2019 ASCCP Risk-Based Management Consensus ...

2019ASCCPRisk-BasedManagementConsensusGuidelinesforAbnormalCervicalCancerScreeningTestsand

CancerPrecursors

BarbaraS.ApgarMD,MS

ProfessorEmeritaofFamilyMedicineMichiganMedicine

UniversityofMichiganAnnArbor,Michigan

Disclosures

• ASCCPCasesoftheMonthCommitteeChair(current)• ASCCPBoardofDirectors,GuidelinesCommittees,DirectorofComprehensiveColposcopyCourses(former)

• NofinancialcompensationfromASCCPapp

•  Images:ApgarB,BrotzmanG,SpitzerM.IntegratedTextandAtlas,2004,2008.ElsevierPublishing.

•  Slides:CompilationofASCCPslides/algorithmsandpersonalcollection• AllslidedataarefromPetersRetalunlessotherwisespecified

Objec&ves

• Understandthedifferencesbetweenthe2012and2019ASCCPguidelines

• Reviewthescien=ficevidenceusedtoconstructthe2019guidelines.

• Summarizetheprinciplesofthe2019guidelines.• UnderstandhowtointerprettheresultsontheASCCPapp.

Equalmanagementforequalrisk

Managementisbasedonrisk,notresults

Na=onalCancerIns=tuteandASCCPcollaboratedonaformalconsensusguidelineprocessin2001,2006,2012andnowin2019.TheroleofNCIepidemiologistsandsta=s=cianswhospecializeincervicalscreeningistoprovideepidemiologicevidenceregardingtestperformancebasedonNCIandotherresearch.TheroleofASCCPistoconveneandconductconsensusconferencesbringingtogetherorganiza=onsand“stakeholders”tocreatetheguidelines.Goalwastoproduceconsensusrecommenda=onsbasedonrisk,toachievealongshelf-lifeforthe2019versionbeforeanotherconsensusconferenceisneededdespitenewcompe=ngtestsandstrategies.18–monthcollabora=veeffortfor2019guidelines.

NCI sta&s&cians had input from many sources

• Therisk-basedapproachprovedadequateformostclinicalscenariosexceptforwomeninspecialpopula=onsandtopicsbesthandledbyconven=onalmanagementalgorithms,guidedbyexpertopinion.

• Risk-basedapproachwastranslatedinto“management”throughuseofclinicalac'onthresholdsthatweredeterminedbytheconsensusgrouprepresen=ngthe19organiza=ons.

• Determinedtrade-offsinbenefitsandharms.

The new risk-based management

consensus guidelines use RISK and CLINICAL ACTION THRESHOLDS to determine the appropriate

course of management of cervical cancer screening abnormali&es.

NCIHPVepidemiologistsandsta=s=cianses=matedtherisksofCIN3+byHPVtests,cytology,pastscreeningtestsand

colposcopicbiopsyresults.

Tables of risk es&mates were generated from a prospec&ve longitudinal cohort of > 1.5 million pa&ents followed for over a

decade at Kaiser Permanente Northern California (KPNC)

Allowedobserva=onofdetaileddataandfollow-upofCIN2andCIN3,AISandcancer.

RISKTABLE:Follow-upofHPV-nega=veASC-US

EnegenDetal.Riskes=matessuppor=ngthe2019ASCCPrisk–basedmanagementconsensusguidelines.JLowGenitTractDis2020;24:132.

Adherence to cervical cancer guidelines

•  Significantdifferencebetweenclinician’sdecisionsandactualguidelinestheybelievedtheywerefollowing.

• Confusionandoverloadmaycontributetononadherencebyclinicians.•  Skepticismofutilityofguidelines.

• Mayreverttooverscreeningto“playitsafe”.• Maybelievethatguidelinesareriskyandinappropriate.• Needtoexplainguidelinestoskepticalpatientsevenifbelieveguidelinesareauthoritative

• Maybelievebenefitsandharmsarenotbalanced.

