What are the management recommendations for patients with abnormal Pap (Papanicolaou) test results?

Management Recommendations for Abnormal Pap Test Results

The management of abnormal Pap test results should follow the 2019 ASCCP Risk-Based Management Consensus Guidelines, which prioritize patient-level risk assessment rather than specific test results to guide clinical decisions. 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 based on risk for CIN 3 (cervical intraepithelial neoplasia grade 3) 1
• This approach identifies high-risk patients who require colposcopy or expedited treatment and low-risk patients who can safely defer invasive diagnostic procedures 1
• Electronic tools (smartphone applications or the ASCCP website) can facilitate implementation of these guidelines 1

Management Based on Pap Test Results

Atypical Squamous Cells of Undetermined Significance (ASC-US)

• For women aged ≥21 years with ASC-US, three management options are available: 1
  • HPV DNA testing (preferred approach)
  • Repeat Pap tests at 6 and 12 months
  • Prompt colposcopy (appropriate if concerns about follow-up adherence exist)
• If HPV testing is positive, immediate colposcopy is recommended 1
• If HPV testing is negative, repeat testing in 12 months is recommended 1

Low-Grade Squamous Intraepithelial Lesion (LSIL)

• Colposcopy is recommended for women with LSIL and positive HPV test 1
• For women with LSIL who had negative HPV testing or cotest within the previous 5 years, repeat HPV test with or without concurrent Pap test in 1 year is recommended instead of immediate colposcopy 1

High-Grade Squamous Intraepithelial Lesion (HSIL)

• Colposcopy or expedited treatment is recommended for women with HSIL 1
• For women with HSIL and positive HPV 16, expedited treatment is preferred for non-pregnant patients aged ≥25 years 1
• Colposcopy with biopsy is an acceptable option if desired by patient after shared decision-making 1

Atypical Glandular Cells (AGC)

• Colposcopy is recommended for all subcategories of AGC 1
• Endocervical sampling should be performed during colposcopy 1
• Endometrial sampling is recommended in conjunction with colposcopy for women ≥35 years with AGC 1
• HPV DNA testing alone or repeat cytology is unacceptable for initial triage of AGC 1

Special Considerations

HPV Genotyping Results

• HPV 16 is the highest-risk HPV type 1
  • For HSIL cytology with HPV 16 positive, expedited treatment should be considered 1
  • For other cytology results with HPV 16 positive, colposcopy is recommended even if cytology is normal 1
• HPV 18 has a high association with adenocarcinoma 1
  • Colposcopy is recommended in all cases, even with normal cytology 1
  • Endocervical sampling is acceptable at the time of colposcopy due to association with adenocarcinoma 1
• For non-16/18 HPV types with normal cytology, return in 1 year is typically recommended 1

Follow-Up After Abnormal Results

• HPV testing or cotesting is preferred to cytology alone for follow-up after abnormal results 1
• After treatment for high-grade precancer, 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
• Long-term surveillance includes testing at 3-year intervals if using HPV testing or cotesting, or annual testing if using cytology alone 1

Common Pitfalls to Avoid

• Inadequate sampling: Use both spatula and cytobrush for cervical sampling to improve collection of adequate samples containing endocervical cells 2
• Inappropriate HPV testing: HPV testing should not be used for:
  • Deciding whether to vaccinate
  • STD screening
  • Testing patients <21 years
  • Primary cervical cancer screening as a stand-alone test 1
• Insufficient biopsies: The likelihood of finding CIN 2 or higher increases when two or more cervical biopsies are performed during colposcopy 3
• Lack of follow-up systems: Clinics should develop protocols to identify women who miss follow-up appointments to ensure they receive needed evaluation and treatment 1
• Over-treatment: For low-risk findings (e.g., ASC-US or LSIL with recent negative HPV test), immediate colposcopy may represent over-treatment 1

By following these risk-based management guidelines, clinicians can provide appropriate care for patients with abnormal Pap test results while minimizing unnecessary procedures and maximizing detection of significant cervical disease.