Cervical Cancer Screening: Risk Assessment, Evaluation, and Management of Abnormal results
Department of Obstetrics and Gynecology
Prof. Mykhailo Medvediev
Introduction to Cervical Cancer Screening
Screening Methods
Cervical cytology (Pap test) and HPV testing for oncogenic subtypes
Follow-up
Colposcopy and cervical biopsies for abnormal results
Diagnosis
May result in CIN or cervical cancer diagnosis
Reference: Perkins RB, et al. 2019 ASCCP Risk-Based Management Consensus Guidelines. J Low Genit Tract Dis 2020;24:102
Cervical Cytology Terminology
Bethesda System Classifications
  • NILM (Negative for Intraepithelial Lesion or Malignancy)
  • ASC-US (Atypical Squamous Cells of Undetermined Significance)
  • ASC-H (Cannot Exclude High-Grade SIL)
  • LSIL (Low-Grade Squamous Intraepithelial Lesion)
  • HSIL (High-Grade Squamous Intraepithelial Lesion)
Reference: Nayar R, Wilbur DC. The Pap Test and Bethesda 2014. Cancer Cytopathol 2015;123:271
HPV Genotypes and Cancer Risk
HPV 16
Highest risk of CIN 3+ progression. Accounts for 50-60% of high-grade lesions
HPV 18
Second highest risk. Together with HPV 16, causes 70% of cervical cancers
Other High-Risk Types
HPV 31, 33, 45, 52, 58 - moderate to high oncogenic potential
Reference: Demarco M, et al. Partial HPV Genotyping Study. J Low Genit Tract Dis 2020;24:144
Risk-Based Management Framework
Risk Assessment
Current HPV and cytology results plus past screening history
Risk Calculation
Immediate and 5-year CIN 3+ risk estimates
Management Decision
Assigned to one of six clinical action thresholds
Management decisions based on immediate CIN 3+ risk ≥4% threshold, balancing cancer prevention with potential harms of overtesting and overtreatment.
Reference: Egemen D, et al. Risk Estimates Supporting 2019 ASCCP Guidelines. J Low Genit Tract Dis 2020;24:132
Six Clinical Action Thresholds
01
Expedited Treatment
Immediate CIN 3+ risk >60%
02
Expedited Treatment or Colposcopy
Immediate risk 25-59%
03
Colposcopy
Immediate risk 4-24%
04
Surveillance in 1 Year
Immediate risk <4%, 5-year risk ≥0.55%
05
Surveillance in 3 Years
Immediate risk <4%, 5-year risk 0.15-0.54%
06
Surveillance in 5 Years
Immediate risk <4%, 5-year risk <0.15%
Reference: Perkins RB, et al. 2019 ASCCP Risk-Based Management Consensus Guidelines. J Low Genit Tract Dis 2020;24:102
ASCCP Management Guidelines Application
Digital Tools Available
Online and smartphone applications to determine patient's immediate and 5-year CIN 3+ risk
Access Online App
Key Features
  • Calculates immediate and 5-year risk estimates
  • Incorporates current and past screening results
  • Provides optimal management strategy
  • Based on 1.5 million patient study data
  • Allows for precise CIN 3+ risk calculations
Reference: ASCCP Management Guidelines Application. Available at: https://app.asccp.org/
Expedited Treatment: Risk >60%
Preferred Management
Treatment with excision (LEEP) without prior colposcopy for nonpregnant patients ≥25 years
Examples
HSIL with HPV 16-positive (60% risk) or under-screened patients with HSIL and HPV-positive (64% risk)
Contraindications
Patients <25 years, pregnant patients, those planning future childbearing
Reference: Perkins RB, et al. 2019 ASCCP Risk-Based Management Consensus Guidelines. J Low Genit Tract Dis 2020;24:102
Expedited Treatment or Colposcopy: Risk 25-59%
Clinical Examples
  • HPV-positive with HSIL (49% risk)
  • HPV-positive with ASC-H (26% risk)
  • HPV-negative with HSIL (25% risk)
Decision Factors
Consider risk of loss to follow-up, childbearing plans, and patient concerns about pregnancy outcomes
Treatment Option
Preferred for patients at risk for loss to follow-up or completed childbearing
Colposcopy Option
Allows for diagnostic evaluation before treatment decision
Reference: Perkins RB, et al. 2019 ASCCP Risk-Based Management Consensus Guidelines. J Low Genit Tract Dis 2020;24:102
Colposcopy: Risk 4-24%
HPV+ with ASC-US
Immediate CIN 3+ risk: 4.4%
HPV+ with LSIL
Immediate CIN 3+ risk: 4.3%
HPV 16/18+ with NILM
Genotype-specific risk assessment
Colposcopic-guided biopsies provide information to guide clinical decision-making regarding treatment with excision, ablation, or observation.
