What are the key points of the 2019 American Society for Colposcopy (ASCCP) and Cervical Pathology Risk-Based Management Consensus Guidelines for abnormal cervical cancer screening tests and cancer precursors?

From the Guidelines

The 2019 ASCCP Risk-Based Management Consensus Guidelines prioritize a risk-based approach to managing abnormal cervical cancer screening tests, focusing on personalized management recommendations based on patient-level risk data and clinical action thresholds. The guidelines aim to identify individuals at high risk who require colposcopy or expedited treatment and those at low risk who can safely defer invasive diagnostic procedures 1. Key points of the guidelines include:

• Colposcopy can be deferred for patients at low risk, with follow-up in 1 year instead of colposcopy recommended for patients with minimally abnormal test results who have had a negative screening HPV test or cotest within the past 5 years 1.
• Referral to colposcopy is recommended if cytology test results are abnormal or the HPV test is positive at the 1-year follow-up visit 1.
• Treatment can be expedited for high-risk patients, with loop electrosurgical excision procedure (LEEP) recommended for patients with high-grade cytology results and HPV type 16 positive 1.
• The guidelines emphasize surveillance with HPV testing or co-testing at 1-year intervals for most patients with minor abnormalities rather than immediate colposcopy 1.
• Management is now more personalized, considering factors such as age, pregnancy status, and immunosuppression, with the aim of reducing unnecessary procedures while ensuring appropriate follow-up for those at higher risk 1.

From the Research

Key Points of the 2019 ASCCP Risk-Based Management Consensus Guidelines

• The 2019 American Society for Colposcopy and Cervical Pathology (ASCCP) Risk-Based Management Consensus Guidelines recommend one of six clinical actions based on the risk of cervical intraepithelial neoplasia grade 3, adenocarcinoma in situ, or cancer (CIN 3+) for different combinations of current and recent past screening results 2.
• The guidelines present recommendations for the management of abnormal screening test and histology results, with key risk estimates supporting the guidelines 2, 3.
• The risk estimates were developed based on data from 1.5 million patients undergoing triennial cervical screening by cotesting at the Kaiser Permanente Northern California from 2003 to 2017 2, 3.
• The guidelines recommend clinical action based on the risk of CIN 3+, with options including treatment, optional treatment or colposcopy/biopsy, colposcopy/biopsy, 1-year surveillance, 3-year surveillance, and 5-year return to regular screening 2.
• The risk-based management is derived from the estimated risks of CIN 3+ for different clinical scenarios and combinations of past and current human papillomavirus and cytology test results 3.
• The guidelines also take into account the role of HPV genotyping in risk-based triage for women with atypical squamous cells-undetermined significance (ASC-US) and low-grade squamous intraepithelial lesions (LSIL) cytology 4.
• The guidelines promote personalized risk-based management, incorporating knowledge of current results with prior results, and streamline incorporation of new test methods as they are validated 5.

Clinical Actions and Risk Estimation

• The guidelines recommend the following clinical actions:
  • Treatment
  • Optional treatment or colposcopy/biopsy
  • Colposcopy/biopsy
  • 1-year surveillance
  • 3-year surveillance
  • 5-year return to regular screening
• Risk estimation is based on the risk of CIN 3+ for different combinations of current and recent past screening results 2, 3.
• The risk estimates are presented in tables for different clinical scenarios, and are available online at https://CervixCa.nlm.nih.gov/RiskTables 2.

Implications for Laboratories and Pathologists

• The guidelines have implications for laboratories, pathologists, and cytotechnologists, and promote clinical management recommendations aligned with our increased understanding of HPV biology and cervical carcinogenesis 5.
• The guidelines support the principles of "equal management for equal risk" and "balancing harms and benefits" adopted in the 2012 version of the guidelines 5.
• Pathology organizations were closely involved in the development of these guidelines, and the guidelines will be able to adjust for decreasing CIN3+ risks as more patients who received HPV vaccination reach screening age 5.