What are the next steps for patients with abnormal Human Papillomavirus (HPV) and cytology test results?

Management of Abnormal HPV and Cytology Test Results

For patients with abnormal HPV and cytology test results, management should follow the 2019 ASCCP Risk-Based Management Consensus Guidelines, which recommend specific follow-up based on test results, HPV genotype, and patient history to reduce morbidity and mortality from cervical cancer. 1

Risk-Based Management Framework

The 2019 ASCCP guidelines use a risk-based framework that combines patient-level risk data with clinical action thresholds to generate personalized management recommendations. This approach focuses on the risk of CIN 3 (severe dysplasia) rather than specific test results.

Key Management Principles:

1. For HPV-positive patients with normal cytology (NILM):

   • If first-time HPV positive: Repeat HPV test with or without cytology in 1 year 1
   • If HPV positive twice consecutively: Colposcopy required 1
   • If positive for HPV 16 or 18: Immediate colposcopy regardless of cytology results 1, 2

2. For HPV-positive patients with abnormal cytology:

   • ASC-US or LSIL with no prior negative screening: Colposcopy 1
   • ASC-US or LSIL with negative HPV test or cotest within past 5 years: Repeat testing in 1 year 1
   • ASC-H: Colposcopy or expedited treatment 1
   • HSIL with HPV 16: Expedited treatment preferred for non-pregnant patients ≥25 years 1, 2
   • HSIL with other HPV types: Colposcopy or expedited treatment 1
   • AGC: Colposcopy 1

HPV Genotype-Specific Management

HPV genotype significantly impacts risk stratification:

• HPV 16 positive: Highest risk genotype (57.8% risk of CIN3+ with abnormal cytology, 19.9% with normal cytology) 3

  • Expedited treatment should be considered for HSIL cytology 1, 2
  • Colposcopy recommended in all other cases, even with normal cytology 1, 2

• HPV 18 positive: High association with adenocarcinoma (40.2% risk of CIN3+ with abnormal cytology, 10.8% with normal cytology) 3

  • Colposcopy recommended in all cases, even with normal cytology 1
  • Endocervical sampling acceptable at time of colposcopy 1

• Other high-risk HPV types: Lower but still significant risk (31.4% risk of CIN3+ with abnormal cytology, 5.5% with normal cytology) 3

  • If cytology is normal: Return in 1 year for repeat testing 1
  • If cytology is abnormal: Follow management based on cytology result 1

Special Considerations for E6/E7 mRNA Detection

If HPV mRNA E6/E7 is detected:

• Immediate colposcopy is mandatory regardless of cytology results 2
• This indicates active oncogenic HPV infection with higher risk of cervical intraepithelial neoplasia 2

Post-Treatment Surveillance

For patients treated for high-grade precancer (CIN2+):

• Initial surveillance:

  • HPV test or cotest at 6,18, and 30 months 1
  • If using cytology alone: Testing at 6,12,18,24, and 30 months 1

• Long-term surveillance:

  • Continue for at least 25 years from initial CIN diagnosis 1, 2
  • HPV testing or cotesting every 3 years 1
  • If using cytology alone: Annual testing 1

Common Pitfalls to Avoid

1. Inappropriate HPV testing: HPV testing should not be performed for:

   • Deciding whether to vaccinate against HPV
   • Testing for low-risk HPV types (6 and 11)
   • Managing patients with genital warts
   • Routine screening in persons <25 years
   • Testing oral or anal specimens 1

2. Premature discontinuation of surveillance: After treatment for high-grade precancer, surveillance should continue for at least 25 years, even if it extends past age 65 1, 2

3. Relying solely on cytology: HPV testing or cotesting is preferred to cytology alone for follow-up after abnormal results, as negative HPV testing is less likely to miss disease 1

4. Inappropriate management of non-16/18 high-risk HPV: While risk is lower than HPV 16/18, studies show 15.6% of women with non-16/18 high-risk HPV develop ≥HSIL lesions, which is too high to be overlooked 4

By following these evidence-based guidelines, clinicians can effectively manage patients with abnormal HPV and cytology results to reduce morbidity and mortality from cervical cancer.