Correctlyaddressing<50%ofscreening-relatedques=onssignificantlymorelikelyamong:-  MDs>40years,prac=cing>20years-  workingsuburbanprivateprac=ce-  performing<20cervicalcytologytests/mo.PrimaryHPVtes=ngunderu=lizedandoverscreeningwithcytologyrampant.Consistentlyoverscreened<age21years,>age65(averageriskandadequatescreening)Cotes=ngtoosooninaverageriskpa=ent.

Adherencetocervicalcancerguidelines

• Translatingevidence-basedinterventionsintoclinicalpracticeisincrediblycomplexandchallenging(84%ofcliniciansthoughtguidelinesunclear).

• Howtoimprove:

• Capitalizeuseoftechtoolstoincreaseadherence.• Decreasealgorithmuse(risk,notresults).

Whywererevisionstothe2012guidelinesneeded?

• Revisionmotivatedbythecomplexityofthe2012guidelinesasnewtestsbecameavailable.

• Toomany“acceptable”choicestocontinueasbefore.• MANYmorealgorithmswouldberequiredfornewtestslikeextendedgenotypingandinfluenceofpast-historyoncurrentresults.


• SufficientdatabecameavailableintheUSshowingthatincorporationoftherisk-basedapproachcouldprovidemoreappropriateandpersonalizedmanagementforthepatient.

• Basedoncurrentresultsandpasthistory.

• Newrecommendationsforcervicalcancerscreeningintroducedsince2012.

• PrimaryHPVtestingasascreeningoptionforpatients25yearsandolder.


• 2012guidelinespresentedaconceptualbreakthroughinrisk-basedmanagement.

• Retainedacontinuedrelianceoncomplicatedalgorithmswithoutincorporatingpastscreeninghistory.

• 2019guidelinesreflectamorenuancedunderstandingofhowpriorresultsaffectrisk.

• MorevariablesavailableincludingthenaturalprogressionofHPV.

Comparison of 2012 and 2019 guidelines

•  Changefromtestresults-basedalgorithms(2012)• “ColposcopyisrecommendedforpatientswithHPV-positiveASC-US,LSIL”.

• Changetorisk-basedguidelines(2019)

• “Colposcopyisrecommendedforanycombinationofhistoryandcurrenttestresultsyieldinga4.0%orgreaterprobabilityoffindingCIN3+.”

2019guidelinesemphasizereductionofinvasiveprocedureswhilemaintaininghighstandardsofcancerprevention

• Colposcopicbiopsyconfirminglow-gradeornormalhistologyreducestheestimatedriskofhavingprecancer/cancerinthenext3years.

• AllowspatientswithHPV+ASC-USorLSILattheir1-yearfollow-upvisitaftercolposcopicbiopsyshowingnormalorlow-gradehistologytoreturnforrepeatHPV-basedtestingin1moreyear,ratherthanimmediatelyreturntocolposcopy.

TREATwomenwithhighrisk

ofdevelopinginvasivedisease

OBSERVEwomenwhoarenotathighriskofdevelopinginvasive

diseaseand

protectthemfromover-treatment

2012PrinciplesCarriedForward

• Timelydetectionandtreatmentofthehighestgradeofprecancers(CIN3/AIS)arethebenchmarkusedforallguidelines.

• Guidelinesapplytoallindividualswithacervix.

• Includestransgendermenwithacervix,includingthosewhohaveundergonesupracervicalhysterectomy.

2012PrinciplesCarriedForward

Guidelinesapplytoasymptomaticpatientswhorequiremanagementofabnormalcervicalscreeningtestresults.

• Abnormaluterineorvaginalbleedingoravisiblyabnormal-appearingcervixrequireappropriatediagnostictestingtoR/Ocancer.

• Balancingbenefitsandrisks.• Guidelinesmaximizecervicalcancerpreventionandminimizeharmsfromovertreatmentandovertesting.

