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Update on Controversy Over Managing Abnormal Pap Smears

Am Fam Physician. 2002 Sep 1;66(5):884-885.

Significant controversy surrounds the optimal management of abnormal squamous cells of undetermined significance (ASCUS) reported on Papanicolaou (Pap) screening for cervical cancer. The recommendations of the ASCUS LSIL (low-grade squamous intraepithelial lesion) Triage Study (ALTS) have been challenged. Solomon and colleagues address these challenges and reaffirm the recommended management options for patients with ASCUS.

The initial ALTS protocol provided two treatment options for ASCUS: immediate referral for colposcopy or repeat cytology with referral for colposcopy if ASCUS (or more severe lesions) were present on the second screening. Both options have serious limitations. Only 5 percent of women with ASCUS have severe cervical intraepithelial neoplasia (CINIII) or cancer, resulting in multiple costly and uncomfortable examinations to detect few positives. Conversely, repeat Pap smears lack sensitivity and risk patients being lost to follow-up.

More recent discussions provide three management options. The option of immediate colposcopy is retained. Repeat Pap screening is also retained as a recommended option, but the indications for referral to colposcopy are more stringent, requiring high-grade squamous intraepithelial lesions (HSIL) on follow-up screening to avoid colposcopy in women with minimal lesions. The new option introduces screening for human papillomavirus (HPV) DNA and referral for colposcopy if HPV is detected. The overall goal is to detect the maximum proportion of cancer cases with the minimum number of colposcopies.

The authors summarized data from several sources to conclude that (1) HPV testing triages 96 percent of CINIII, while referring 56 percent of women for colposcopy; (2) using HSIL as the trigger for referral to colposcopy identifies 44 percent of CINIII but only refers 7 percent of women to colposcopy; (3) using ASCUS or higher as the trigger for colposcopy refers 59 percent of women for colposcopy and identifies 85 percent of CINIII cases.

After careful and critical reanalysis of all available data, the authors conclude that HPV testing is a viable option in the management of ASCUS. They disagree strongly with the strategy of follow-up cytology using HSIL as the threshold for referral to colposcopy. They describe this strategy as unsupported by the evidence and potentially dangerous. This controversy is likely to continue. An attached editor's note calls for solutions that are practical and cost-effective, and that will reduce the rate of invasive carcinoma of the cervix.

Solomon D, et al. ASCUS LSIL triage study (AL TS) conclusions reaffirmed: response to a November 2001 commentary. Obstet Gynecol. April 2002;99:671–4.

editor's note: When the experts disagree so profoundly and publicly, the news media interpret the controversy, and patients may perceive that screening has lost importance or is futile. Women's health appears to be rife with such controversies (e.g., mammography hormone-replacement therapy). Family physicians are on the front lines of these controversies, trying to do the best for individual patients. We are the ones who carefully dissect from the mass of information (only some of which is “evidence”) the best strategy for each woman. Some women need the more specific answer from colposcopy and have the will and means to get the examination. Others may have risk factors and barriers to colposcopy that make HPV testing a reasonable intermediate screening strategy. Above all, physicians must avoid losing patients to follow-up. Over 20 years, we may have come to regard cervical cancer as a nuisance on a positive Pap smear, but those of us who remember young women dying from this disease do not want to have to care for patients in those situations again.—a.d.w.

 

Copyright © 2002 by the American Academy of Family Physicians.
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