Clinical Review

• Improved cytology reports • New guidelines: ASC-US triage, HPV testing • ALTS findings • Breakthrough on HPV vaccine

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A 2001 adjustment in the terminology used to report cytology results was the first of 4 recent advancements that, in sum, have fundamentally changed how we interpret and follow-up Pap smears. Another breakthrough in cervical disease reveals clear potential for a vaccine for human papillomavirus (HPV). This Update on Cervical Disease reviews these pivotal developments:

  • The 2001 revision of the Bethesda System—also known as Bethesda 3—for reporting cervical cytologic results.
  • The 2001 consensus guidelines on managing women with abnormal cytology and cer-vical cancer precursors.
  • Interim guidance on the use of HPV DNA testing as an adjunct to cervical cytology for screening.
  • Findings of the National Cancer Institute’s ASCUS/LSIL Triage Study (ALTS).
  • A proof-of-principle trial demonstrating the potential clinical utility of a vaccine for HPV type 16 (HPV-16) in young adults.

New terms aim to reduce unnecessary repeat Paps

Solomon D, Davey D, Kurman R, et al. The 2001 Bethesda System: terminology for reporting results of cervical cytology. JAMA. 2002;287:2114-2119.

By deleting a few categories, changing several definitions, and adding new information to the report, the new Bethesda System for reporting results of screening cytology has created a simpler, more precise, and more helpful report.

Elements of the widely utilized 1991 system were believed to cause confusion and lead to unnecessary repeat testing, as well as undue concerns and expenses; these have been refined. Key original features that served well, however, remain. For example, results are still shown in 3 distinct sections: specimen adequacy; general interpretation of normal or abnormal; and specific interpretation, or type of abnormality, if present.

Simpler classifications with notes added when indicated are a step forward from the standpoint of physicians and patients alike.

  • Specimen adequacy is now either “satisfactory” or “unsatisfactory” for evaluation. The confusing category “satisfactory but limited by …” was eliminated because it seemed to lead to many unnecessary repeat Pap tests. Under the old system, specimens were categorized as “satisfactory but limited by …” for any number of reasons, including lack of a transformation-zone component, partially obscuring blood, inflammation, or poor presentation. Such specimens are now classified as “satisfactory for evaluation,” and a statement describing any flaws in the specimen is added.
  • “Benign cellular changes,” a classification that confused patients, was also appropriately eliminated. Cases that fell into that category under the old system are now classified as “negative for intraepithelial lesion or malignancy” (ie, normal), and include a statement explaining that organisms, reparative changes, radiation effect, atrophy, or other conditions are present.
“Atypical squamous cells of undetermined significance” (ASCUS), which previously described all nondiagnostic or borderline squamous cytologic abnormalities, was subdivided in an attempt to reduce the number of cases inappropriately classified as having borderline changes.

ASCUS was changed to “atypical squamous cells” (ASC), with 2 subcategories: “undetermined significance” (ASC-US) and “suggestive of a high-grade squamous intraepithelial lesion” (ASC-H) (Atypical squamous cells: The case for HPV testing”

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