What is the next step for a 70-year-old female patient with a Pap (Papanicolaou) test and Human Papillomavirus (HPV) testing result showing atypical squamous cells, cannot rule out high-grade, and HPV (Human Papillomavirus) negative?

From the Guidelines

For a 70-year-old female patient with Pap results showing atypical squamous cells cannot exclude high-grade lesion (ASC-H) but with negative HPV testing, the recommended next step is colposcopy with possible biopsy. This procedure should be performed within 3 months of the abnormal Pap result. During colposcopy, the cervix is examined under magnification after application of acetic acid and Lugol's solution to identify any suspicious areas that require biopsy. Despite the negative HPV result, colposcopy is still necessary because ASC-H findings carry approximately a 50% risk of underlying high-grade cervical dysplasia, even in older women, as noted in the study by 1. The negative HPV test is somewhat reassuring but doesn't eliminate the need for further evaluation given the concerning cytology. Following colposcopy, management will depend on findings - if normal or showing only low-grade changes, repeat co-testing in 12 months may be recommended; if high-grade lesions are found, treatment options would include excisional procedures like LEEP (Loop Electrosurgical Excision Procedure), as discussed in 1 and 1. Age alone should not preclude appropriate evaluation of abnormal cervical cytology, especially with findings that suggest possible high-grade disease. It's also important to consider the potential risks and benefits of treatment, including the risk of overdiagnosis and overtreatment, as highlighted in 1 and 1. However, the most recent and highest quality study, 1, supports the recommendation for colposcopy with possible biopsy as the next step in management.

Key points to consider:

• ASC-H findings carry a significant risk of underlying high-grade cervical dysplasia, even in older women
• Negative HPV testing does not eliminate the need for further evaluation
• Colposcopy with possible biopsy is the recommended next step in management
• Management will depend on findings, with options including repeat co-testing or excisional procedures like LEEP
• Age alone should not preclude appropriate evaluation of abnormal cervical cytology.

From the Research

Next Steps for a 70-year-old Female Patient

• The patient has a Pap test and Human Papillomavirus (HPV) testing result showing atypical squamous cells, cannot rule out high-grade, and HPV negative.
• According to the study 2, if the result of the HPV test is negative, the risk of CIN ≥2 lesions in women with ASC-H cytology is low.
• The study 3 suggests that HPV testing for triage of ASC-H in routine practice has the potential to reduce the number of women who are referred for colposcopy without an increased risk of failure to detect HSIL among HPV-negative women.
• The study 4 found that a negative HR-HPV result was an excellent predictor of the absence of HSIL, and HPV-DNA testing may serve as a means to better select which patients with ASC-H on Pap smear should undergo colposcopic examination.

Considerations for Management

• The American Society for Colposcopy and Cervical Pathology guidelines recommend universal colposcopy for the management of women with atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion (ASC-H) on cytology, regardless of human papillomavirus (HPV) test results 2.
• However, the study 2 suggests that reflex HPV testing, rather than immediately performing invasive and expensive colposcopy with biopsy, should be an option for the management of women with ASC-H.
• The study 5 found that patients with negative cervical biopsies after a Pap test interpretation of ASC-H still require close surveillance and follow-up because their risk of being diagnosed with follow-up cervical abnormalities is significantly above baseline.

Potential Next Steps

• Consider reflex HPV testing to confirm the negative result and assess the risk of CIN ≥2 lesions 2, 4.
• If the reflex HPV test is negative, the patient may not require immediate colposcopy, but close surveillance and follow-up are still necessary 2, 5.
• If the reflex HPV test is positive, or if the patient has a history of cervical abnormalities, colposcopy with biopsy may be necessary to rule out high-grade lesions 3, 6.