What is the recommended management for a 32-year-old patient with an abnormal Pap (Papanicolau) smear showing Atypical Squamous Cells of Undetermined Significance (ASCUS) and a negative Human Papillomavirus (HPV) test?

Management of ASCUS Pap with Negative HPV Test in a 32-Year-Old Patient

For a 32-year-old patient with ASCUS Pap smear and negative HPV test, follow-up with cotesting (Pap and HPV test) in 3 years is recommended. 1

Rationale for 3-Year Follow-up

The American Cancer Society (ACS) and American Society for Colposcopy and Cervical Pathology (ASCCP) guidelines specifically address this scenario. While earlier recommendations had suggested a 5-year interval for HPV-negative ASCUS results, more recent and comprehensive data from the Kaiser Permanente Northern California (KPNC) cohort of over 1 million women demonstrated that:

• The risk of CIN3+ (high-grade cervical intraepithelial neoplasia) after HPV-negative ASCUS is higher than after a completely negative cotest 1
• The risk profile is more comparable to that of women with a negative Pap test alone 1, 2

The 5-year CIN3+ risk after HPV-negative ASCUS (0.48%) is significantly closer to the risk after a negative Pap test (0.31%) than after a negative cotest (0.11%), supporting the 3-year interval recommendation 2.

Management Algorithm

1. Initial result: ASCUS Pap with negative HPV test
2. Next step: No immediate colposcopy needed (risk is below the threshold for colposcopy) 1
3. Follow-up timing: Return for cotesting (Pap + HPV) in 3 years 1
4. If follow-up is normal: Resume routine screening
5. If any abnormality on follow-up: Manage according to specific findings

Key Considerations

• No need for HPV genotyping: The consensus conference agreed that HPV 16/18 genotyping should not be used to further assess women with ASC-US Pap test results 1

• No need for immediate colposcopy: The KPNC results showed that current risk for CIN3+ after an ASC-US Pap with negative HPV is below the agreed threshold for colposcopy 1

• No need for more frequent testing: The negative HPV test provides sufficient reassurance that immediate follow-up is not necessary 1

Important Caveats

• Documentation is essential: Clearly document test results and follow-up recommendations 3

• Patient education: Ensure the patient understands that:

  • This finding is low-risk but requires follow-up
  • The 3-year interval is safe and evidence-based
  • She should return sooner if new symptoms develop (abnormal bleeding, etc.)

• Compliance challenges: Studies show that provider adherence to guideline-consistent recommendations varies by specialty 4, and patient compliance with recommended follow-up intervals can be suboptimal 5

• Special consideration for age 65+: If this finding occurs in a woman approaching age 65, different rules apply. Women who reach 65 years with an HPV-negative ASC-US result should be retested in 3 years and continue surveillance until they have 2 consecutive negative cotests or 3 consecutive negative Pap tests 1

By following this evidence-based approach, you can ensure appropriate management that balances the need for surveillance with avoiding unnecessary procedures for this low-risk finding.