Changesfrom2012GuidelinesPatientswithminorabnormalities

• Colposcopycanbedeferredforcertainpatients.

• PatientswithLSILorASC-UScytologycandefercolposcopyifresultswereprecededby:

•  negativescreeningwithHPV-basedtestingwithinthepast5years

•  colposcopywhereprecancerwasnotfoundinthepastyear.• Pasthistoryisimportant!

• Newdataindicatethatfollow-upinoneyearissafe.

Changes from 2012 Guidelines Treatment

• ExcisionaltreatmentispreferredtoablativetreatmentforhistologicHSIL(CIN2or3)intheUS.• Excisionisalsorecommendedforadenocarcinomainsitu(AIS)

• ObservationispreferredforLSIL(CIN1)

ManagementofwomenwithBiopsy-confirmedHistologicHSIL(CIN2and3)

2012EitherExcisionorAblationofT-zone

Isacceptable

2019DiagnosticExcisionalProcedureisPreferredAblationisacceptable

Changes from 2012 Guidelines Treatment guidelines divided into pa&ents

younger than age 25 years or 25 years or older

•  2012guidelinesconsideredpatientsages21-24tobeaspecialpopulation.Term“youngwomen”isnolongerused(2019).

•  2019guidelinesrecognizethatpatientsofvariousagesareconcernedaboutthepotentialimpactoftreatmentonfuturepregnancyoutcomes.

• Appwillaskyouifpatientisconcernedaboutfuturepregnancy.

•  Shareddecision-makingiscriticalwhenpatientsconsidertreatmentofhistologicHSIL(CIN2)andabnormalitieswithalowlikelihoodofunderlyingCIN3+suchashistologicLSIL(CIN1).

3years

2019Guidelines:Patientsolderthan65years

• Approximately20%ofcervicalcancersoccurinpatients>65yrs.

• Samemanagementaspatientsaged25to65yearsifscreeningisperformedandabnormalitiesfound.

• Dataonprognosticvalueofspecificscreeningresultsislimitedinolderpatients.

Ifpatientisundergoingsurveillanceforabnormalresultsortreatmentforprecancer,stoppingsurveillanceisunacceptableifpatientishealthybut

acceptableiflimitedlifeexpectancy.

2019Specialpopulations:Immunocompromised• HIV***

• Cervicalcancerscreeningguidelinessupportedbypublications.• Literatureislimitedforconditionsthatsuppresscell-mediatedimmunitybutwhichhavebeenassociatedwithvirallyinducedcancers,includingcervicalcancer.

• Solidorganorstemcelltransplant***• Systemiclupuserythematous•  Inflammatoryboweldisease• Rheumatologicdiseaserequiringimmunosuppressivetx

• Lackofdata(KPNC)precludesriskestimationforimmunosuppressed.

RiskofCIN3+amongHIV+women

• HIV+womenhavehigherriskofCIN3+withlow-gradecytologicabnormalities.

• SexuallyactiveHIV+patientswithHPVhaveahighrateofprogressiontoprecancer.

• HighprevalenceofHPVbeforeage30years.• HigherratesofacquiringHPVandlowerratesofclearingit,thanHIV-negativewomen.

• HIV+womenare2.5timesmorelikelytohaveanHPVinfectionprogresstoHSILthanHIV-negativepatients.

LiuG,etal.HIV-posi=vewomenhavehigherriskofhumanpapillomavirusinfec=on,precancerouslesions,andcervicalcancer.AIDS.2018;32(6)HilaryKetal.CancerEpidemiolBiomarkersPreven=on2017;26(6):886.

ImmunocompromisedwomenwithoutHIV

• UsethesamecervicalcancerscreeningandabnormalresultmanagementguidelinesdevelopedforwomenwithHIV.

• Screeningshouldbeginwithin1yearoffirstinsertionalsexualactivityandcontinuethroughoutpatient’slifetime.

