Management of Sequential HPV-Negative Abnormal Cytology in a 60-Year-Old Woman
This patient should undergo cotesting (Pap + HPV) at 3-year intervals rather than returning to routine 5-year screening, and she cannot discontinue screening at age 65 based on these HPV-negative abnormal results alone. 1
Rationale for Enhanced Surveillance
The key issue here is that despite consistently negative HPV testing, this patient has had multiple abnormal cytology results (LSIL followed by two ASC-US results). This pattern places her at higher risk than women with completely negative screening histories.
Risk stratification data demonstrates:
- HPV-negative ASC-US carries a 5-year CIN3+ risk of 1.1%, which is significantly higher than negative cotesting (0.27%) 1
- This elevated risk persists even after negative colposcopy 1
- Women with prior LSIL or ASC-US abnormalities require more frequent surveillance even after achieving negative HPV results 1
Specific Management Algorithm
Immediate next steps:
- Perform cotesting (Pap + HPV) at 3-year intervals 1
- Do not return to routine 5-year screening intervals despite negative HPV results 1
Criteria for returning to routine screening:
- The patient must achieve either 2 consecutive negative cotests OR 3 consecutive negative Pap tests before she can return to standard 5-year intervals 1
- This requirement applies specifically because of her history of abnormal cytology 1
Special Considerations for Age 65 and Beyond
Critical pitfall to avoid: This patient cannot discontinue screening at age 65 based on her current screening history. 1
Requirements for discontinuation:
- She must establish adequate negative screening history (2 consecutive negative cotests or 3 consecutive negative Paps) before discontinuation can be considered 1
- The most recent test must be within the past 5 years 2
- Women over 65 with ASC-US should continue screening even if HPV-negative 2
Why Not Return to Routine Screening?
Although the absolute risk after HPV-negative ASC-US is relatively low (5-year CIN3+ risk of 0.54% to 1.1%), this is still 4-fold higher than after negative cotesting. 2, 1 The ASCCP consensus conference determined that this level of risk warrants enhanced surveillance with 3-year cotesting rather than routine 5-year intervals. 1
The negative colposcopy does not change this recommendation because:
- Colposcopy has limited sensitivity for detecting all lesions 2
- The pattern of recurrent abnormal cytology despite negative HPV suggests either sampling issues or a persistent low-grade process 1
- Long-term surveillance is needed to ensure no progression occurs 1
Management if Future Tests Are Abnormal
If any subsequent cotest shows: