New guidance for managing further testing for individuals with minimal abnormalities detected during cervical cancer screenings have been issued. Led by researchers at Boston Medical Center and the University of California, San Francisco and published in JAMA Insights, these guidelines introduce a reduction to invasive procedures. If patients with common abnormal results have a history of negative screening using human papillomavirus (HPV) tests, they no longer require a colposcopy (a magnified view of the cervix, typically done with a biopsy). The new guidelines, which follow new ASCCP-led national consensus guidelines for managing abnormal cervical cancer screening tests, estimate risk based on an individual patient's risk factors, allowing for more personalized care management.
In April 2020, 19 organizations created consensus guidelines that formalized the best way to manage cervical cancer test results using estimates of underlying high-grade precancerous lesions or cancer, derived from screening outcomes in 1.5 million people. Of those, 90 percent of test results were normal and only 0.75 percent was severely abnormal. Overall, a colposcopy is still recommended if the estimated risk of currently having a precancer or cancer is from four to 24 percent, if testing results are positive for the HPV types 16 or 18 (known to cause cervical cancer), or if cytology testing cannot be performed.
Cervical cancer screening is recommended for everyone with a cervix, meaning all women and trans-men who have not undergone hysterectomy. Testing for HPV, known to potentially cause cervical cancer, can be done as a standalone screening test or with concurrent cytology testing, commonly known as the Papanicolau or Pap test. Approximately one in ten cervical cancer screening results will be abnormal, meaning that it is common for people to have abnormal results throughout their lifetime.
“These new guidelines can improve care for individuals with the most common abnormalities by reducing the need for invasive procedures while keeping the same standard of cancer prevention,” says Rebecca Perkins, MD, co-first author of the guidelines and obstetrician and gynecologist at Boston Medical Center. “We are guiding clinical practice forward with increased precision, and a better risk assessment for patients.’’
Underlying risks of precancerous lesions or cancer were estimated for combinations of cytology, HPV testing, and HPV genotyping for types 16 and 18. The management of the most common minimally abnormal test results are highlighted in the paper. If a patient is estimated to have a risk of precancer between four and 24 percent, a colposcopy is still recommended. If the risk is less than four percent, repeated testing in one to three years is recommended.
The most common abnormal result is a positive HPV test with a normal cytology (Pap test) result. This combination has a precancer risk of two percent, so follow-up in one year is recommended. However, if there is a positive test result for HPV type 16 or 18, a colposcopy is still warranted due to elevated risk.
The other common abnormalities are minor changes in squamous cells of the cervix (thin, flat cells that make up the epidermis, or the outermost layer of the skin), sometimes described as “low-grade” or “atypical.” If these results are accompanied by a negative HPV test, the risk of precancer is very low, so the patient can come back in 1 year (if “low-grade) or 3 years (if “atypical”). If the HPV test is positive, colposcopy is usually recommended. However, a change from prior guidelines is the recommendation not to immediately jump to colposcopy if the patient has had a history of negative screening with HPV tests. In this case, the patient does not immediately require a biopsy, but can come back in a year to see if the HPV infection and abnormal cells have resolved.
“Dissemination of new guidelines into clinical practice often takes a period of time to implement,” says Perkins, also an associate professor of obstetrics and gynecology at Boston University School of Medicine. “In addition to implementing these recommendations, clinicians can continue to improve cervical cancer prevention by encouraging appropriate HPV vaccination and increasing HPV screening in populations that have lower rates of screening.”
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About Boston Medical Center
Boston Medical Center (BMC) is a private, not-for-profit, 514-bed, academic medical center that is the primary teaching affiliate of Boston University School of Medicine. It is the largest and busiest provider of trauma and emergency services in New England. BMC offers specialized care for complex health problems and is a leading research institution, receiving more than $166 million in sponsored research funding in fiscal year 2019. It is the 13th largest funding recipient in the U.S. from the National Institutes of Health among independent hospitals. In 1997, BMC founded Boston Medical Center Health Plan, Inc., now one of the top ranked Medicaid MCOs in the country, as a non-profit managed care organization. Boston Medical Center and Boston University School of Medicine are partners in Boston HealthNet – 12 community health centers focused on providing exceptional health care to residents of Boston. For more information, please visit http://www.bmc.org.