highlights of new guidelines

✽ ✽ ✽ ✽ ✽ ✽ ✽ ✽ ✽
LSIL on cytology. Management of LSIL has also been carved out into its own grouping with options more dependent on HPV correlations in the over 30 year olds and more conservative in women 21 to 24. For women over 30 with LSIL cytology and no HPV test or positive HPV test, colposcopy is recommended. However, the conservative option of co-testing at one year without colposcopy is preferred in women with HPV-negative LSIL. In women 21 to 24 with LSIL, followup cytology at one year is recommended. Colposcopy as an option is limited to women with ASC-H, HSIL, or AGC at one year or ASC-US + at two years.

✽ ✽ ✽ ✽ ✽ ✽ ✽ ✽ ✽
Post-biopsy management options. The recommendation changes post-biopsy are dependent on whether the colpo-histologic findings are preceded by lesser or greater abnormalities and require correlation for the algorithmic followup. When biopsy-proven LSIL (CIN 1) is preceded by a lesser abnormality such as ASC-US or LSIL, management is conservative with co-testing at one-year intervals. Women with biopsy-proven LSIL (CIN 1) preceded by ASC-H or HSIL cytology may have alternative tracks, including co-testing at one and two years or a diagnostic excisional procedure.

Women with LSIL (CIN 1) on endocervical sampling are managed according to the guidelines for CIN 1 and should not be considered as a “positive” ECC. Repeat endocervical sampling is recommended in one year. In this context only abnormal strips in the ECC which constitute findings of HSIL (CIN 2/3) or atypical endocervical glandular epithelium would require a diagnostic excisional procedure.

More conservative management options are again recommended for younger women, even those with biopsy-proven HSIL (CIN 2/3). Here, treatment and observation are acceptable when colposcopy is adequate. Observation in this group is more frequent, at six-month intervals.

Essential changes from prior management guidelines are summarized in Box 1 of the published official ASCCP guidelines update4,5 and the reader is referred there for further study and review of the algorithm charts.

Only time will tell how successful the guidelines will be in balancing simplicity with precision in management. Although recommendations for more conservative management in younger women and in women with lower-grade lesions seem logical, the intricacies of the new algorithms with respect to index cytology, HPV status, age, and colposcopic correlation may be difficult to tease apart in advising patients and planning management. Widely differing intervals for followup among age groups and categories may lead to confusion, with some women being followed too frequently and others too late. Computerized algorithmic strategies may be helpful.

Interpretation of the new management guidelines may also be hampered by the failure to incorporate the new LAST recommendations. The guidelines do not fully embrace the LAST classification, and this raises the question whether the management guidelines will need to be rewritten to align more completely with the new histologic terminology. The disconnect may be a source of confusion to practitioners and pathologists.

Concern has also been expressed about how the extended screening intervals and variable followup intervals will affect the patient’s return for routine screening and for followup of abnormal findings. Further complicating followup will be how physicians and practice groups manage the recall of women as their ages and status evolve over time. Great care will have to be taken and educational effort made to ensure that women understand the new call-back intervals with regard to cervical cancer screening and management of abnormal findings.n

References

1. Saslow D, Solomon D, Lawson HW, Killackey M, et al. American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer. Am J Clin Pathol. 2012; 137(4):516–542.
2. Moyer VA. U.S. Preventive Services Task Force. Screening for cervical cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012;156(12):880–891.
3. Darragh TM, Colgan TJ, Cox JT, Heller DS, et al. The Lower Anogenital Squamous Terminology Standardization Project for HPV-associated lesions: background and consensus recommendations from the College of American Pathologists and the American Society for Colposcopy and Cervical Pathology. J Low Genit Tract Dis. 2012; 16(3):205–242.
4. Massad LS, Einstein MH, Huh WK, Katki HA, et al. 2012 updated consensus guidelines for the management of abnormal cervical cancer screening tests and cancer precursors. J Low Genit Tract Dis. 2013; 17(5 suppl 1):S1–S27.
5. Massad LS, Einstein MH, Huh WK, Katki HA, et al. 2012 updated consensus guidelines for the management of abnormal cervical cancer screening tests and cancer precursors. Obstet Gynecol. 2013;121(4):829–846.
6. Katki HA, Schiffman M, Castle PE, Fetterman B, et al. Benchmarking CIN 3+ risk as the basis for incorporating HPV and Pap cotesting into cervical screening and management guidelines. J Low Genit Tract Dis. 2013; 17(5 suppl 1):S28–S35.

Dr. Ghofrani is director of cytopathology and women’s health, Department of Pathology, PeaceHealth Laboratories, Vancouver, Wash. Dr. Winkler is medical director of pathology, Department of Pathology, Mt. Kisco Medical Group PC, Mt. Kisco, NY. Both are members of the CAP Cytopathology Committee.