What further investigation is needed for a 62-year-old with reactive cellular changes and repair on a Pap (Papanicolaou) smear when human papillomavirus (HPV) testing is normal?

From the Guidelines

Further investigation is recommended for a 62-year-old with reactive cellular changes and repair on a Pap smear, even with normal HPV testing, and the next step should be colposcopy with directed biopsies of any abnormal areas. These cellular changes, while often benign and due to inflammation or infection, warrant additional evaluation in older patients due to increased cancer risk with age 1. The procedure of colposcopy allows direct visualization of the cervix using a microscope and application of acetic acid and iodine solutions to identify suspicious areas. During colposcopy, the physician will take small tissue samples from any concerning areas for pathological examination.

Key Considerations

• The patient's age increases the risk of cervical cancer, and thorough evaluation is necessary to rule out precancerous or cancerous conditions 1.
• Reactive cellular changes can be benign responses to inflammation, infection, or hormonal changes, but evaluation is crucial to determine the underlying cause 1.
• Colposcopy with directed biopsies is a recommended next step for further investigation, as it provides a detailed examination of the cervix and helps identify any abnormal areas that may require further testing or treatment.

Procedure and Expectations

• Colposcopy typically takes 15-20 minutes in an outpatient setting and may cause mild cramping 1.
• The procedure involves the use of a microscope to visualize the cervix, and the application of acetic acid and iodine solutions to identify suspicious areas.
• The physician will take small tissue samples from any concerning areas for pathological examination, which will help determine the presence of any precancerous or cancerous cells.

Importance of Further Investigation

• Further investigation is necessary to rule out precancerous or cancerous conditions, especially in patients over 60 where age-related cancer risk increases and cellular repair mechanisms may be less efficient 1.
• The patient's normal HPV testing results do not eliminate the need for further investigation, as reactive cellular changes can still be a cause for concern 1.

From the Research

Further Investigation for Reactive Cellular Changes and Normal HPV Testing

• For a 62-year-old with reactive cellular changes and repair on a Pap smear when human papillomavirus (HPV) testing is normal, further investigation is needed to rule out any potential cervical lesions or cancer 2.
• According to the study by 2, reactive cellular changes in normal cervical smears should be further investigated, and HR-HPV testing could be used as an effective triage in cases of reactive cellular changes.
• The study by 3 suggests that HPV testing for hrHPV types might be a safe enough approach to warrant extension of the screening interval of hrHPV-/Pap-women even in low-resource settings.
• However, the study by 4 found that among women with unsatisfactory ThinPrep Pap tests and positive hrHPV results, 13% had high-grade squamous intraepithelial lesions, and 4.3% had keratinized squamous cell carcinoma of the cervix, highlighting the need for further investigation.

Recommended Follow-Up

• Colposcopy is recommended for those cases showing reactive cellular changes combined with HR-HPV positivity to reduce the risk of failure to diagnose cervical cancer and precancerous lesions 2.
• The American Society for Colposcopy and Cervical Pathology (ASCCP) recommends repeat cytology within 2-4 months for the management of unsatisfactory Pap tests 4.
• Further studies with a larger number of cases are needed to analyze the hrHPV status and biopsy follow-up of cases with unsatisfactory cytology 4.

Screening Methods

• High-risk HPV testing is more sensitive than cytology screening and can provide greater protection against cervical cancer 5.
• However, HPV screening in younger age groups is fraught with high false-positive screening results, leading to more colposcopies and unnecessary treatments with the potential for harm 5.
• The Pap smear test is a highly useful, easy, technically safe, and cost-effective tool for detecting cervical epithelial precancerous lesions, and its power of detection can be potentiated when used with the HPV-PCR test together 6.