• Annuallyfor3years.• Every3years(cytologyonly)untilageof30years• Continuingwithcytologyaloneorcotestingevery3yearsatage30.

2019guidelinesforimmunocompromisedpatientsofanyage

• ColposcopyreferralrecommendedforallwomenwithcytologyresultsofHPV+ASC-US.

• ForallcytologyresultsofLSILorworse,refertocolposcopyregardlessofHPVtestsifdone.

2012 and 2019 Guidelines: Pregnancy

• Pregnancywasconsideredaspecialpopulationwheremanagementoptionsweighedrisktomotherandfetusversusriskofmissingcancer(2012guidelines).

• Rateorriskofprogressiontocervicalcancerisnotdifferentinpregnancy.

• 2019guidelinesdonotlistpregnancyasaspecialpopulation.• Datainpregnancyarelimited.

• Norandomized-controlledtrials.

2019 Guidelines: Pregnancy

• ManagementofabnormalscreeningresultsusesameClinicalActionThresholdsforsurveillanceandcolposcopy/treatmentestablishedfornon-pregnantwomen.

• EMB,ECCandtreatmentwithoutbiopsyareunacceptable.Ectocervicalbiopsiesappeartobesafe.

• Colposcopyperformedbyanexperiencedclinicianpreferred.• Colposcopyexperienceisknowntoaffecttheabilitytodistinguishcancersfrompregnancy-relatedchanges.

Extensivesquamousmetaplasiainpregnancy

canresembleCINorcancer

Apgar,Brotzman,Spitzer

2019 Guidelines: Pregnancy •  2019guidelinesallowdeferralofcolposcopyforminorabnormalitiesinwomenwithpriornegativeHPVtestingorcolposcopy.

•  IfHSIL(CIN2or3)isdiagnosedatthefirstcolposcopy,surveillance(colposcopyandcytology/HPVdependingonage)ispreferredevery12-24weeks.

• Repeatbiopsyisrecommendedifinvasionissuspectedortheappearanceofthelesionworsens.

• Deferringcolposcopytothepostpartumperiodisacceptable.•  Notearlierthan4weeksafterdelivery.

DiagnosticexcisionfordiagnosisortreatmentofHSIL(CIN2,3)shouldbedeferreduntilafterdeliveryunlessinvasivediseaseisdetectedorissuspected.

Excludeinvasionbycolposcopyandbiopsy.

Strongsuspicionofinvasionrequiresadiagnostic

excisiontoexcludeinvasionanddeterminedepthofinvasion.

2019GuidingPrinciple#1

•  ThelongeranHPVinfectionhasbeenpresent,the

highertheriskofpre-cancerandcancer.

•  Timematters.•  Typematters(HPV16mostdangerous).

RiskisgreatlyreducedifpriorscreeningroundwasHPV-negative.

WhatisHPV-basedtesting?PrimaryHPVtestingorcotesting

• MostHPVDNAassaysapprovedforadjuncttestingwithcytology.

•  subsetofassaysapprovedforHPVtestingalone,withoutcytology.

• UseofprimaryHPVscreeningwilllikelyincreaseinthefuture.

• Notalllabsequippedforitnow.• HPV16/18+testshavehighestriskofCIN3andoccultcancers.

• Additionaldiagnosticproceduresrecommendedforall+tests.

PrimaryHPVscreening

FDA-approvedforpatients25yearsandolder

Primary HPV tes&ng and reflex tes&ng

• ReflexcytologyrecommendedforallHPV+primaryscreeningresults,regardlessofHPVgenotype.

•  Ifreflextes=ngnotfeasible,pa=entsshouldgodirectlytocolpo.• Collectcytologyatcolposcopytoprovidefurtherinfoforrisk-basedmanagement.

• Combiningahighspecificitytest(HSILcytology)withahighsensi=vitytest(HPVtest)allowsmoreprecise,risk-basedmanagement.

• Expeditedtreatmentonlypossibleifcytologyisperformed.