Reference: Egemen D, et al. Risk Estimates Supporting 2019 ASCCP Guidelines. J Low Genit Tract Dis 2020;24:132
Surveillance: Immediate Risk <4%
Surveillance is recommended when immediate CIN 3+ risk is <4%. The frequency depends on the 5-year risk for CIN 3+, balancing cancer prevention with potential harms of overtesting and overtreatment.

Clinical Note: These recommendations are based on expert committee opinion with the goal of providing a reasonable balance between cancer prevention and the potential harms of overtesting and overtreatment.
Reference: Perkins RB, et al. 2019 ASCCP Risk-Based Management Consensus Guidelines. J Low Genit Tract Dis 2020;24:102
One-Year Surveillance: 5-Year Risk ≥0.55%
Example 1
HPV+ with NILM, unknown history
Immediate risk <4%
5-year risk: 4.8%
Example 2
HPV+ with LSIL or less, prior HPV-negative
Immediate risk <4%
5-year risk: 2.3-3.8%
Example 3
HPV-negative with LSIL, unknown history
Immediate risk <4%
5-year risk: 2%
These patients have mild abnormalities and do not reach the threshold for evaluation with colposcopy. HPV-based testing recommended in one year.
Reference: Egemen D, et al. Risk Estimates Supporting 2019 ASCCP Guidelines. J Low Genit Tract Dis 2020;24:132
Three-Year Surveillance: 5-Year Risk 0.15-0.54%
Clinical Examples
HPV-Negative with ASC-US
Unknown history
5-year CIN 3+ risk: 0.4%
HPV-Negative with ASC-US
Prior HPV-negative screen
5-year CIN 3+ risk: 0.36%
Follow-up with HPV-based testing in three years is appropriate for this risk category.
Reference: Perkins RB, et al. 2019 ASCCP Risk-Based Management Consensus Guidelines. J Low Genit Tract Dis 2020;24:102
Five-Year Surveillance: 5-Year Risk <0.15%
HPV-Negative, No Cytology
Immediate CIN 3+ risk <4%
5-year CIN 3+ risk: 0.14%
HPV-Negative with NILM
Immediate CIN 3+ risk <4%
5-year CIN 3+ risk: 0.12%
These risks are similar to the general population and therefore follow similar testing intervals as described in cervical cancer screening guidelines. HPV-based testing recommended in five years.
Reference: Perkins RB, et al. 2019 ASCCP Risk-Based Management Consensus Guidelines. J Low Genit Tract Dis 2020;24:102
Management Without the ASCCP App
HPV Positive, Genotyping Performed
Manage according to extended genotyping results and risk stratification table
HPV Positive, Unknown Genotype
NILM: 1-year testing
ASC-US/LSIL: Colposcopy
HSIL: Expedited treatment or colposcopy
HPV Unknown
HSIL: Expedited treatment or colposcopy
LSIL: Colposcopy
ASC-US: 1-year testing
HPV Negative
HSIL: Expedited treatment or colposcopy
LSIL: 1-year testing
ASC-US: 3-year testing
Reference: Perkins RB, et al. 2019 ASCCP Risk-Based Management Consensus Guidelines. J Low Genit Tract Dis 2020;24:102
Extended HPV Genotyping
Risk Stratification Groups
  • Highest Risk: HPV 16, 18
  • High Risk: HPV 45, 33/58, 31, 52
  • Moderate Risk: HPV 35/39/68, 51
  • Lower Risk: HPV 56/59/66
Clinical Application
Extended genotyping provides additional risk stratification beyond HPV 16/18 testing, allowing for more precise management decisions based on specific genotype risk profiles.
