New Pap Management Guidelines – Balancing Benefits and Harms of Cervical Cancer Screening

It’s fitting that this year’s ACOG meeting was held in New Orleans, because navigating the 2013 ASCCP Pap Smear Management Guidelines presented there feels like trying to make my way through the Mississippi bayou. The guidelines include 18 different algorithms encompassing almost any combination of pap and HPV abnormality we docs are likely to encounter among our patients.  But all tributaries lead to the same place, where we achieve optimal reduction in cervical cancer with minimal harm.  

Cervical cancer prevention is a process with benefits and harms. Risk cannot be reduced to zero with currently available strategies, and attempts to achieve zero risk may result in unbalanced harms, including over treatment. …optimal prevention strategies should identify those HPV-related abnormalities likely to progress to invasive cancers while avoiding destructive treatment of abnormalities not destined to become cancerous. Adopted management strategies provide what participants considered an acceptable level of risk of failing to detect high-grade neoplasia or cancer in a given clinical situation.

I’m not even going to try to spell out everything in the guidelines, which come from the American Society of Colposcopy and Cervical Pathology (ASCCP), except to say that they represent further movement away from aggressive screening and treatment of pap smear abnormalities, especially in younger women, in whom treatment carries small but real childbearing risks. The guidelines are increasingly reliant upon HPV testing to determine who and how often to screen, and when to treat.  They also acknowledge the role of testing for HPV 16 and 18 as a way to be sure that those women with adenocarcinoma of the cervix (which is less likely to show up as cancer on a pap smear) are identified and treated. From the guidelines –

What should you expect?

• Less pap smears, for sure. Women should start screening at 21 and have paps every 3 years until age 65 (assuming, of course, that her paps remain normal).  There is no place for HPV as routine screening in women under age 30, as most of these women will acquire HPV one or more times by that age, with little consequence.  HPV testing is used in this age group to manage abnormal paps and to follow those with prior pap abnormalities, but that’s it.  Women age 30 and over have the option of pap with HPV co-testing – if both are normal/negative, she may go up to 5 years before her next pap.
• Little treatment of CIN1. CIN 1 represents HPV infection but is not a true pre-cancer and usually will resolve within two years. (If it does not resolve by then, treatment is an option.)
• Less use of colposcopy in younger women with mildly abnormal paps, even if HPV testing is positive. In women ages 21-24, one may repeat the pap with HPV testing at 12 months rather than go to immediate colposcopy for mild pap smear abnormalities (ASCUS and LGSIL).
• Continued decline in treatment for CIN2. Most CIN2 will resolve without treatment. (I’ve been backing off on cin2 treatment for some time now in younger women and indeed most lesions resolve.)
• The option to observe CIN3. I don’t know how often any of us are going to use that option, though I admit to having already taken it occasionally in younger women with focal CIN3 lesions that were removed at colposcopy.
• Increased interval pap followup in women who have had colposcopy or treatment for CIN2-3.
• Increasing use of HPV 16/18 testing to identify those women with mild pap abnormalities who may need immediate colposcopy.

Confused? There’s an App for that! 

In a very smart move, ASCCP has launched an app for providers wondering just what to do with those abnormal pap results. It’s called ASCCP Mobile, it costs $9.99 and it’s really cool.  Let me show you how it works-

Let’s say you have a 27 yo, non-pregnant patient with an LSIL Pap and HPV+. Just enter the info, click next  and, as Emeril would say – Bam! You’ve got the appropriate algorithm for her right there on your screen!

 Click next steps, and enter her colpo result, which let’s say was CIN3 and Bam!  You are advised to treat her, and to perform 12 month pap/HPV co-testing for follow up.

Of course, you could have pulled out the guidelines and found the right algorithm there, but this is a lot more fun.

ASCCP Mobile is not so much a recipe for patient management as it is a navigator through a complex algorithm that requires a lot more than just tapping a screen to understand and execute. I encourage you to read the actual guidelines article (links below), which provides the background and summarizes the evidence supporting each of the recommendations.

And lest you think we’ve just distilled gynecology into an app, remember that not every patient fits an algorithm. Not all patient populations are suited to follow-up, particularly those who may have spotty or intermittent care. Fortunately, most of the algorithms provide options for management that will allow almost any woman and her provider to come to a management decision that’s right for her.

________________________________________________________________________

• ASCCP Guidelines for Management of Abnormal Cervical Cancer Screening Tests and Cancer Precursors (PDF) (May 2013) (Note – fig 15 in the pdf has an error, so use the Algorithm link below for the corrected version)
• ASCCP Consensus Guideline Algorithms (May 2013)
• USPSTF Guidelines on Pap screening (March 2012)