2019 guidelines prefer HPV tes&ng for follow- up

• SurveillancewithcytologyaloneisacceptableonlyifHPV-basedtes=ngisnotavailable.

• Cytologyislesssensi=vethanHPVtes=ngfordetec=onofprecancerandhastobeperformedmoreolen.

• Cytologyisrecommendedat6-monthintervalswhenHPV-basedtes=ngisrecommendedannually.

• Cytologyisrecommendedannuallywhen3-yearintervalsarerecommendedforHPV-basedtes=ng.

SurveillancewithHPV-basedtestingafterTreatmentCIN2or3

• Con=nueHPV-basedtes=ngat3-yearintervalsforatleast25years.• Con=nuedsurveillanceat3-yearintervalsbeyond25yearsisacceptableifpa=ent’slifeexpectancyandabilitytobescreenedarenotcompromised.

• 2012guidelinesrecommendedreturnto5-yearintervalsanddidnotspecifywhenscreeningshouldstop.

• Newevidenceindicatesthatriskremainselevatedforatleast25years

•  Noevidencethattreatedpa=entseverreturntorisklevelscompa=blewith5-yearintervals.

2019guidelinesalignmanagementrecommendationswithcurrentunderstandingofHPVnaturalhistory

• CurrentHPVtestresults(themostimportantpredictionfactorofCIN3+)arenecessaryformanagement.

◆ IfoncogenicHPVispersistent,theriskofcervicalcancerisincreasedsubstantially.◆ Longerpersistence=greaterrisk.

FindingcarcinogenicHPVtypesdoesnot

provideadiagnosisofCIN3orcancer

ItidentifiesagroupofwomeninwhomCIN3+ismorelikely

WomentestingnegativeforoncogenicHPVhaveextremelylowriskofdevelopingcervicalcancer

over5years(KPNC)

ProgressiontoCervicalCancer

HSIL,HPVtype16,persistentfor10years

Apgar, Brotzman, Spitzer

◆ Natural history of HSIL (CIN 3) implies that it can

progress to cancerCervical HPV persistence is the known necessary event for the

development of cervical cancer HPVinfectionHSIL(CIN3) Cancer

Apgar, Brotzman, Spitzer

ΗΠς ανδ περσιστενχε: µετα-αναλψσισ• AssociationsbetweenHPVpersistenceandCIN2+werestrongerwhenpersistence>12months.

• HPVpersistencestronglyandpositivelyassociatedwithallgradesofCIN.

• AssociationsstrongerforCIN2/3+thanCIN1.• Emphasizedimportanceofpersistenceasaclinicalmarker.

• Long-termHPVpositivityclearlyassociatedwithneoplastictransformation.

KoshiolJetal.AmJEpidemiol2008;168:123-137.

2019GuidingPrinciple#2Personalizedrisk-basedmanagementispossible

• Recommendationsof1,3,5yearsurveillance,colposcopyortreatmentcorrespondtoarangeofriskforCIN3+calleda“ariskstratum”.• determinedbycurrentresultsandpasthistory.

• Thelowerthresholdofeachriskstratum,calledtheClinicalActionThreshold,definesthelevelatwhichthemanagementchangestoanotherlevel.

2019Guidelinesbasedonapatient’sriskofCIN3+ratherthanaspecificcombinationoftestresults

• Estimatingriskallowsmorepersonalizedrecommendationsandstreamlinedincorporationofnewscreeninganddiagnostictechnologiesintoclinicalpractice.

• Managementofabnormaltestresultsshiftsfromalgorithmstoelectronicdecisionaids(ASCCPapp).

Howtherisk-basedmethodwillworkfortheclinician5differentclinicalscenarios

Newabnormalscreeningresult(itallstartshere!)

