From the Guidelines
For a patient with a normal Pap test but positive for Human Papillomavirus (HPV), the next step is to repeat the HPV test with or without a concurrent Pap test in 3 years, as per the 2019 ASCCP Risk-Based Management Consensus Guidelines 1. This approach is based on the latest guidelines that prioritize risk-based management, aiming to identify individuals at high risk who require immediate intervention like colposcopy or expedited treatment, while allowing those at low risk to safely defer invasive diagnostic procedures. The management strategy is tailored to the patient's risk level for cervical intraepithelial neoplasia (CIN) 3, rather than solely on specific test results, incorporating the use of HPV genotyping to guide decision-making, especially for high-risk types like HPV 16 and 18 1. Key considerations include:
- The patient's previous screening results and history of abnormal findings
- The presence of high-risk HPV types, particularly HPV 16 or 18, which may necessitate more immediate action like colposcopy
- The importance of follow-up to monitor for potential progression of HPV infection to more severe cervical lesions
- The role of patient education on the significance of HPV infection, the importance of adherence to follow-up recommendations, and lifestyle factors that can influence immune response and cervical health. Given the high rate of spontaneous resolution of HPV infections, a balanced approach that avoids unnecessary procedures while ensuring timely intervention for those at higher risk is crucial for optimizing outcomes in terms of morbidity, mortality, and quality of life.
From the Research
Next Steps for a Patient with a Normal Pap Test but Positive for HPV
- A patient with a normal Papanicolaou (Pap) test but positive for Human Papillomavirus (HPV) should undergo further evaluation, as HPV infection is a necessary cause of cervical cancer 2.
- The American Cancer Society has recommended high-risk HPV testing as the primary screening method for cervical cancer, and a triage strategy is required for positive results 3.
- Genotyping to specifically detect HPV types 16 and 18 in conjunction with reflex cytology for the remaining high-risk HPV genotypes has been the recommended method 3.
- Alternative testing options, such as Dual Stain for p16/Ki-67 and extended HPV genotyping, are being incorporated into treatment algorithms 3.
- Methylation testing is another promising method being investigated as a potential alternative to Pap test cytology 3.
- Women with a positive HPV test and a normal Pap test result may be offered a second HPV test at least 1 year later, and those who are found to be persistently infected with the same high-risk type of HPV may be offered colposcopy with cervical biopsy 4.
- The risk of cervical intraepithelial neoplasia grade 2 or worse and grade 3 or worse is higher in women who test positive for HPV, particularly those who test positive for HPV 16 5.
Follow-up Intervals
- The follow-up interval for women with a normal Pap test but positive for HPV may vary depending on the specific circumstances and the results of further evaluation 6, 4.
- Women with a negative HPV test and a normal Pap test result may be safely screened at an interval of 3 to 5 years, while those with a positive HPV test may require more frequent follow-up 2, 5.
- The American Society of Colposcopy and Cervical Pathology management guidelines recommend that patients with an unsatisfactory Pap test and negative HPV cotest undergo repeat age-based screening in 2 to 4 months, but a negative HPV cotest result may predict the lack of high-grade squamous intraepithelial lesion (HSIL) and allow for a longer follow-up interval 6.