New Guidance for Testing of Minimal Abnormalities Detected in Cervical Cancer Screening

New guidance for managing further testing for patients with minimal abnormalities detected during cervical cancer screenings have been published in JAMA Insights.¹

Following the new ASCCP-led national consensus guidelines for managing abnormal cervical cancer screening tests, these new guidelines estimate risk based on an individual’s risk factors, thus allowing for more personalized care management.

“These new guidelines can improve care for individuals with the most common abnormalities by reducing the need for invasive procedures while keeping the same standard of cancer prevention,” co-first author of the guidelines Rebecca Perkins, MD, obstetrician and gynecologist at Boston Medical Center, said in a press release.² “We are guiding clinical practice forward with increased precision, and a better risk assessment for patients.’’

In April 2020, 19 organizations developed consensus guidelines that formalized a strategy for management of cervical cancer screening test results using a framework based on estimates of underlying high-grade precancerous lesions or cancer, collectively known as cervical intraepithelial neoplasia grade 3 or worse (CIN3+). These estimates were developed from screening outcomes observed in more than 1.5 million individuals aged 25 to 65 years enrolled in a prepaid health plan.

Among the population used, approximately 90% of test results were found to be normal and approximately 0.75% were deemed severely abnormal. The remaining results were considered minimally abnormal.

Overall, the guidelines suggested a colposcopy is still recommended if the estimated risk of currently having a precancer or cancer ranges from 4% to 24%, if testing results are positive for the HPV types 16 or 18, which are known to cause cervical cancer, or if cytology testing cannot be performed. If the risk is found to be less than 4%, repeated testing in 1 to 3 years is recommended.

Underlying risks of precancerous lesions or cancer were also estimated for combinations of cytology, HPV testing, and HPV genotyping for types 16 and 18. The most common abnormal result is a positive HPV test with a normal Pap test result. This combination has a precancer risk of 2%, therefore a 1-year follow-up is recommended. However, should there be a positive test result for HPV type 16 or 18, a colposcopy is still necessary due to elevated risk according to the recommendations.

Other common abnormalities identified were minor changes in squamous cells of the cervix, sometimes described as low-grade or atypical. If such results are accompanied by a negative HPV test, the risk of precancer is very low, therefore the patient can come back in 1 year if low-grade or 3 years if atypical. If the HPV test is positive though, colposcopy was recommended in most cases.

Importantly, a notable change from prior guidelines is the recommendation not to immediately perform a colposcopy if the patient has had a history of negative screening with HPV tests. In cases such as this, the guidelines recommend a patient does not immediately require a biopsy and can come back in a year to see if the HPV infection and abnormal cells have resolved.

“Dissemination of new guidelines into clinical practice often takes a period of time to implement,” Perkins, also an associate professor of obstetrics and gynecology at Boston University School of Medicine, said in the release. “In addition to implementing these recommendations, clinicians can continue to improve cervical cancer prevention by encouraging appropriate HPV vaccination and increasing HPV screening in populations that have lower rates of screening.”

References:

1. Sawaya GF, Lamar R, Perkins RB. Managing Minimally Abnormal Cervical Cancer Screening Test Results. JAMA Insights. doi: 10.1001/jama.2020.12488

2. Managing Minimally Abnormal Cervical Cancer Screening Test Results, Following New Guidelines [news release]. Published September 25, 2020. Accessed October 1, 2020. https://www.bmc.org/news/press-releases/2020/09/25/managing-minimally-abnormal-cervical-cancer-screening-test-results