What is the management plan for a patient over 65 with a positive Atypical Squamous Cells of Undetermined Significance (ASCUS) result from a Pap (Papanicolaou) screening?

Management of ASCUS in Women Over 65

Women over 65 with ASCUS results—regardless of HPV status—cannot exit screening based on this result alone and must continue surveillance until achieving 2 consecutive negative cotests or 3 consecutive negative Pap tests. 1, 2

Immediate Management Based on HPV Status

If HPV-Positive ASCUS

• Repeat co-testing (Pap and HPV) in 3 years is the recommended management strategy 2
• Do not proceed directly to colposcopy unless the repeat test shows abnormalities 2
• Do not use HPV 16/18 genotyping for further risk stratification, as it does not alter management in ASCUS cases 1, 2

If HPV-Negative ASCUS

• Repeat co-testing in 3 years (this represents an update from older 5-year interval recommendations) 3
• At the 3-year follow-up visit:
  • If both tests remain negative: return to routine age-based screening 3
  • If either HPV is positive OR cytology shows abnormalities: refer to colposcopy 3

Critical Age-Specific Considerations for Exiting Screening

The ASCUS result—even if HPV-negative—is NOT sufficient for exiting screening at age 65. 1

Why This Matters

• Women ages 60-64 with HPV-negative ASCUS demonstrate disproportionately higher cancer risk compared to those with completely negative cotests, despite having low dysplasia risk 1, 3
• This elevated cancer risk is based on Kaiser Permanente Northern California data showing that although CIN3+ risk is low (0.48% over 5 years), cancer risk specifically is concerning in this age group 1

Requirements Before Exiting Screening

To discontinue screening at or after age 65, the patient must achieve either:

• 2 consecutive negative cotests within the past 10 years, with the most recent within 5 years 2, 4, OR
• 3 consecutive negative Pap tests within the past 10 years, with the most recent within 5 years 1, 2, 4

Additionally, the patient must have no history of CIN2+ within the last 20 years 1, 4

Rationale for Continued Surveillance

Risk Stratification Evidence

• The 5-year CIN3+ risk after HPV-negative ASCUS (0.48%) is higher than after a completely negative cotest but similar to a negative Pap test alone 3
• HPV-positive ASCUS carries even higher risk, with studies showing 20-41% prevalence of CIN2-3 depending on age and repeat cytology results 5
• The risk profile requires standardized follow-up based on the principle of "equal management of equal risks" 2, 3

Guideline Consensus

• The American Cancer Society initially considered allowing HPV-negative ASCUS to count as negative for exit purposes, but the American Society for Colposcopy and Cervical Pathology (ASCCP) raised concerns about elevated cancer risk in women over 60 1
• Current consensus from the National Comprehensive Cancer Network and ASCCP prioritizes continued surveillance in this population 1, 2

Common Pitfalls to Avoid

• Do not allow exit from screening at age 65 with a recent ASCUS result of any kind—this is the most critical error to avoid 2, 4
• Do not extend the screening interval beyond 3 years for follow-up of ASCUS, as older 5-year recommendations have been revised 2, 3
• Do not refer directly to colposcopy for initial ASCUS results unless repeat testing shows persistent abnormalities 2, 3
• Do not assume HPV-negative ASCUS is equivalent to a completely negative cotest for risk stratification purposes in women over 60 1, 3

Evidence Quality Note

This recommendation carries a "weak" grade by GRADE framework due to sparse data (based on very small numbers of cancer cases in this age group), but represents the most current consensus prioritizing patient safety 1. The recommendation affects approximately 0.5-1% of women in their 60s annually 1.