What is the recommended management for a 42-year-old patient with a PAP (Papanicolaou) smear showing Atypical Squamous Cells of Undetermined Significance (ASCUS) and a negative Human Papillomavirus (HPV) test?

Management of ASCUS Pap with Negative HPV in a 42-Year-Old Patient

For a 42-year-old patient with Pap smear showing ASCUS and a negative HPV test, follow-up with repeat cotesting (Pap and HPV) in 3 years is recommended. 1

Rationale for 3-Year Follow-Up

The management of ASCUS Pap results with negative HPV testing has evolved based on accumulating evidence:

• Initially, a 5-year follow-up interval was recommended based on early data suggesting that the risk after HPV-negative ASCUS was similar to that of a negative cotest 1

• However, updated data from Kaiser Permanente Northern California (KPNC) with larger sample sizes demonstrated that the risk after HPV-negative ASCUS is actually higher than after a negative cotest 1

• The 5-year CIN3+ and cancer risks after HPV-negative ASCUS results were found to be closer to the risks after a negative Pap test alone than after a negative cotest 2

• Based on this evidence and the principle of "equal management of equal risks," the American Cancer Society revised their recommendation to a 3-year follow-up interval rather than 5 years 1

Risk Assessment

The cytologic interpretation of ASCUS represents a category of morphologic uncertainty, but when HPV-negative, the risk is relatively low:

• While the absolute risk of CIN3+ is low after an HPV-negative ASCUS result, it is more comparable to the risk among women with negative cytology alone than to women with a negative cotest 1

• The negative predictive value of HPV testing for high-grade lesions is very high (99.6%) 3, making it an excellent tool for risk stratification

Management Algorithm

1. Current result: ASCUS Pap with negative HPV

   • Recommendation: Return for repeat cotesting in 3 years 1

2. At 3-year follow-up:

   • If both Pap and HPV are negative: Return to routine screening
   • If HPV is positive: Refer for colposcopy
   • If repeat cytology shows ASC-US or greater: Refer for colposcopy 4

Important Considerations

• HPV-negative ASCUS results are not sufficiently reassuring to allow women to stop undergoing screening at age 65 years 1

• Women who reach 65 years of age with an HPV-negative ASCUS result should be retested in 3 years and should continue surveillance until they have 2 consecutive negative cotests or 3 consecutive negative Pap tests 1

• The management approach differs from that of HPV-positive ASCUS, which would require immediate colposcopy 1

• Avoid overtreatment for ASCUS with negative HPV, as the risk of progression to high-grade lesions is low 4

Documentation Requirements

• All test results, follow-up appointments, and management decisions must be clearly documented in the patient's record 4

• Provide the patient with printed information about cervical cancer screening value and indications 4

• A copy of the Pap test result should be provided to the patient when available 4

By following these evidence-based guidelines, you can ensure appropriate management of this common clinical scenario while minimizing both the risk of missing significant disease and the burden of unnecessary follow-up.