Reference: Massad LS, et al. Extended Genotyping Management Guidelines. J Low Genit Tract Dis 2025;29:134
Management of Patients <25 Years
1
Conservative Approach
High spontaneous regression rates of HPV and relatively low risk of cervical cancer in this age group
2
LSIL, ASC-US with HPV+
Repeat cytology (without HPV testing) in 1 and 2 years
3
ASC-US with HPV-
Repeat cytology in 3 years
4
High-Grade Lesions
HSIL, ASC-H, or AGC at any point requires colposcopy
Reference: Perkins RB, et al. 2019 ASCCP Risk-Based Management Consensus Guidelines. J Low Genit Tract Dis 2020;24:102
Special Populations: Pregnant Patients
Key Management Principles
  • Not candidates for expedited treatment
  • Endocervical curettage contraindicated
  • Gentle endocervical canal sampling with cytobrush acceptable
  • Cervical biopsy only if high-grade lesion suspected
  • Postpartum evaluation at 4 weeks

Important: Pregnancy-related physiologic changes result in more metaplastic cells and reactive changes, making evaluation of atypical squamous cells more challenging.
Reference: Perkins RB, et al. 2019 ASCCP Risk-Based Management Consensus Guidelines. J Low Genit Tract Dis 2020;24:102
Immunocompromised Patients
HIV Infection
Increased incidence of CIN related to higher prevalence of HPV infection (64% vs 27%)
Immunosuppressive Therapy
Transplant recipients and patients with autoimmune diseases at increased risk
Enhanced Screening
More frequent screening and careful monitoring required for this population
Risk increases with increasing degrees of immunosuppression (lower CD4 counts, higher HIV RNA load).
Reference: Massad LS, et al. 2012 Updated Consensus Guidelines. J Low Genit Tract Dis 2013;17:S1
Patients with History of Hysterectomy
Screening Indications
Cervical cancer screening is not routinely performed for patients who have undergone hysterectomy for benign disease.
Continue screening for 25 years if history of CIN 2+ prior to hysterectomy.
LSIL and HPV+ ASC-US
Manage with repeat testing in one year
ASC-H and HSIL
Manage with immediate colposcopy
Reference: Perkins RB, et al. 2019 ASCCP Risk-Based Management Consensus Guidelines. J Low Genit Tract Dis 2020;24:102
Patients >65 Years
Discontinuation Criteria
Cervical cancer screening generally discontinued at age 65 if prior screening results were normal
Continue Screening If
History of abnormal screening results or prior treatment for precancer
Abnormal Results After 65
Manage similarly to patients aged ≥25 years using risk-based estimates
Exception
Discontinuation only recommended in patients with poor health or limited life expectancy
Reference: US Preventive Services Task Force. Screening for Cervical Cancer. JAMA 2018;320:674
Specimen Adequacy: Satisfactory for Evaluation
Adequacy Criteria
  • Conventional Pap: 8,000-12,000 well-visualized squamous cells
  • Liquid-based: Minimum 5,000 well-visualized squamous cells
  • Any specimen with abnormal cells considered satisfactory
1
EC/TZ Component
At least 10 well-preserved endocervical or squamous metaplastic cells required
2
Obscuring Factors
Partially obscured when 50-75% of cells cannot be visualized
Reference: Nayar R, Wilbur DC. The Pap Test and Bethesda 2014. Cancer Cytopathol 2015;123:271
Unsatisfactory Cervical Cytology
Scant Cellularity
Fewer than required well-visualized squamous cells. Common in postmenopausal patients due to atrophy
Obscuring Factors
More than 75% of cells obscured by blood, inflammation, or air-drying artifact
Processing Issues
Unlabeled specimen or unable to be processed by laboratory (broken vial/slide)
Occurs in approximately 1-2% of samples. Management depends on age and HPV testing results.
Reference: Moriarty AT, et al. Unsatisfactory Reporting Rates. Arch Pathol Lab Med 2009;133:1912
Management of Unsatisfactory Cytology: Patients ≥25 Years

Special Considerations: Treat infection if identified before repeating Pap test. Postmenopausal patients may benefit from vaginal estrogen therapy prior to repeat testing.
Reference: Perkins RB, et al. 2019 ASCCP Risk-Based Management Consensus Guidelines. J Low Genit Tract Dis 2020;24:102
Absent EC/TZ Component
Clinical Significance
Absent or insufficient endocervical cell/transformation zone component noted in 10-20% of cytology specimens.
