ALERT

Abstract

UPDATE: MANAGEMENT OF ABNORMAL CERVICAL CYTOLOGY Invasive cervical cancer is a preventable disease in large majority of women, as long as preinvasive cervical lesions are effectively detected and treated. The Family PACT Program has adopted the 2006 Consensus Guidelines of the American Society for Colposcopy and Cervical Pathology (ASCCP), which are included with this Alert. KEY POINTS • The purpose of cervical cancer screening is the detection and treatment of high-grade squamous epithelial lesions (CIN 2, 3), adenocarcinoma precursors, and cervical cancers. • Women with biopsy proven CIN 1 should be observed carefully and treated only if the lesion progresses to CIN 2, 3, is persistent for two years or more, or if the woman insists upon early treatment. • An office-based tracking system should be used to ensure that women with abnormal cytology findings have been notified of their results and that those who are being followed are reminded of the need for return visits, tests, and procedures. • The tables included in this Alert summarize the 2006 ASCCP Guidelines, but more comprehensive versions are listed as references. Since not all recommended interventions are Program benefits, please refer to the Family PACT Policies, Procedures and Billing Instructions (PPBI) for more information. QUESTIONS AND ANSWERS What is the role of HPV-DNA testing in women under 21 years old? The new guidelines emphasize that there is no role for HPV-DNA testing in women under 21 years old, since incident HPV infections are common and a positive test result would have no impact on client management. HPV infections in young women are likely to be transient and most will resolve quickly. What is the preferred approach to managing ASC-US? Adolescents with results of ASC-US or LSIL should have repeat cytology in one year, but not HPV testing or colposcopy. Consequently, in women under 21 years old, “reflex HPV tests for ASC-US” must not be ordered when submitting the Pap request to the laboratory. Women 21 years of age and older can be managed by either repeat cytology in six months, reflex HPV-DNA testing, or colposcopy. Why aren’t all women with CIN 1 treated with cryotherapy or LEEP? Of women with CIN 1 lesions, fewer than 20 percent will develop a high grade lesion, with even lower progression rates in adolescents. For women 21 years and older, observation is recommended, with treatment only if the CIN 1 lesion progresses or persists for at least two years. Should all women with CIN 2 or 3 be treated? In general, the treatment for CIN 2 or 3 is cryotherapy or a LEEP procedure. However, the preferred treatment for adolescent and young women with CIN 2 and satisfactory colposcopy is observation, which consists of colposcopy plus cytology every six months for up to 24 months. If the colposcopic pattern worsens or a high grade lesion persists for more than 24 months from diagnosis, treatment is necessary. What are the indications for colposcopy? • Cytology result with ASC-H, HSIL, or suspicion of cancer • Cytology with LSIL in a women >21 years old (unless pregnant or post-menopausal) • Cytology with atypical glandular cells (AGC), unless AGC-atypical endometrial cells and positive endometrial sampling • Cytology showing ASC-US in the following circumstances: • Women who are unwilling to return for frequent follow-up • Repeat cytology test with ASC-US or worse performed during observation period (except adolescents) • High-risk HPV-DNA present at initial or subsequent testing (except adolescents) • Cervical leukoplakia (visible white lesion) or other unexplained cervical lesion regardless of cytology result • Unexplained or persistent cervical bleeding regardless of cytology result Why doesn’t Family PACT pay for LEEP cone or “cold knife” cone biopsies? Family PACT is a limited benefit family planning and sexually transmitted infection (STI) program. When a woman requires a medically necessary service and does not have other coverage, the California Breast and Cervical Cancer Treatment Program (BCCTP) may provide support. Family PACT providers can easily certify and enroll clients in the BCCTP via an internet application. PROGRAM POLICY