Cervical Colposcopy: Indications and Risk Assessment
Am Fam Physician. 2020 Jul 1;102(1):39-48.
Patient information: A handout on this topic is available at https://familydoctor.org/colposcopy/.
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The practice of colposcopy, a diagnostic procedure to evaluate for vaginal, vulvar, and cervical dysplasia, has evolved to incorporate patient risk factors for high-grade cervical intraepithelial neoplasia (CIN) and cancer. Changes in cervical cancer screening and guidelines, human papillomavirus (HPV) vaccination recommendations, and colposcopy standards from the American Society for Colposcopy and Cervical Pathology (ASCCP) have implications for all primary care clinicians, not only those who perform colposcopies. Primary care clinicians should offer HPV vaccination to all patients between the ages of nine and 26, in addition to cervical cancer screening and follow-up guidance. Primary care clinicians should recognize the degrees of risk of high-grade CIN and cancer conferred by cytology, HPV subtype, and persistence of HPV infection. Clinicians should address modifiable risk factors such as tobacco use, and provide counseling to patients about colposcopy based on their individual risks. Clinicians should conduct shared decision-making about immediate loop electrosurgical excision procedure vs. colposcopy with multiple biopsies and endocervical sampling for patients with the highest risk of cervical cancer, and for patients who are older than 25 years with at least two of the following: HPV-16, HPV-18, and high-grade squamous intraepithelial lesion cytology. Primary care clinicians should be familiar with the 2019 ASCCP guidelines and develop clinic-based systems to ensure appropriate follow-up of abnormal cytology, positive high-risk HPV testing, diagnosed CIN, and cervical cancer. Patients with an abnormal cervical cancer screening history require surveillance, which differs from routine screening for patients with normal prior screening results. Long-term surveillance is recommended for patients with CIN 2 or worse.
Three recent developments show promise to reduce cervical cancer incidence in the United States. In 2016, the U.S. Food and Drug Administration approved a two-dose series of the 9-valent human papillomavirus (HPV) vaccine for children aged nine to 14.1 For patients aged 15 to 26, a three-dose series is recommended.2 Educating families about two-dose HPV vaccination should lead to improved vaccine initiation rates and the shorter series should improve vaccine completion rates. The U.S. Preventive Services Task Force endorsed HPV-only cervical cancer screening every five years for women 30 and older as an alternative to screening with cytology every three years or cotesting with cytology and HPV every five years.3 HPV self-sampling accuracy is similar to traditional office-based clinician sampling, and it has the potential to improve access to cervical cancer screening.4 Lastly, in 2018, the U.S. Food and Drug Administration expanded its approval of the three-dose 9-valent HPV vaccine to people between the ages of 27 and 45. The Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices recommends shared clinical decision-making for patients in this age group who are not vaccinated or who are undervaccinated who might benefit from HPV vaccination.5 Because older patients are less likely to clear high-risk HPV infections,5 this could decrease cervical cancer incidence.
WHAT IS NEW ON THIS TOPIC
Recommendations from the American Society for Colposcopy and Cervical Pathology 2019 guidelines for the management of abnormal cervical cancer screening tests and cancer precursors are based on risk, not results.
The American Society for Colposcopy and Cervical Pathology 2017 consensus recommendations for colposcopy practice incorporate a patient's risk factors for high-grade CIN 2 or worse into decision-making about tissue sampling.
Long-term follow-up in a Swedish study of women older than 30 years uncovered no patients with CIN 2 or worse who cleared their high-risk HPV infections and a 100% progression to CIN 2 or worse over 13 years when high-risk HPV persisted.
A high-quality study of 47,000 women undergoing colposcopy found that a random biopsy in the setting of a normal colposcopic impression diagnosed 21% of the total CIN 2 and 19% of CIN 3 or worse, primarily in patients with HPV-16 and HPV-18.
CIN = cervical intraepithelial neoplasia; HPV = human papillomavirus.
SORT: KEY RECOMMENDATIONS FOR PRACTICE
|Clinical recommendation||Evidence rating||Comments|
Advisory Committee on Immunization Practices recommendations
For patients older than 25 years with two or more of the following—HPV-16, HPV-18, and high-grade squamous intraepithelial lesion—the risk of high-grade CIN is enough to justify immediate LEEP for simultaneous diagnosis and treatment rather than colposcopy.19–21
Pooled cohort study data
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