Management of ASCUS with Non-High-Risk HPV Positive in a 60-Year-Old Female
For a 60-year-old female with ASCUS and positive non-high-risk HPV, follow-up with repeat co-testing (Pap and HPV) in 3 years is recommended, and she should not exit screening at age 65 without additional negative tests. 1
Recommended Management Algorithm
Initial Assessment
- ASCUS with HPV-positive (non-high-risk strain) in a 60-year-old woman represents a situation requiring careful follow-up due to increased risk compared to women with negative co-testing 1
- The risk of cervical intraepithelial neoplasia grade 3 or higher (CIN3+) in women with HPV-negative ASCUS is higher than with negative cytology alone, and this risk is even more concerning in women over 60 years of age 1
Follow-up Recommendations
- Return for screening in 3 years with co-testing (Pap and HPV testing) 1
- This 3-year interval recommendation is based on data from Kaiser Permanente Northern California (KPNC) showing that women with HPV-negative ASCUS have a higher risk than those with negative co-testing 1
- For women with HPV-positive results (even non-high-risk types), closer monitoring is warranted due to increased risk of progression 2
Considerations for Exiting Screening
- Women who reach age 65 with an HPV-positive ASCUS result should not exit screening 1
- Continued surveillance is necessary until the patient has 2 consecutive negative co-tests or 3 consecutive negative Pap tests 1
- KPNC data show that although dysplasia risk may be low after HPV-negative ASCUS in women over 60, cancer risk is disproportionately high 1
Evidence Strength and Considerations
- The American Cancer Society (ACS) recommendation for 3-year follow-up is graded as "weak" due to limited data, but represents the most current consensus 1
- This recommendation is based on analysis of approximately 1.1 million women from KPNC with extended follow-up 1
- The principle of "equal management of equal risks" guides these recommendations - women with HPV-positive ASCUS have risk profiles requiring standardized follow-up 1
Special Considerations for Older Women
- Women over 60 years with HPV-positive ASCUS may have a higher risk for cervical cancer during follow-up than women with negative co-test results 1
- Risk estimates for cancer among women with HPV-positive ASCUS test results in this age group are based on limited data, but suggest caution is warranted 1
- Approximately 0.5% to 1.0% of all women in their 60s will have an HPV-negative ASCUS result, and the risk is higher for HPV-positive results 1
Common Pitfalls to Avoid
- Don't allow exit from screening at age 65 with a recent HPV-positive ASCUS result - this is insufficient for exiting screening 1
- Don't extend screening interval beyond 3 years - the previous 5-year interval recommendation has been revised based on newer evidence 1
- Don't assume non-high-risk HPV types are benign - while high-risk types pose greater risk, any HPV positivity warrants appropriate follow-up 2
- Don't use HPV 16/18 genotyping to further assess women with ASCUS Pap test results, as this does not alter management in this context 1