More common in adolescents and postmenopausal patients due to hypoestrogenism.
Management Approach
  • Age ≥30 years: Manage based on co-tested HPV results
  • Age 21-29 years: May return to routine screening
  • Postmenopausal: Consider vaginal estrogen before repeat Pap
Controversy exists regarding significance, but patients followed prospectively do not appear at increased risk of squamous cell abnormalities or CIN.
Reference: Perkins RB, et al. 2019 ASCCP Risk-Based Management Consensus Guidelines. J Low Genit Tract Dis 2020;24:102
Benign-Appearing Endometrial Cells
Reporting Criteria
Reported only in patients ≥45 years (changed from ≥40 years in Bethesda 2001)
Clinical Significance
  • May reflect physiologic shedding (first half of menstrual cycle)
  • May indicate pathologic process (endometrial hyperplasia or carcinoma)
  • Postmenopausal patients at increased risk
Evaluation Required
All postmenopausal patients and premenopausal patients with risk factors or symptoms
Reference: Nayar R, Wilbur DC. The Pap Test and Bethesda 2014. Cancer Cytopathol 2015;123:271
HPV-Positive Results: General Considerations
First Positive Result
Most likely represents new infection. Over 50% clear in 6-18 months, 80-90% resolve within 2-5 years
Recurrent Positive Result
May represent reactivation of latent infection or new infection. Often same HPV type as past infection
Persistent Positive Result
Consecutively positive HPV results ≥12 months apart. Necessary step for progression to clinically relevant disease
Most infections detected over years of screening are reactivations of latent infections acquired at or near sexual debut.
Reference: Perkins RB, et al. 2019 ASCCP Risk-Based Management Consensus Guidelines. J Low Genit Tract Dis 2020;24:102
HPV Persistence and Progression Risk
Persistence Factors
Older Age
50% persistence in patients >55 years vs 20% in patients <25 years
Duration
Longer observed infection takes longer to clear
HPV Type
High-oncogenic-risk subtypes more likely to persist
21% of patients with highly oncogenic HPV infections persisting over 12 months developed CIN 2+ over 30 months of follow-up.
Reference: Rodríguez AC, et al. Rapid Clearance of HPV. J Natl Cancer Inst 2008;100:513
CIN Terminology and Histology
1
CIN 1 (LSIL)
Low-grade lesion. Mildly atypical cellular changes in lower third of epithelium. HPV cytopathic effect often present
2
CIN 2 (HSIL if p16+)
High-grade lesion. Moderately atypical changes in basal two-thirds of epithelium. Poor reproducibility
3
CIN 3 (HSIL)
High-grade lesion. Severely atypical changes encompassing >2/3 of epithelial thickness or full-thickness
Reference: Darragh TM, et al. LAST Project Recommendations. Int J Gynecol Pathol 2013;32:76
Cervical Transformation Zone
Anatomic Considerations
The transformation zone is regarded as the site of carcinogenesis mediated by oncogenic HPV infection.
Squamocolumnar Junction: Area where squamous epithelium meets columnar epithelium
Transformation Zone: Dynamic area of metaplasia where glandular epithelium has been replaced by squamous epithelium

Recent data suggest the primary site of carcinogenic HPV-related CIN and cervical cancer is a small population of cuboidal cells at the squamocolumnar junction.