Managementofafollow-uptestresultata1,or3or5-yearsurveillancereturnvisit

Interpretationofacolposcopicbiopsydiagnosis

Follow-upofpostcolposcopysurveillanceofpatientsnotinitiallyfoundtoneedtreatment(e.g.,abiopsyof<CIN2)

Posttreatmentfollow-up

Clinical Ac&on Thresholds • Clinicalac=onsaleranabnormalscreeningresultareiden=fied

Expeditedtreatmentwithoutbiopsyispreferred.Treatmentorcolposcopicbiopsiesacceptable.Colposcopicbiopsiesarerecommended.Colposcopynotneededbutsurveillanceatshortenedintervalsisrecommended.

1and3yearsmaintainedasthe2levelsofconcerntoreducetherisksof“intervalcancers”occurringbeforethenexttes=ngvisit.

Con=nuescreeningatthe5-yearinterval.

Pa&ent will likely aYend >1 management visit aZer ini&al abnormal screening results

• Mostvisitswillinvolvecommon,benignandminorcytologicabnormali5es.

1.Thecommonini=alvisitsthataremainlyminorabnormali=esarehandledbyuseofrisktablesandclinicalac=onthresholds.

• Postcolposcopymanagementdecisionsareabout½asfrequentasini=almanagementvisits.

2.Treatmentandposoreatmentvisitsareuncommon(1/10thasfrequentasini=almanagementvisits)butareimportantforpreven=ngcancer.

Managementafteranabnormalscreeningresult

• Recommendationsforcolposcopy,treatmentorsurveillancewillbebasedonthepatient’sriskofCIN3+asdeterminedby:

•  Currentresults•  Pasthistory(includingunknownhistory)

• CurrentHPVtestresults(themostimportantpredictionfactorforCIN3+)arenecessaryformanagement.

• Thesamecurrenttestresultsmayyielddifferentmanagementrecommendationsdependingonthepasttestresults.

2019Guidelines:CurrentResultsandHistory

• 2centralquestionsunderlieriskestimates.

• Whatarethecurrentresults?• Resultsforwhichtheclinicianisseekingguidance:anHPVtestorcotestresultoracolposcopy/biopsyresult.

• Whatpastresults(notedunderhistory)affecttheriskestimateforthecurrentresults?

• DocumentednegativecytologyprovidesrelativelylessreductioninriskcomparedwithanegativeHPVorcotestashistory.

Iden&fy risk of CIN 3+ for each pa&ent Egermenetal.Riskestimatessupportingthe2019ASCCPrisk-basedmanagementconsensus

guidelines.JLowGenitTractDis2020;24:132-143.

• Mostpa=entscanbemanagedbyiden=fyingtheirrisklevelandlinkingittoarecommendedclinicalac1on.

• Returntorou=nescreening.• Surveillancewithrepeattes=ngat1,3or5yearintervals.• Colposcopy.• Treatment.

• Thisinforma=onisaccessibleviasmartphoneapp(purchase)orwebthroughhop://www.asccp.org(nocost)

Management Surveillanceinterval

ClinicalActions

How is the pa&ent’s risk determined?

• Managementbasedonapatient’sriskofCIN3+.• 2019guidelinesmakerecommendationsbasedon:

• ImmediateCIN3+riskistheprobabilityofpatientcurrentlyhavingCIN3+.

• 5-yearCIN3+riskistheprobabilityofdevelopingCIN3+overthenext5years.

• Extensivedataanalysisproducedriskestimatesforallcombinationsoftestsandrecentscreeninghistory.

CIN3+chosenasthebestsurrogateforcancerrisk

•  CIN3+includesCIN3,AISandrarecasesofinvasivecancerfoundatscreening.

•  CIN3+chosenasendpointinsteadofcancer.•  CancerisuncommoninUS.• Riskissignificantlydecreasedbyprecursortreatment.

•  CIN3+choseninsteadofCIN2.•  Isamorepathologicallyreproduciblediagnosis.• HPVtypesinCIN3+lesionsapproximateclosertoinvasivecancerthanthelargerrangeoftypesinCIN2.

•  CIN2hasappreciableregressionratesinabsenceoftreatment.

