ASCCP Pap Guidelines: A Recent Update

Introduction

ASCCP stands for the American Society for Colposcopy and Cervical Pathology. It is a professional medical organization dedicated to improving the health of individuals through the study, prevention, diagnosis, and management of cervical disorders, particularly cervical cancer. The ASCCP is known for its guidelines and recommendations related to cervical cancer screening, colposcopy, and the management of cervical abnormalities. The latest guidelines were published in 2019, and significant changes were made in the ASCCP pap guidelines.

What Is Pap?

A Pap smear, also known as a Pap test or cervical cytology, is a medical screening procedure used to detect abnormal cervical cells and early signs of cervical cancer in individuals with a cervix. It is a critical component of cervical cancer prevention and early diagnosis. Here is how the Pap smear procedure works:

• Sample Collection: During a Pap smear, a speculum is used to open the vaginal canal, providing access to the cervix. They then use a specialized tool (cytobrush or spatula) to collect a small sample of cells from the cervix.

• Sample Preparation: The collected cells are placed on a glass slide or in a liquid solution. In some cases, the liquid-based cytology method is used, which allows for better preservation and examination of the cells.

• Laboratory Analysis: The cells collected from the cervix are sent to a laboratory where they are observed closely under a microscope. A trained cytotechnologist or pathologist reviews the cells to check for any abnormalities.

• Results: After proper laboratory analysis, the pathologist will provide a result whether there is evidence of cervical cancer or at risk for developing the same.

Grading:

The grade of dysplasia (presence of an abnormal type of tissue) depends on how much of the cervical tissue has abnormal cells. CIN-1 (low-grade) affects only the lower 1/3 or less of the tissue, while CIN-2 and CIN-3 (high-grade) involve the entire thickness of the tissue. So, CIN-2 and CIN-3 are more severe because they cover a larger area of the tissue.

What Is the Significance of the 2019 ASCCP Pap Guidelines?

The new guidelines from 2019 for managing cervical cancer risks are different from the old ones. They focus more on understanding a person's risk and use both current test results and past screening history. These guidelines say it's important to do HPV testing, either by itself or with cytology, to assess risk and recommend what to do if the test results are abnormal.

If there's no clear guidance in a situation, it is still fine to follow the 2012 guidelines for abnormal cervical cancer screening results and early signs. For people aged 25 or older who are screened with cytology alone, it's best to stick with the 2012 guidelines. They suggest doing colposcopy for all cytology results showing low-grade squamous intraepithelial lesions (LSIL) or worse.

What Are the Guiding Principles of ASCCP Pap Guidelines?

The 2019 American Society of Colposcopy and Cervical Pathology (ASCCP) guidelines for managing cervical cancer screening abnormalities are based on several guiding principles. Four new principles were introduced in 2019, while others were carried forward from the 2012 guidelines:

New 2019 Principles:

• HPV-Based Testing: These guidelines emphasize the use of HPV-based testing (including primary HPV testing or HPV testing combined with cervical cytology) as the foundation for assessing risk.

• Personalized Risk-Based Management: Management decisions are tailored to each patient's risk, considering current and past results and previous treatment for precancerous conditions. Risk thresholds guide recommendations.

• Flexibility for New Technologies: The guidelines are designed to incorporate new technologies and adapt to changes in cervical cancer prevention strategies, such as HPV vaccination, without requiring full consensus conferences.

• Colposcopy Standards: These guidelines highlight adherence to ASCCP Colposcopy Standards, emphasizing the importance of biopsies to detect precancers accurately.

2012 Principles Carried Forward:

• Cancer Prevention: The primary goal is preventing cervical cancer by detecting and treating high-grade cervical abnormalities. Early diagnosis of cervical cancer is a secondary goal.

• Universal Application: These guidelines are for everyone with a cervix, including transgender men who still have their cervix after a supracervical hysterectomy.

• Equal Management for Equal Risk: Management recommendations are based on a patient's risk, regardless of the specific combination of results and history used to estimate that risk.

• Balancing Benefits and Harms: The guidelines aim to maximize cervical cancer prevention while minimizing overtesting and overtreatment, as these interventions can cause harm.

• Symptomatic Patients: The guidelines apply to asymptomatic patients with abnormal cervical screening results. Symptomatic patients with signs such as abnormal bleeding require appropriate diagnostic evaluation.

• Geographic Applicability: These guidelines are intended for use in the United States, recognizing that management approaches may vary in different regions and healthcare settings.

What Are the 2019 ASCCP Pap Guidelines?

The 2019 ASCCP Risk-Based Management Consensus Guidelines represent a significant shift from results-based to risk-based management for cervical cancer screening. Here are the key points highlighted:

• Recommendations for colposcopy, treatment, or surveillance are determined by a patient's risk of CIN 3+ (This refers to when abnormal cells are found in over two-thirds of the tissue surface) based on a combination of current results and history.

• Colposcopy can be postponed for certain patients with minor screening abnormalities indicating low-risk HPV infection.

• Earlier treatment, without preceding colposcopic biopsy, is now better defined and recommended for specific risk levels, especially for patients with high-grade squamous intraepithelial lesion (HSIL) cytology and HPV 16-positive results.

• Excisional treatment is preferred over ablative treatment for histologic HSIL (CIN 2 or CIN 3) in the United States, with a recommendation for excision for adenocarcinoma in situ (AIS).

• Observation is preferred over treatment for CIN 1.

• Reports should include CIN 2 or CIN 3 qualifiers based on Lower Anogenital Squamous Terminology (LAST)/World Health Organization (WHO) recommendations.

• All positive primary HPV screening tests should have additional reflex triage testing from the same laboratory specimen, allowing for expedited treatment when appropriate.

• After treatment and the first follow-up care, it is suggested to continue monitoring with HPV testing or co-testing every three years for at least 25 years for HSIL, CIN 2, CIN 3, or AIS.

• Observation with cytology alone is acceptable when HPV or co-testing is not feasible.

• Use HPV tests that are approved by the FDA for screening, and follow their approved use as per the regulations in the United States.

Conclusion

The ASCCP pap guidelines were modified in 2019 by making significant changes to the guidelines published in 2012. These guidelines prioritize personalized risk assessment and management, recognizing that persistent HPV infection plays a crucial role in the development of precancer and cancer. The guidelines allow for more precise management while reducing unnecessary interventions based on a patient's history of HPV tests and colposcopy results.