Reference: Herfs M, et al. Squamocolumnar Junction Cells. Proc Natl Acad Sci USA 2012;109:10516
HPV Molecular Pathogenesis
1
Latent Infection
No physical, cytologic, or histologic manifestations. Most common outcome (>90% of infections)
2
Active Infection
HPV undergoes vegetative replication without genome integration. Produces characteristic cellular changes
3
Neoplastic Transformation
HPV integrates into human genome. Disruption of E1/E2 leads to E6/E7 overexpression
4
Tumor Suppressor Inactivation
E6 binds p53, E7 interacts with Rb. Disabling of major tumor suppressors central to transformation
Reference: Snijders PJ, et al. HPV-Mediated Cervical Carcinogenesis. J Pathol 2006;208:152
Cofactors in CIN Pathogenesis
Cigarette Smoking
Synergistic effect with HPV. 66-fold increased risk with both smoking and HPV vs 15-fold with HPV alone
Immunosuppression
HIV infection, transplant recipients, immunosuppressive therapy increase CIN risk
Oral Contraceptives
Long-term use implicated as cofactor in HPV-positive patients. Risk declines after discontinuation
Reference: Luhn P, et al. Role of Co-factors in HPV Progression. Gynecol Oncol 2013;128:265
Smoking and Cervical Cancer Risk
Mechanism of Action
  • Cigarette breakdown products concentrated in cervical mucus
  • Nicotine, cotinine, and NNK induce cellular abnormalities
  • Decreased local immunity allows viral persistence
  • Cumulative exposure (pack-years) strongly related to CIN risk
2x
CIN Risk
With smoking alone vs nonsmokers
15x
CIN Risk
With HPV alone vs HPV-negative nonsmokers
66x
CIN Risk
With both smoking and HPV vs HPV-negative nonsmokers
Reference: Olsen AO, et al. Combined Effect of Smoking and HPV. Epidemiology 1998;9:346
Primary Prevention: HPV Vaccination
Primary Approach
Vaccination against oncogenic HPV infection is the primary prevention strategy for CIN and cervical cancer
Target Population
Recommended for females and males aged 9-26 years. Catch-up vaccination through age 26
Vaccine Efficacy
Highly effective in preventing HPV 16/18-related precancers and cancers when given before exposure

Condoms provide only partial protection against HPV transmission due to skin-to-skin contact in areas not covered.
Reference: Human Papillomavirus Vaccination Guidelines. Available at: www.cdc.gov/vaccines/vpd/hpv
Secondary Prevention: Screening and Treatment
Secondary prevention is aimed at cervical cancer rather than CIN itself. For patients with CIN, appropriate monitoring and treatment are used to prevent progression to malignant disease.
Screening Programs
Regular cervical cytology and HPV testing according to guidelines
Risk-Based Management
Appropriate follow-up based on individual risk assessment
Treatment Options
Excision or ablation for high-grade lesions to prevent cancer
Reference: Perkins RB, et al. 2019 ASCCP Risk-Based Management Consensus Guidelines. J Low Genit Tract Dis 2020;24:102
CIN Regression Rates
1
Year 1
38% regression rate in young patients (13-24 years) with CIN 2
2
Year 2
63% cumulative regression rate by year 2
3
Year 3
68% cumulative regression rate by year 3
Even for patients who develop CIN, the lesion most commonly clears spontaneously, especially in younger patients. This supports conservative management approaches in select populations.
Reference: Moscicki AB, et al. Rate of CIN 2 Regression. Obstet Gynecol 2010;116:1373
HPV Clearance and Immune Response
Clearance Timeline
  • Over 50% of new HPV infections clear in 6-18 months
  • 80-90% resolve within 2-5 years
  • Average duration in young patients: 8-13 months
Immune Mechanisms
Resolution associated with HPV antibody formation and recruitment of macrophage NK cells and activated CD4+ T-lymphocytes.

Unclear whether HPV-negative patients after positive test actually clear virus or retain it in inactive/low-level state.
Reference: Ho GY, et al. Natural History of Cervicovaginal HPV Infection. N Engl J Med 1998;338:423
Age-Related HPV Prevalence
33.8%
Ages 20-24
Peak prevalence in young adults
27.5%
Ages 30-39
Moderate prevalence continues
19.6%
Ages 50-59
Lower but persistent prevalence
Overall prevalence in females aged 14-59 years: 26.8%. Point prevalence peaks at 30-50% in teens and twenties, decreases to 5-15% at ages 40-60, then increases up to 30% after age 50.
Reference: Dunne EF, et al. Prevalence of HPV Infection Among Females. JAMA 2007;297:813
Sexual Transmission and Epidemiology
Transmission Facts
HPV is transmitted through sexual contact. Cervical cancer and precursors are almost nonexistent in patients without sexual relationships.
HPV infection is endemic among sexually experienced individuals.
75-80%
Lifetime Risk
Of sexually active patients will acquire genital
HPV by age 50
4-20%
Risk with One Partner
Even with single lifetime partner
HPV infection of the cervix or lower female genital tract is asymptomatic and only clinically apparent if genital warts or neoplastic lesions develop.
