From the Guidelines
For a 54-year-old female with normal Pap smear cytology but positive high-risk HPV results for two consecutive years, the recommended next step is colposcopy with possible biopsy. This recommendation is based on the most recent guidelines for managing abnormal cervical cancer screening tests and cancer precursors, as outlined in the 2021 study 1. According to these guidelines, a colposcopy is recommended for women with a normal Pap test result and a positive high-risk HPV result, particularly if the HPV result is positive for genotype HPV 16, HPV 18, or both.
The rationale behind this recommendation is that persistent high-risk HPV infection, even with normal cytology, increases the risk for developing cervical dysplasia and potentially cervical cancer over time. High-risk HPV types, particularly 16 and 18, are associated with approximately 70% of cervical cancers, and persistent infection for two years suggests the virus has not been cleared by the immune system.
During colposcopy, if suspicious areas are identified, targeted biopsies should be taken from these regions for histological examination. After colposcopy, management will depend on findings - if no lesions are detected, continued surveillance with co-testing (Pap and HPV) in 12 months is typically recommended, while identified dysplasia would be managed according to its severity.
It's worth noting that the 2014 study 1 and the 2004 study 1 provide additional context and guidelines for cervical cancer screening, but the most recent and relevant guidelines for this specific scenario are outlined in the 2021 study 1.
Key points to consider in this recommendation include:
- The importance of colposcopy in identifying abnormal areas that may not be detectable on routine Pap testing
- The need for targeted biopsies if suspicious areas are identified during colposcopy
- The management of findings after colposcopy, including continued surveillance or treatment of identified dysplasia
- The association between high-risk HPV types and cervical cancer, and the implications of persistent infection for two years.
From the Research
Next Steps for a 54-year-old Female with Normal Pap Smear Cytology but Positive High-Risk HPV Results
- The patient has had two consecutive years of normal Pap smear cytology but positive high-risk Human Papillomavirus (HPV) results.
- According to the study by 2, all women testing positive for HPV, regardless of Pap smear result, should be referred to colposcopy.
- The study by 3 suggests that repeat testing can help assess the risk of high-grade cervical intraepithelial neoplasia (≥CIN2) more accurately than single-visit testing.
- Another study by 4 found that 15.6% of women infected with non-16/18 high-risk HPV subgroups developed ≥HSIL lesions, highlighting the importance of further evaluation.
- The study by 5 found that initial HPV 16 viral load was highly associated with HPV 16 infection outcome, but this was not observed for HPV 18.
- A study by 6 found that women with persistent high-risk HPV were more likely to develop abnormal cervical cytology and had an increased risk of developing an abnormal colposcopic impression.
Recommendations
- Based on the studies, the next recommended step for the patient would be to undergo colposcopy, as suggested by 2.
- Repeat testing, as suggested by 3, may also be considered to assess the risk of ≥CIN2.
- The patient's HPV subtype and viral load, as discussed in 4 and 5, may also be taken into consideration when determining the next steps.
- The patient's history of persistent high-risk HPV, as discussed in 6, highlights the importance of continued monitoring and evaluation.