2001 Guidelines - Diagnosis of Cervical Cancer
From September 6 through September 8, 2001, the American Society for Colposcopy and Cervical
Pathology (ASCCP) hosted a consensus conference to develop guidelines for the management of women with cervical cytological abnormalities. The 2001 Bethesda system subdivides atypical squamous cells into two categories: Atypical Squamous Cells of Undetermined Significance (ASCUS) and Atypical Squamous Cells, Cannot Exclude HSIL (ASC-H). A women with a cervical cytology result from a Pap test interpreted as ASCUS has a 5 to 17% chance of having CIN 2, 3 confirmed by biopsy, while CIN 2, 3 is identified in 24 to 94% of those with ASC-H.
The risk of invasive cervical cancer with a woman with ASC is low (approximately .1% to .2%). Immunosupressed women with ASC are at increased risk for CIN 2, 3 high risk types of HPV are frequently detected in immunosupressed women, suggesting that these women require special consideration. Conversely, post-menopausal women with ASC appear to be at lower risk for CIN 2, 3 then pre-menopausal women.
CIN 1 denotes low grade pre-cursor of cervical cancer and CIN 2, 3 denotes high grade precursor of cervical cancer. The sensitivity of a single repeat test for detecting CIN 2, 3 for those with ASC is relatively low (.67-.85). Repeat cytological testing is often used for women with ASC. Repeating cervical cytological testing has several disadvantages. It can delay the diagnosis of CIN 2, 3 or cervical cancer. The advantage of colposcopy for evaluation of women with ASC is that it immediately informs both the women and the clinician of the presence or absence of significant disease.
Several large studies have evaluated the performance of DNA testing to detect high risk types of HPV for the management of women with ASC. The sensitivity of HPV DNA testing for the detection of biopsy-confirmed CIN 2, 3 in women with ASC is .83-1.0 and is higher than the sensitivity of a single repeat cervical cytological test. Between 31% and 60% of all women with ASC will have high risk types of HPV identified.
“Reflex” HPV testing is an approach in which the original cytology specimen is tested for HPV only if an ASCUS result is obtained. Reflex HPV testing offers significant advantages since women do not need an additional specimen collection and many women will be spared a colposcopy. Also, women testing negative for HPV can rapidly be assured that they do not have a significant lesion.
All women who test positive for HPV should be referred for colposcopy. When a program of repeat cytological testing is used, women with ASCUS should undergo repeat cytological testing at 4 to 6 month intervals. Women with ASCUS or greater abnormality on the repeat test should be get a colposcopy. A colposcopy is recommended for all immunosupressed patients with ASCUS.
2001 Consensus Guidelines for the Management of Women With Cervical, Cytological Abnormalities, Journal of the American Medical Association 287:2120 (2002)