Reference: Workowski KA, et al. STI Treatment Guidelines 2021. MMWR Recomm Rep 2021;70:1
Colposcopy Procedure and Indications
Procedure Overview
Magnified visual examination of cervix, vagina, and vulva using colposcope after application of acetic acid
Key Indications
Abnormal cytology results, positive HPV testing with abnormal cytology, persistent HPV infection
Biopsy Guidance
Allows for directed biopsies of abnormal-appearing areas for histologic diagnosis
Colposcopy is the gold standard for evaluating abnormal cervical cancer screening results and guiding management decisions.
Reference: Perkins RB, et al. 2019 ASCCP Risk-Based Management Consensus Guidelines. J Low Genit Tract Dis 2020;24:102
Treatment Options for CIN
Excisional Procedures
  • LEEP: Loop Electrosurgical Excision Procedure
  • Cold Knife Conization: Surgical excision with scalpel
  • Laser Conization: CO2 laser excision
Provide tissue for histologic examination
Ablative Procedures
Cryotherapy, laser ablation, thermocoagulation. Do not provide tissue specimen
Observation
Appropriate for select low-grade lesions with close follow-up
Reference: Perkins RB, et al. 2019 ASCCP Risk-Based Management Consensus Guidelines. J Low Genit Tract Dis 2020;24:102
Reproductive Considerations
1
Excisional Procedure Risks
Associated with potential adverse pregnancy outcomes including preterm delivery and low birth weight
2
Balancing Considerations
For patients planning future childbearing, concerns about pregnancy outcomes may outweigh cancer concerns
3
Alternative Approaches
Colposcopy with biopsies provides information to guide decision between treatment and observation
4
Shared Decision-Making
Thorough discussion required between provider and patient regarding risks and benefits
Reference: Perkins RB, et al. 2019 ASCCP Risk-Based Management Consensus Guidelines. J Low Genit Tract Dis 2020;24:102
Follow-Up After Treatment
Patients with history of CIN 2+ require long-term surveillance due to increased risk of recurrence and progression.
1
6 Months
First post-treatment HPV testing
2
12 Months
Repeat HPV testing if negative at 6 months
3
25 Years
Duration of surveillance for CIN 2+ history
Reference: Perkins RB, et al. 2019 ASCCP Risk-Based Management Consensus Guidelines. J Low Genit Tract Dis 2020;24:102
Quality Assurance in Screening
Specimen Adequacy
Most important quality assurance component of Bethesda system. Ensures reliable screening results
Cytology Review
Standardized terminology and interpretation criteria for consistent reporting
Follow-Up Systems
Tracking mechanisms to ensure appropriate management of abnormal results
Evaluation of specimen adequacy is considered by experts to be the most important quality assurance component of the Bethesda system.
Reference: Nayar R, Wilbur DC. The Pap Test and Bethesda 2014. Cancer Cytopathol 2015;123:271
Liquid-Based vs Conventional Cytology
Liquid-Based Cytology
  • Cells suspended in preservative solution
  • Minimum 5,000 well-visualized cells required
  • Allows for HPV testing from same sample
  • Reduced unsatisfactory rate
  • Better preservation of cellular detail
Conventional Pap Smear
Cells directly smeared on glass slide. Requires 8,000-12,000 well-visualized cells. Fixed immediately
Reference: Nayar R, Wilbur DC. The Pap Test and Bethesda 2014. Cancer Cytopathol 2015;123:271
HPV Testing Methods
FDA-Approved Assays
Only FDA-approved tests should be used for HPV genotyping in clinical practice
Detection Methods
PCR-based, signal amplification, and hybrid capture methods available
Genotyping Capability
Tests may detect high-risk HPV pool or provide specific genotype identification
Various HPV testing systems are available. The specific test used should be recorded in the report.
Reference: Perkins RB, et al. 2019 ASCCP Risk-Based Management Consensus Guidelines. J Low Genit Tract Dis 2020;24:102
Patient Communication and Counseling
Key Discussion Points
  • Nature of HPV infection and transmission
  • Meaning of screening results
  • Risk assessment and management options
  • Importance of follow-up
  • Prevention strategies including vaccination
  • Partner management considerations

When appropriate, medical interpreters and cultural navigators should be included to increase shared decision-making, reduce misunderstandings, and promote compliance.
