What is the recommended treatment for a patient with Atypical Squamous Cells of Undetermined Significance (ASCUS) pap result in the presence of Human Papillomavirus (HPV) 18?

Management of ASCUS Pap with HPV 18 Positivity

For a patient with ASCUS Pap result and positive HPV 18, colposcopy is recommended in all cases due to the relatively high association of HPV 18 with cervical cancer, even if the cytology test is normal. 1

Rationale for Colposcopy Recommendation

• HPV 18 has a relatively high association with cancer, particularly adenocarcinoma, making immediate colposcopy the standard of care 1
• Because of the association of HPV 18 with adenocarcinoma, endocervical sampling is acceptable at the time of colposcopy 1
• The 2021 CDC STI treatment guidelines specifically recommend colposcopy for HPV 16 or 18 positive results, regardless of cytology findings 1

Management Algorithm

1. Immediate referral for colposcopy is the first step for ASCUS with HPV 18 positivity 1
2. Endocervical sampling should be performed during colposcopy due to HPV 18's association with adenocarcinoma 1
3. Follow-up after colposcopy will depend on findings:
   • If high-grade lesions are found and treated, surveillance should continue for at least 25 years 1
   • Initial post-treatment testing includes HPV test or cotest at 6,18, and 30 months 1

Evidence Strength

• The recommendation for colposcopy with HPV 18 positivity is consistent across multiple guidelines and is based on the higher risk of progression to cancer 1
• Studies have shown that HPV testing is more sensitive than repeat cytology for detecting underlying high-grade lesions in women with ASCUS 2, 3
• Research demonstrates that HPV 16/18 positive women with ASCUS have a significantly higher rate (43%) of CIN/VAIN2+ than women with ASCUS and non-16/18 HPV types (19%) 4

Important Clinical Considerations

• HPV testing or cotesting is preferred to cytology testing alone for follow-up after an abnormal test result 1
• Ideally, cytology testing should be performed by the laboratory as a reflex test from the same specimen to avoid the need for the patient to return to the clinic 1
• Document the HPV testing methodology used, as different tests have varying sensitivities for detecting specific HPV types 5

Common Pitfalls to Avoid

• Do not delay colposcopy for ASCUS with HPV 18 positivity, as this differs from management of ASCUS with non-16/18 HPV types 1, 5
• Avoid confusing management protocols for ASCUS/HPV-positive (but negative for high-risk types) with those for ASCUS/HPV 16 or 18-positive, which require immediate colposcopy 5
• Ensure patient understanding of the follow-up plan and importance of adherence to recommended surveillance 5