2021 Update on cervical disease
The current state of HPV vaccination, cervical cancer screening guidelines that consider age plus immune status and prior abnormality, and guidance on individualized risk-based management
New ASCCP management guidelines focus on individualized risk assessment
Perkins RB, Guido RS, Castle PE, et al; 2019 ASCCP Risk-Based Management Consensus Guidelines Committee. 2019 ASCCP risk-based management consensus guidelines for abnormal cervical cancer screening tests and cancer precursors. J Low Genit Tract Dis. 2020;24:102-131.
The ASCCP risk-based management guidelines introduce a paradigm shift from managing a specific cervical cancer screening result to using a clinical action threshold based on risk estimates that use both current and past test results to determine frequency and urgency of testing, management, and surveillance (FIGURE).20 The individualized risk estimate helps to target prevention for those at highest risk while minimizing overtesting and overtreatment.
Estimating risk and determining management
The new risk-based management consensus guidelines use risk and clinical action thresholds to determine the appropriate management course for cervical screening abnormalities.20 New data indicate that a patient’s risk of developing cervical precancer or cancer can be estimated using current screening results and previous screening test and biopsy results, while considering personal factors such as age and immunosuppression.20 For each combination of current test results and screening history (including unknown history), the immediate and 5-year risk of CIN 3+ is estimated.
With respect to risk, the following concepts underlie the changes from the 2012 guidelines:
- Negative HPV tests reduce risk.
- Colposcopy performed for low-grade abnormalities, which confirms the absence of CIN 2+, reduces risk.
- A history of HPV-positive results increases risk.
- Prior treatment for CIN 2 or CIN 3 increases risk, and women with this history need to be followed closely for at least 25 years, regardless of age.
Once an individual’s risk is estimated, it is compared with 1 of the 6 proposed “clinical action thresholds”: treatment, optional treatment or colposcopy/biopsy, colposcopy/ biopsy, 1-year surveillance, 3-year surveillance, or 5-year return to regular screening (<0.15% 5-year CIN 3+ risk).
Key takeaways
Increasing knowledge of the natural history of HPV has led to improved approaches to prevention, including the nonvalent HPV vaccine, which protects against 7 high-risk and 2 low-risk HPV types; specific screening guidelines that take into consideration age, immune status, and prior abnormality; and risk-based management guidelines that use both current and prior results as well as age to recommend the best approach for managing an abnormal result and providing surveillance after an abnormal result. ●
Using the ASCCP risk thresholds, most patients with a history of an abnormal result, especially CIN 2+, likely will need more frequent surveillance testing for the foreseeable future. As increasing cohorts are vaccinated and as new biomarkers emerge that can help triage patients into more precise categories, the current risk categories likely will evolve. Hopefully, women at high risk will be appropriately managed, and those at low risk will avoid overtreatment.
