Managing women with
Diane D. Davey, MD
Wright TC, Cox JT, Massad LS, et al. 2001 consensus guidelines for the management of women with cervical cytological abnormalities. JAMA. 2002;287: 2120-2129.
Of the estimated 50 million Pap tests performed each year in the United States, about seven percent are abnormal, requiring additional patient testing or followup. This JAMA article represents a landmark in the management of abnormal Pap tests: 121 experts, including representatives of the CAP and 28 other organizations, were invited to participate in developing the evidence-based consensus guidelines. The American Society for Colposcopy and Cervical Pathology, or ASCCP, was the principal sponsoring organization. Working groups drafted guidelines about six months before the conference, and open Internet discussion boards were used to promote interaction and comments. Guidelines underwent discussion, revision, and formal voting at the Sept. 6-8, 2001 consensus meeting.
Because of space limitations, only a few management examples are cited here. Professionals active in interpreting or managing Paps should obtain the full JAMA text and additional information posted on the ASCCP Web site (www.asccp.org). The same issue of JAMA contains the 2001 Bethesda System manuscript (Solo-mon D, Davey D, Kurman R, et al. JAMA. 2002; 287: 2114-2119). The 2001 Bethesda System was discussed in detail in the January 2002 issue of CAP TODAY (page 43).
Women with atypical squamous cells of undetermined significance (ASC-US) can be managed by repeat cervical cytology, DNA testing for high-risk HPV types, or colposcopy. Reflex HPV DNA testing is the preferred approach when liquid-based Pap collection is used. Repeat Pap tests, when selected, should be done at four- to six-month intervals until two consecutive "negative for intraepithelial lesion or malignancy" results are obtained. The recommended management for women with either LSIL or atypical squamous cells, cannot exclude HSIL (ASC-H), is colposcopic evaluation. Colposcopy with endocervical assessment is the initial recommendation for women with HSIL. Colposcopy with endocervical sampling is the recommended followup for all women with atypical glandular cells, or AGC, except that women with atypical endometrial cells may undergo endometrial sampling first. Additional endometrial evaluation is also recommended in women older than 35 years with AGC, or younger women with unexplained bleeding. Managing the treatment of women with AGC by repeat Pap testing is unacceptable.
The guideline discusses several special circumstances including postmenopausal women with ASC-US or LSIL, adolescents with LSIL, pregnant women, and immunocompromised women. Additional management following colposcopy is also discussed, although treatment of biopsy-confirmed lesions will be detailed in another manuscript. For example, management options for women with low-grade lesions (ASC and LSIL) who have undergone colpos-copy include repeat Pap testing at six and 12 months or HPV testing at 12 months. If either yields an abnormal result, colposcopy is suggested.
Dr. Davey is an advisor to the CAP Cytopathology Committee. She is in the Department of Pathology, University of Kentucky Chandler Medical Center, Lexington.