Howtodeterminethepatient’srisk?

• Firststep.• DeterminewhethertheimmediateriskofCIN3+is>4%or<4%.

• Secondstep.• Forimmediaterisks>4%,therecommendedcolposcopy/treatmentisdeterminedbytheimmediateCIN3+risk.

• Forimmediaterisks<4%,the5-yearriskisusedtodeterminetherecommendedfollow-upinterval.

Whythe4%estimatedriskofCIN3+?

• TheClinicalActionThresholdofa4%immediateriskofCIN3+wasconsideredareasonablebalanceofbenefitsandharms.

• ValidationoftheThresholdincludedseveralstudypopulations:KPNC,NMHPVPapRegistry,CDCbreastandcervicalcancerearlydetectionprogram,BDOnclaritytrials.

• 4%thresholdfunctionedsimilarly.• Examinedclustersofpatientsindifferentresultgroups.

• High-graderesults• Low-graderesults• Combinationsforwhichcolpohasnotbeenperformed.

management

4%

Formanagement

Howpa=entriskisevaluatedforcurrentresultsandhistory

TheimmediateCIN3+riskisexamined

Treatmentor

Colposcopy

Determinewhetherpa=entsshouldreturnin1,3or5years

Management Surveillanceinterval

That important clinical ac&on threshold Consensus:Theclinicalac1onthresholdforreferraltocolposcopy

ortreatmentisa>4.0%immediateriskofCIN3+.

•  Op=onsbasedonimmediateriskofCIN3+>4.0%:• Expeditedtreatmentwithoutbiopsyispreferred.

• Treatmentorcolposcopicbiopsiesacceptable. • Colposcopicbiopsiesarerecommended.

Es&mated risk of CIN 3+

• Ifthees=matedriskisfrom4-24%oriftes=ngresultsare+forHPVtypes16or18,colposcopywithbiopsyisrecommended.

• Iftheriskis25-59%,eithercolposcopywithbiopsyorexpeditedtreatmentisrecommended.

• Iftheriskis60%orhigher,expeditedtreatmentispreferred.

Expedited Treatment (ET) is defined as treatment without preceding colposcopic biopsy

• Fornon-pregnantpa=ents>25years,ETispreferredwhentheimmediateriskofCIN3+is>60%.

• Acceptableforthosewithrisksbetween25%and60%.

• ETispreferredfornon-pregnantpa=ents>25yearswithHPVtype16+HSILandneverorrarelyscreenedpa=entswithHPV+HSILcytologyregardlessofgenotype.

Expedited Treatment

Shareddecision-makingshouldbeusedwhenETisconsidered,especiallyforpa=entswithconcerns

aboutthepoten=alimpactoftreatmentonpregnancy

outcomes.

ThatimportantclinicalactionthresholdConsensus:Theclinicalactionthresholdforreferraltosurveillance

isa<4.0%immediateriskofCIN3+

• OptionsbasedonanimmediateriskofCIN3+<4%.• Lookatthe5-yearCIN3+risk

• FindthesurveillanceintervallevelandrepeatHPV-basedtestingin1,3or5years

Below the threshold for colposcopy (4%) Es&mated 5-year risk of CIN 3+ Surveillance based on current results and past history

•  Ifthees=mated5-yearriskofCIN3+is>0.55%,repeatHPV-basedtes=ngin1year.

•  Ifthees=mated5-yearriskofCIN3+is0.15%orgreaterbutlessthan0.55%,repeatHPV-basedtes=ngtes=ngin3years.

•  Ifthees=mated5-yearriskofCIN3+is<0.15%,repeatHPV-basedtes=ngin5-years.

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•  1. Management of routine screening results: Management of HPV and/or cytology results obtained during routine cervical cancer screening.

•  2. Return visit during pre-colposcopy surveillance: management of HPV and/or cytology results obtained in patients where prior screening results did not result in colposcopy, but where risk was too high to return to routine screening.

