Management of Elderly Female with ASCUS and Negative HPV
An elderly female with ASCUS and negative HPV should return for repeat cervical cancer screening (co-testing with cytology and HPV) in 3 years, not 5 years, and should continue screening until she has adequate negative screening history before discontinuing at age 65. 1
Primary Management Recommendation
Repeat co-testing (cytology and HPV) in 3 years is the recommended management for HPV-negative ASCUS results, based on updated evidence showing that the risk of CIN3+ and cervical cancer is higher after HPV-negative ASCUS compared to negative co-testing, though still very low (at or below 0.5% over 5 years). 1
This represents a change from earlier recommendations that suggested 5-year intervals, as expanded data from over 1.1 million women demonstrated that HPV-negative ASCUS carries intermediate risk—higher than negative co-testing but comparable to negative cytology alone. 1
Critical Consideration for Elderly Women
Women with HPV-negative ASCUS results around age 65 should NOT exit screening based on this result alone. 1
Data suggest that women older than 60 years with HPV-negative ASCUS may have disproportionately higher cancer risk during follow-up compared to women with negative co-test results, despite low dysplasia risk. 1
If this patient is approaching or at age 65 with an HPV-negative ASCUS result, she should be retested in 3 years and continue surveillance until she achieves 2 consecutive negative co-tests or 3 consecutive negative Pap tests. 1
Only after achieving adequate negative screening (3 consecutive negative cytology tests or 2 consecutive negative co-tests within 10 years, with the most recent within 5 years) should screening be discontinued. 1
Rationale for 3-Year Interval
The recommendation is based on several key principles: 1
Risk stratification: Women with HPV-negative ASCUS have higher risk than those with negative co-testing (the lowest risk group), warranting shorter follow-up intervals than the 5 years used for negative co-tests.
Consistency with evolving screening paradigms: As cervical cancer screening transitions to HPV primary testing with 3-year intervals, all HPV-negative women will be rescreened at 3 years regardless of cytology results.
Large population impact: Over 500,000 women have HPV-negative ASCUS results annually in the United States, making this a clinically significant recommendation.
Alternative Management Options (Less Preferred)
While the 3-year co-testing approach is preferred, alternative strategies exist for specific circumstances: 1
Repeat cytology at 12 months: If HPV testing is not available or feasible, repeat cytology alone at 12 months is acceptable, though less optimal. 1
Immediate colposcopy: Generally not recommended for HPV-negative ASCUS due to low risk (<12% detection of CIN2+), but may be considered if there are concerns about patient adherence to follow-up. 1
Common Pitfalls to Avoid
Do not allow this patient to exit screening at age 65 based on HPV-negative ASCUS alone: This result does not provide sufficient reassurance, particularly given the elevated cancer risk observed in older women with this finding. 1
Do not extend the screening interval to 5 years: Although the absolute risk is low, it is higher than negative co-testing, and the 3-year interval is now the consensus recommendation. 1
Do not perform HPV genotyping: HPV 16/18 genotyping is not indicated for HPV-negative results and does not alter management. 1
Do not assume this represents adequate negative screening: Approximately 0.5-1.0% of women in their 60s will have HPV-negative ASCUS results, and this should not be equated with a completely negative screening test for the purpose of discontinuing screening. 1
Evidence Quality Note
This recommendation carries a "weak" grade in the GRADE framework due to limited data and uncertainty about optimal intervals, though it represents the best available evidence from large cohort studies and consensus guidelines. 1 The recommendation is consistent across the American Cancer Society (ACS) and American Society for Colposcopy and Cervical Pathology (ASCCP) guidelines. 1