Clinical Practice Guideline Watch
Cervical Cancer Screening in Adolescents: Sometimes Less Is More
Updated guidelines state that HPV DNA testing has no role in the management of adolescents with abnormal Pap smears.
Elucidation of the link between cervical cancer and infection with high-risk types of human papillomavirus (HPV) has led to increased use of HPV DNA testing in the management of women with abnormal Pap smears. However, 80% of female adolescents become HPV DNA positive soon after their first sexual encounters, with the vast majority of these infections clearing spontaneously within 2 years. Hence, HPV DNA testing in adolescents with abnormal cervical cytology would lead to the referral of many adolescents for colposcopy even though they are at low risk for cervical cancer.
In 2006, the American Society for Colposcopy and Cervical Pathology (ASCCP) convened a consensus conference to update its evidence-based guidelines for managing women with abnormal cervical cancer screening tests. Based on current data on the ubiquity and natural history of HPV infection in teenagers and results from the National Cancer Institute–sponsored Atypical Squamous Cells of Undetermined Significance (ASC-US) Low-Grade Squamous Intraepithelial Lesion (LSIL) Triage Study (ALTS), the consensus conference recommended that HPV DNA testing should not be used to manage adolescents with abnormal Pap smears.
New recommendations for adolescents (age, 20) are as follows:
- Adolescents with ASC-US should undergo repeat Pap smears every 12 months. At 12 months, only adolescents with high-grade squamous intraepithelial lesion (HSIL) or greater should be referred for colposcopy. At 24 months, only those with ASC-US or greater should be referred for colposcopy.
- Adolescents with LSIL should undergo repeat Pap smears every 12 months. At 12 months, only those with HSIL need to be referred for colposcopy. At 24 months, only those with ASC-US or greater should be referred.
- In adolescents with either ASC-US or LSIL, “HPV DNA testing is unacceptable . . . and if inadvertently performed, should not influence management.”
Comment: Implementation of these recommendations will save money (the cost of an HPV DNA test can exceed US$100). In addition, teenagers will no longer need to worry about carrying a “high-risk” (cancer-causing) strain of HPV. Copies of the guidelines complete with algorithms can be downloaded from the American Society for Colposcopy and Cervical Pathology website.
When it comes to managing adolescents with abnormal Pap smears, doing less is better than doing more.
— Alain Joffe, MD, MPH, FAAP
Published in Journal Watch Pediatrics and Adolescent Medicine December 12, 2007
Wright TC Jr et al. 2006 consensus guidelines for the management of women with abnormal cervical cancer screening tests. Am J Obstet Gynecol 2007 Oct; 197:346.
Medline abstract (Free)
2006 consensus guidelines for the management of women with abnormal cervical cancer screening tests.
Department of Pathology, College of Physicians and Surgeons of Columbia University, New York, NY 10032, USA. firstname.lastname@example.org
A group of 146 experts representing 29 organizations and professional societies met September 18-19, 2006, in Bethesda, MD, to develop revised evidence-based, consensus guidelines for managing women with abnormal cervical cancer screening tests. Recommendations for managing atypical squamous cells of undetermined significance and low-grade squamous intraepithelial lesion (LSIL) are essentially unchanged. Changes were made for managing these conditions in adolescents for whom cytological follow-up for 2 years was approved. Recommendations for managing high-grade squamous intraepithelial lesion (HSIL) and atypical glandular cells (AGC) also underwent only minor modifications. More emphasis is placed on immediate screen-and-treat approaches for HSIL. Human papillomavirus (HPV) testing is incorporated into the management of AGC after their initial evaluation with colposcopy and endometrial sampling. The 2004 Interim Guidance for HPV testing as an adjunct to cervical cytology for screening in women 30 years of age and older was formally adopted with only very minor modifications.
PMID: 17904957 [PubMed – indexed for MEDLINE]