Reference: Perkins RB, et al. 2019 ASCCP Risk-Based Management Consensus Guidelines. J Low Genit Tract Dis 2020;24:102
Global Perspective on Cervical Cancer
604K
New Cases Annually
Worldwide cervical cancer incidence
342K
Deaths Annually
Global cervical cancer mortality
90%
In Low-Resource Settings
Of deaths occur in developing countries
These guidelines are intended for use in the United States and other high-resource settings. Management may differ in low-resource settings where access to colposcopy, pathology review, and follow-up may be limited.
Reference: WHO Global Strategy to Accelerate Cervical Cancer Elimination. Available at: www.who.int
Future Directions in Screening
AI-Assisted Screening
Machine learning algorithms to improve cytology interpretation and risk stratification
Self-Collection
HPV self-sampling to increase screening access and participation rates
Novel Biomarkers
p16/Ki-67 dual staining and methylation markers for improved triage
Emerging technologies and approaches aim to improve screening accuracy, accessibility, and patient compliance while reducing healthcare disparities.
Reference: Perkins RB, et al. 2019 ASCCP Risk-Based Management Consensus Guidelines. J Low Genit Tract Dis 2020;24:102
Implementation Challenges
EMR Integration
Modules for risk calculation being developed for electronic medical record systems
Provider Education
Training needed on risk-based management approach and use of ASCCP app
Resource Availability
Ensuring access to colposcopy, pathology services, and follow-up care
Successful implementation of risk-based guidelines requires system-level changes, provider education, and patient engagement strategies.
Reference: Perkins RB, et al. 2019 ASCCP Risk-Based Management Consensus Guidelines. J Low Genit Tract Dis 2020;24:102
Key Principles of Risk-Based Management
01
Equal Management for Equal Risks
Same current results may lead to different management based on past testing history
02
HPV as Primary Risk Factor
HPV results more predictive than cytology alone for future CIN 3+ risk
03
Balance Benefits and Harms
4% immediate risk threshold balances cancer prevention with overtesting/overtreatment
04
Individualized Approach
Management tailored to individual patient risk profile and circumstances
Reference: Perkins RB, et al. 2019 ASCCP Risk-Based Management Consensus Guidelines. J Low Genit Tract Dis 2020;24:102
Evidence Base for Guidelines
Kaiser Permanente Study
Risk estimates derived from approximately 1.5 million patients screened with HPV and cytology, followed for over a decade.
Large population allows for precise risk calculations for CIN 3+ and rare outcomes.
Validation Studies
Risks compared with other large US cohort studies of patients receiving regular HPV and cytology testing.
Consistent findings across multiple populations support guideline recommendations.
Reference: Egemen D, et al. Risk Estimates Supporting 2019 ASCCP Guidelines. J Low Genit Tract Dis 2020;24:132
Clinical Pearls and Practical Tips
Use the ASCCP App
Digital tools provide accurate risk calculation and management recommendations based on current evidence
Document Past Results
Prior HPV and cytology history significantly impacts current risk assessment and management
Consider Patient Factors
Age, pregnancy plans, immunosuppression, and loss to follow-up risk affect management decisions
Ensure Follow-Up
Robust tracking systems essential for patients requiring surveillance or repeat testing
Shared Decision-Making
Involve patients in management decisions, especially when multiple options available
Reference: Perkins RB, et al. 2019 ASCCP Risk-Based Management Consensus Guidelines. J Low Genit Tract Dis 2020;24:102
Summary and Conclusions
Risk-Based Approach
2019 ASCCP guidelines use immediate and 5-year CIN 3+ risk to guide management decisions
HPV Central Role
HPV testing and genotyping provide superior risk stratification compared to cytology alone
Individualized Care
Management tailored to individual risk profile, considering current and past results
Prevention Focus
Primary prevention through HPV vaccination and secondary prevention through screening and treatment

Key Takeaway: Implementation of evidence-based, risk-stratified management optimizes cervical cancer prevention while minimizing harms of overtesting and overtreatment.
Reference: Perkins RB, et al. 2019 ASCCP Risk-Based Management Consensus Guidelines for Abnormal Cervical Cancer Screening Tests and Cancer Precursors. J Low Genit Tract Dis 2020;24:102-108
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