Cervical cancer update: The latest on screening & management
Here are updated guidelines for prevention, testing, and treatment. Elimination of causative HPV continues to hold center stage in the global effort to curb disease.
PRACTICE RECOMMENDATIONS
› Encourage eligible patients to be vaccinated against human papillomavirus (HPV) because the vaccine is highly effective for preventing cervical dysplasia, especially when given to patients previously unexposed to the virus. A
› Screen for cervical disease with either cytology plus HPV testing or primary HPV testing with secondary triage for cytology; both protocols are more accurate than screening with cervical cytology alone, and allow you to widen the screening interval. A
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Primary HPV screening
Primary HPV testing was approved by the US Food and Drug Administration in 2015 and recommended as an appropriate screening option by professional societies
In contrast to cytology-based screening, HPV testing has high sensitivity (≥ 90%); the population-based negative likelihood ratio is near zero.20 This degree of sensitivity allows for extended screening intervals. However, primary HPV testing lacks specificity for persistent infection and high-grade or invasive lesions, which approximately doubles the number of patients who screen positive. The potential for excess patients to be referred for colposcopy led to the need for secondary triage.
Instituting secondary triage. Cytology is, currently, the primary method of secondary triage, reducing the number of referrals for colposcopy by nearly one-half, compared to referrals for all high-risk HPV results, and with better overall accuracy over cytology with high-risk HPV triage.21 When cytology shows ASCUS, or worse, refer the patient for colposcopy; alternatively, if so-called reflex testing for HPV types 16 and 18 is available and positive, direct referral to colposcopy without cytology is also appropriate.
In the future, secondary triage for cytology is likely to be replaced with improved technologies, such as immunostaining of the specimen for biomarkers associated with cervical precancer or cancer, or for viral genome methylation testing.22
Management of abnormal cervical cancer screening results
Routine screening applies to asymptomatic patients who do not require surveillance because they have not had prior abnormal screening results. In 2020, ASCCP published risk-based management consensus guidelines that were developed for abnormal cervical cancer screening tests and for cancer precursors.16 Guiding principles, and screening situations in which the guidelines can be applied, are summarized in TABLE 3
Continue to: ASCCP guidelines...
