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P RACTICE BULLET IN
clinical management guidelines for obstetrician – gynecologists
Number 168, October 2016 (Replaces Practice Bulletin Number 157, January 2016)
INTERIM UPDATE: This Practice Bulletin is updated to reflect limited, focused changes in the recommendations for
cervical cancer screening in adolescents and young women who are infected with human immunodeficiency virus or
who are otherwise immunocompromised.
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prevalence of high-risk HPV infections and the low inci- a statistically significant reduction of CIN 3 or cancer
dence of cervical cancer in sexually active women in this detection in the second round of screening, and a second
age group (6, 86). Use of cotesting in women younger study demonstrated a statistically significant reduction
than 30 years largely would detect transient HPV infec- from 0.03% to 0% in the second phase of screening (90,
tion without carcinogenic potential. In women younger 91). The difference in the rate of cancer detection was
than 30 years, the increased sensitivity and decreased not reported in the third trial (92).
specificity of cotesting would result in more testing than Cytology alone has been much less effective for
would cytology screening alone, without an appreciable the detection of adenocarcinoma of the cervix than
decrease in cancer incidence (87). for the detection of squamous cancer (93). Cotesting has
Women aged 30 years and older with a negative the additional advantage of better detection of adenocar-
cervical cytology screening result and a negative high- cinoma of the cervix and its precursors than cytology
risk HPV test result have been shown to be at extremely screening alone (94, 95).
low risk of developing CIN 2 or CIN 3 during the next It is important to educate patients about the nature of
4–6 years (88). This risk was much lower than the risk cervical cancer screening, its limitations, and the ratio-
for women who had only a negative cytology test result nale for prolonging the screening interval. Regardless
(85). In the Kaiser Permanente Northern California of the frequency of cervical cancer screening, patients
cohort, the 5-year risk of CIN 3+ was 0.26 in women should be counseled that annual well-woman visits are
with negative cytology alone and 0.08 in women with a recommended even if cervical cancer screening is not
negative cotest result (89). performed at each visit (96).
Three randomized trials have compared cotest-
ing with cytology screening alone in women aged What is the optimal frequency of cervical
30–65 years (90–92). Each of the trials had a com- cytology screening for women aged
plex protocol and differed in the way that women with 21–29 years?
HPV-positive test results were evaluated. In each trial,
cotesting detected an increased proportion of high-grade Few studies have been performed that specifically
dysplasia in the first round of screening and a low rate of address the interval for screening women aged 21–29
cancer with subsequent testing with cytology screening years. A modeling study that examined outcomes for
alone in the second round. The first trial demonstrated women aged 20 years and screened over a 10-year
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Figure 1. Management of women 30 years and older, who are cytology negative, but HPV positive. Abbreviations: ASC, atypical squa-
mous cells; ASCCP, American Society for Colposcopy and Cervical Pathology; HPV, human papillomavirus. (Reprinted from Massad LS,
Einstein MH, Huh WK, Katki HA, Kinney WK, Schiffman M, et al, for the 2012 ASCCP Consensus Guidelines Conference. 2012 Updated
Consensus Guidelines for the Management of Abnormal Cervical Cancer Screening Tests and Cancer Precursors. J Low Genit Tract Dis
2013;17:S1–S27.) ^
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