Am Fam Physician. 2008;78(1):118-122
Background: Consensus guidelines for treating women with abnormal cervical cancer screening results were published in 2001. However, shortly after the publication of these guidelines, it became apparent that changes were needed for treating special populations, such as adolescents and postmeno-pausal women. Specifically, the guidelines needed to include more recent evidence from large-scale studies and formally evaluate the effects of human papillomavirus (HPV) DNA testing in combination with abnormal cervical cancer screening results.
New guidelines published in 2006 reflect that the same cytologic result suggests different risks for cervical cancer in various subsets of women. For instance, adolescents (females 20 years or younger) have high rates of HPV infection and low-grade cytologic abnormalities, such as atypical squamous cells or low-grade squamous intraepithelial lesions (LSIL), but a much lower risk of invasive cervical cancer than older women. This is because most HPV infections spontaneously resolve within two years without long-term clinical effects.
The Study: In 2006, the American Society for Colposcopy and Cervical Pathology (ASCCP) and other organizations revised the evidence-based consensus guidelines for treating women with abnormal cervical cancer screening results. The guidelines include several modified recommendations for managing abnormal cytologic results in adolescents (20 years or younger).
Recommendations: The treatment of most women with atypical squamous cells of undetermined significance (ASCUS) should follow the 2001 guidelines (i.e., high-risk HPV [types 6 and 11] DNA testing, colposcopy, or repeat cervical cytologic testing at six and 12 months); reflex HPV DNA testing is the preferred approach.
However, adolescents with ASCUS or LSIL should now have annual cytologic testing. Colposcopy in these patients is recommended only if high-grade squamous intraepithelial lesion (HSIL) or greater is present at the 12-month follow-up or if ASCUS or greater are present at the 24-month follow-up. It is now considered unacceptable to perform HPV DNA testing in adolescents with ASCUS or LSIL. If HPV DNA testing is performed, the results should not influence management.
Adolescents with HSIL or atypical squamous cells for which HSIL cannot be excluded should receive colposcopy. If cervical intraepithelial neoplasia 2 or 3 is not detected despite an adequate examination, adolescents may be observed with colposcopy and cytology every six months for up to 24 months. Annual cytologic testing may be resumed if there are normal findings at two consecutive examinations. An HSIL should be evaluated with biopsy if it persists for 12 months, and a diagnostic excisional procedure (e.g., conization, loop electrosurgical excision procedure) should be performed if the HSIL persists for 24 months. Diagnostic excisional procedures are also recommended if colposcopy is unsatisfactory or if cervical intraepithelial neoplasia of any grade is identified on endocervical assessment.
In addition to modified recommendations for adolescents, the guidelines include several changes for managing abnormal cytologic results in pregnant, immunosuppressed, and postmenopausal women, which are available on the ASCCP Web site at http://www.asccp.org/consensus/cytological.shtml.
Conclusion: Colposcopy is no longer recommended for the initial management of LSIL or ASCUS in adolescents because of the lower risk of malignant transformation in this population compared with older women. HPV testing is also no longer recommended for adolescents with LSIL or ASCUS, and the testing should not influence management if it is performed. An initial colposcopy should be performed in adolescents with HSIL or atypical squamous cells for which HSIL cannot be excluded.