Management of ASCUS Without HPV Testing in Elderly Patients
For an elderly patient with ASCUS on Pap test and no HPV result available, perform HPV testing immediately (reflex HPV testing on the original specimen if possible, or recall for HPV testing), as management cannot be appropriately determined without knowing HPV status, particularly in this high-risk age group. 1
Why HPV Status is Critical in Elderly Patients
The management of ASCUS fundamentally depends on HPV status, and this is especially important in elderly patients because:
- Women over 60 with HPV-positive ASCUS have disproportionately high cancer risk compared to younger women, even when dysplasia risk appears low 1
- The risk of 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
- HPV-negative ASCUS in elderly patients still carries higher risk than a completely negative cotest, with a 5-year CIN3+ risk of 0.48% and cancer risk of 0.043% 2
Immediate Action Steps
If the original Pap specimen is available:
- Request reflex HPV testing on the original liquid-based cytology specimen 1, 3
- This avoids requiring the patient to return for an additional visit
If reflex testing is not possible:
- Recall the patient for HPV testing immediately 1
- Do not wait or proceed with management based on cytology alone
Management Based on HPV Results
If HPV Testing Returns Positive:
Follow-up with repeat co-testing (Pap and HPV) in 3 years 1
- This recommendation is based on analysis of approximately 1.1 million women from Kaiser Permanente Northern California with extended follow-up 1
- The American Cancer Society updated this from a previous 5-year interval to 3 years based on expanded data 1, 3
Critical consideration for screening exit:
- This patient should NOT exit screening at age 65 without additional negative tests 1
- Continued surveillance is necessary until the patient has 2 consecutive negative co-tests or 3 consecutive negative Pap tests 1
- Do not allow exit from screening at age 65 with a recent HPV-positive ASCUS result 1
Do not perform HPV 16/18 genotyping, as this does not alter management in the ASCUS context 1
If HPV Testing Returns Negative:
Follow-up with repeat co-testing in 3 years 3, 4
- Although the risk is lower than HPV-positive ASCUS, it remains higher than a completely negative cotest 3, 4
- The American Cancer Society updated this recommendation from 5 years to 3 years based on expanded data showing the risk profile is closer to a negative Pap alone (0.48% 5-year CIN3+ risk) rather than a negative cotest (0.11% 5-year CIN3+ risk) 2
Important caveat for elderly patients:
- False negative rates of HPV testing for CIN2+ in ASCUS patients older than 50 years may increase with age 5
- Approximately 6.2% false negative rate overall in ASCUS patients, but this becomes higher after age 50 5
- This supports the more conservative 3-year interval rather than 5-year interval in this population 1, 3
Screening exit considerations:
- HPV-negative ASCUS results are NOT sufficiently reassuring to allow women to stop screening at age 65 years 4
- To qualify for discontinuation of screening, the patient needs negative primary HPV tests (preferred) or negative co-testing at ages 60 and 65 years 6
Common Pitfalls to Avoid
- Do not proceed with management based on cytology alone without obtaining HPV status 1
- Do not perform immediate colposcopy for ASCUS without knowing HPV status, as this leads to overtreatment in HPV-negative cases 3, 4
- Do not extend the screening interval to 5 years after HPV-negative ASCUS, as the previous recommendation has been revised to 3 years 1, 3
- Do not assume HPV-negative ASCUS carries the same ultralow risk as a negative cotest - the risk is intermediate 3, 4
- Do not allow this patient to exit screening at age 65 without meeting the updated criteria of negative tests at both ages 60 and 65 1, 6