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Testing / Treatment Guidelines and Recommendations

PAP SCREENING RECOMMENDATIONS AND GUIDELINES   Gyn2.JPG

The American College of Obstetrician and Gynecologists (ACOG) has affirmed new screening guidelines for the early detection of cervical cancer as published by the American Cancer Society (ACS), American Society for Colposcopy and Cervical Pathology (ASCCP), and the American Society for Clinical Pathology (ASCP).  (Am J Clin Pathol 2012; 137:516-542).

The guidelines as stated in the article are summarized below:
For additional recommendations or to print the guidelines below click on the link below:

Summary of Recommendations

To read the entire journal article click on the link below:

New Screening Guidelines

Summary of New Guidelines:

Patients aged < 21 years: No screening recommended

Patients aged 21-29: Cytology alone is recommended every 3 years.  HPV testing should NOT used for screening in this age group, but is recommended as a reflex for ASC-US (not LSIL).  For HPV-positive ASC-US or LSIL cytology or more severe: Refer to ASCCP guidelines**.  For cytology negative or HPV-negative ASC-US: Rescreen in 3 years. 

**The 2006 ASCCP Guidelines on Management of Abnormal Screening Tests and CIN/AIS have been updated and will be jointly published in April in ACOG's Obstetrics and Gynecology and ASCCP's Journal of Lower Genital Tract Disease.  At that same time, ASCCP will begin offering revised algorithm booklets and an app of the guidelines for iPhone, iPad and Android devices.

Patients aged 30-65: There are two recommended strategies.
1.  HPV and cytology "co-testing" every 5 years (preferred)
2.  Cytology alone every 3 years

Follow-up:  HPV positive, cytology negative
There are two follow-up options:
1.  Repeat co-testing in 12 months:
     If the follow-up co-test is positive, women should be referred to colposcopy
     If the follow-up co-test is negative, women should be screened again with co-testing in 5 years
2.   Immediate, HPV genotype-specific testing for HPV16 or HPV16/18.
      Women testing positive for either HPV16 or HPV18 should be referred directly to colposcopy
      Women testing HPV16 or HPV16/18 negative should be co-tested in 12 months
                    If the follow-up co-test is positive, women should be referred to colposcopy
                    If the follow-up co-test is negative, women should be screened again with co-testing in
                    5 years
Women testing HPV positive, cytology negative should NOT be referred directly to colposcopy and NOT be tested for individual HPV genotypes other than HPV16 and HPV18 or for non-HPV biomarkers.

Follow-up: HPV negative, ASC-US cytology:
Continue to be screened with co-testing in 5 years or with cytology alone in 3 years

Women over 65 years of age:
 women over 65 years of age with evidence of adequate negative prior screening* and no history of CIN2 or more severe diagnosis or cervical cancer within the last 20 years should not be screened for cervical cancer with any modality.  Once screening is discontinued it should not resume even if a woman reports having a new sexual partner.

*Adequate negative prior screening is defined as 3 consecutive negative cytology results or 2 consecutive negative cotests within the last 10 years before ceasing screening, with the most recent test performed within the past 5 years.

Women with a history of CIN2 or a more severe diagnosis:
Following spontaneous regression or appropriate managment of CIN2 or a more severe diagnosis, routine screening should continue for at least 20 years (even if this extends screening past age 65).

Women post-hysterectomy for benign reasons:
Women at any age following a hysterectomy with removal of the cervix for benign reasons (i.e. no history of CIN2 or more severe diagnosis or cervical cancer) should not be screened for vaginal cancer using any modality.  Evidence of adequate negative prior screening is not required.  Once screening is discontinued it should not resume even if a woman reports having a new sexual partner.

Women with a history of HPV vaccination:
Women at any age with a history of HPV vaccination should be screened according to the age-specific recommendations for the general population.

UPDATED ASCCP MANAGEMENT GUIDELINES FOR WOMEN WITH ABNORMAL
CERVICAL CANCER SCREENING TESTS

In addition to the new screening guidelines, the ASCCP has new updated consensus management guidelines for women with abnormal Pap tests.  To obtain the algorithms for managing these patients please contact Physicians Laboratory.  

ENDOCERVICAL BRUSHINGS

Occasionally Physicians Laboratory receives requests to process and report gynecologic cytology specimens from endocervical brushings.  There are two fairly recent articels in the CAP Today magazine which address this type of sample (see May 2010 and July 2010 issues under the Q and A section).

Cytology specimens submitted as "endocervical brushings" are gynecologic cytology specimens but are not Pap tests.  They may either be smeared on a slide or submitted in a ThinPrep vial.  An advantage to submitting them in liquid-based form is that a cell block can sometimes be obtained.  They are screened by a cytotech and reviewed and signed out by a pathologist.  If the sample is a direct smear the billing CPT code is most likely 88104, if prepared from a liquid-based sample from a liquid-based sample it would be an 88112.
Reporting is up to individual laboratories.  At Physicians Laboratory we use a modified Bethesda Systlm which would attempt to describe and grade any epithelial abnormality.  Comments about specimen adequcy as regards the Bethesda System do not apply to these specimens as they are not Pap tests.  As always, good communication between clincian and pathologist with adequate patient history is important for the optimal patient care and management.