Management of ASC-US with Negative HPV in a 47-Year-Old Woman
For a 47-year-old woman with ASC-US and negative HPV testing, repeat co-testing (cytology and HPV) should be performed in 3 years. 1
Primary Management Recommendation
The combination of ASC-US cytology with negative high-risk HPV testing places this patient in a low-risk category that does not require immediate colposcopy or short-interval follow-up. 1, 2
The preferred management is repeat co-testing at 3 years, as this patient is over 30 years of age and the negative HPV result provides strong reassurance against high-grade disease. 1
The 5-year risk of CIN3+ after HPV-negative/ASC-US is only 0.48%, which is closer to the risk after a negative Pap test (0.31%) than after a negative co-test (0.11%), supporting a 3-year return interval rather than immediate intervention. 2
The negative HPV test has a negative predictive value of approximately 99% for excluding high-grade cervical intraepithelial neoplasia, making aggressive follow-up unnecessary. 1, 3
Why Not More Aggressive Management?
Colposcopy is not indicated for HPV-negative ASC-US in women over 30 years of age. 1
Colposcopy is reserved for HPV-positive ASC-US cases, where the risk of CIN2+ is approximately 11%, compared to only 3.8% in all ASC-US cases regardless of HPV status. 3
The American Society for Colposcopy and Cervical Pathology guidelines specifically state that reflex HPV testing is the preferred triage method for ASC-US, and only HPV-positive results warrant colposcopy. 1
Alternative Acceptable Options
While 3-year co-testing is preferred, the following are also acceptable:
Repeat cytology at 12 months is an acceptable alternative, though less efficient than waiting 3 years given the low risk. 1
If repeat cytology at 12 months shows ASC-US or greater, then colposcopy would be indicated. 1
Common Pitfalls to Avoid
Do not perform repeat testing at 6-month intervals for HPV-negative ASC-US—this is only recommended for cases where HPV testing was not performed or when managing HPV-positive results. 1
Do not order HPV testing at intervals less than 12 months, as this is explicitly discouraged in guidelines and provides no clinical benefit. 1
Do not refer for immediate colposcopy based solely on the ASC-US result when HPV is negative, as this represents overtreatment and exposes the patient to unnecessary procedures. 1
Regarding Other Laboratory Results
The elevated C-reactive protein (16 mg/L) noted in this patient's labs is unrelated to cervical cytology management and should be evaluated separately based on clinical context. The other laboratory values (triglycerides, uric acid, ASO, RF, ANA) do not impact cervical cancer screening recommendations. 1
Key Evidence Supporting This Approach
The 2018 update to cervical cancer screening guidelines emphasizes that HPV-negative with ASC-US results should be followed with co-testing at 3 years, not 5 years, distinguishing this from completely negative co-test results. 1
Studies demonstrate that sensitivity of HPV testing for detecting high-grade lesions is 87.5%, with specificity of 72.5%, making the negative result highly reliable. 3
The positive predictive value of HPV testing for biopsy-proven HSIL is only 11.3%, but the negative predictive value approaches 99%, supporting conservative management when HPV is negative. 3