The Role of Human Papilloma Virus Testing in Cervical Cancer Prevention

Molly C. Fey, FNP, MSN; Margaret W. Beal, CNM, PhD

Disclosures

J Midwifery Womens Health. 2004;49(1) 

In This Article

ASC-H and LSIL

Compared with women with ASC-US, the results of women with ASC-H on routine Pap are much more likely to have moderate to severe CIN, with estimates ranging widely from 24% to 94%. As a result, these patients should be referred for colposcopy (Figure 3). Repeat cytology and HPV testing are indicated for risk assessment only if colposcopic findings are negative for CIN.[15]

Figure 3.

Triage of women with ASC-H and LSIL Pap test results.
*Colposcopy deferral only for postmenopausal women who are low risk with a negative screening history; cytology may be repeated approximately 1 week after a course of intravaginal estrogen.
Following a result of ASC-H, if negative for biopsy confirmed CIN: re-review of all samples is recommended; diagnosis is subject to change.

Fifteen to 30 percent of women with LSIL Pap results harbor underlying moderate to severe CIN, whereas the remaining women generally have either no lesion or mild CIN. High-risk HPV infection is very prevalent in women with LSIL, ultimately devaluing the potential benefits of HPV testing. In the ALTS trial, 84% of women with LSIL tested positive for high-risk HPV, resulting in high rates of referral to colposcopy.[21] Testing for high-risk strains was found to have lower specificity for detecting severe CIN in this population than for those with ASC-US. In women with LSIL who are HPV positive, spontaneous regression of precancerous lesions often occurs, further deeming HPV testing to be of less benefit in determining follow-up options for this group. Repeat cytology is also not acceptable for follow-up of women with LSIL due to high rates of subsequent abnormal repeat cytology (53%-76%) and the associated risk of delaying identification of serious disease. As a result, women with LSIL should be referred for colposcopy, with the exception of adolescent and low-risk postmenopausal women. In most cases, follow-up with repeat cytology or HPV testing are recommended options only if colposcopic findings support the absence of CIN (Figure 3).[15,51]

The 2001 Consensus Guidelines offer two exceptions to universal colposcopy referral for women with LSIL.[15] In adolescents and low-risk postmenopausal women, it is acceptable to forego colposcopy and follow-up with repeat cytology or HPV testing. At either end of the age spectrum, the clinical implications of cervical abnormalities and HPV testing vary.[15]

Sexually active adolescents have a higher prevalence of HPV infection and related cervical abnormalities than older women, and most of these abnormalities are low-grade changes classified as ASC-US or LSIL. The younger population also has a much higher likelihood of spontaneous regression of HPV-associated cervical intraepithelial lesions. Even in those with HSIL, only 5% to 15% will progress to carcinoma, and this process often takes years. Considering the high prevalence of HPV, high rates of viral clearance, and low rates of HSIL in younger women, a conservative approach to follow-up LSIL Pap test results is warranted and deferral of colposcopy acceptable. Indiscriminate referral of adolescents with LSIL for colposcopy would likely result in the overtreatment of minor lesions that would otherwise spontaneously regress. Instead, follow-up with cytology or HPV testing offers a less costly, less invasive, and less anxiety-producing option.[31,45]

For low-risk postmenopausal women, it is also acceptable to defer colposcopy in follow-up of LSIL.[15] Compared with younger women, older women are more likely to have false-positive cytology results and are less likely to be positive for high-risk HPV.[21,51] As in the adolescent population, the recommended follow-up is either testing for high-risk HPV or repeat serial cytology. Although little research exists to support deferral of colposcopy in the postmenopausal age group, this approach is recommended in the new guidelines based on grounds such as clinical experience and the advice of those who participated in the expert consensus committee.[15]

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