•  3. Evaluation of a colposcopic biopsy: Management of biopsy results after colposcopy.

•  4. Management of results during post-colposcopy surveillance: Management of current HPV and/or cytology results for patients who previously were triaged to 1-year, 3-year, or 5-year follow-up after colposcopy.

•  5. Follow-up after treatment: Management of current HPV and/or cytology results for patients who have previously been treated for dysplasia.

How to use the ASCCP app Publica&ons and Defini&ons tab

• Publica=onstab-Thishasallthemainpapersthatwereusedinconjunc=onwiththedevelopmentoftheguidelines.Therearealsocytologyfigures,histologyfigures,datatables,andtheoldercytologyalgorithmsforreference.

• Defini=onstab-Defini=onsoftermsintheapp,asummaryofthechangesinthecurrentguidelinesfrompriorguidelines,andfrequentlyaskedques=ons.

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What if you don’t want to use the ASCCP app?

EnegenDetal.Riskes=matessuppor=ngthe2019ASCCPrisk–basedmanagementconsensusguidelines.JLowGenitTractDis2020;24:132.

Cases

• 32-year-oldpa=entpresentsforcervicalcancerscreening.Shedeniesanyabnormali=es.Shedeniescolposcopyorcervicaltreatmentinthepast.Hermedicalrecordsarenotavailablesoherprecisehistoryisunknown.ScreeningshowsHPV+ASC-US.Nogenotypingwasavailable.

• WhatisherimmediateriskofCIN3+?

35-year-old G0P0 presents for cervical cancer screening. Had abnormal

screening 5 years ago but was not treated. Using OCPs. Will start trying to

conceive in 3 months.

2019 Guiding Principle #3 Guidelines will allow updates

•  Incorporatenewtestmethodsastheyarevalidated.

• AdjustfordecreasingCIN3+risksasmorepatientswhoreceivedHPVvaccinationreachscreeningage.

•  The2019guidelinesbuildaframeworkthatallowsincorporationofnewtechnologiesandmodifiedstrategieswithoutrequiringfullconsensusconferences.

• Revisionsmayrapidlyincorporatenewfindingsandbequicklydisseminatedtooptimizepatientcare.

2019GuidingPrinciple#4

ColposcopypracticemustfollowguidancedetailedintheASCCPColposcopyStandards.

• Colposcopywithtargetedbiopsyremainstheprimarymethodofdetectingprecancersrequiringtreatment.

• Biopsiesshouldbetakenofalldiscreteacetowhiteareas,usually2-4biopsies/colposcopy.

• ASCCPStandardsemphasizetheneedforbiopsiesevenwhenthecolpoimpressionisnormalbutanydegreeofacetowhiteness,metaplasiaorotherabnormalityispresent.

KhanMJ,WernerCL,DarraghTM,etal.ASCCPColposcopyStandards:RoleofColposcopy.JLowerGenitTractDis2017;21:223-229.

2019 Guiding Principle #4

Colposcopy prac&ce must follow guidance detailed in the ASCCP Colposcopy Standards.

42-year-oldwithASC-US,HPV16+SCJfullyvisible

Lesionnotfullyvisible

2019GuidingPrinciple#4Colposcopyprac=cemustfollowguidancedetailedintheASCCPColposcopyStandards

50–year-oldwithHSILcytologyDidnotfollow-upforHSIL5years

agoCervixnotfullyvisibleSCJnotfullyvisible


35-year-oldwithASC-HcytologyCervixnotfullyvisibleSCJnotfullyvisible

38-year-oldwithLSILcytology,HPV+others

Persistentfor5yearsSCJfullyvisible


Formanagement

Howpa=entriskisevaluatedforcurrentresultsandhistoryTheimmediateCIN3+riskisexamined

Treatmentor

Colposcopy

Determinewhetherpa=entsshouldreturnin1,3or5years

Thanks!

2019 ASCCP Risk-Based Management Consensus ...

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