Jfac 142
Jfac 142
Jfac 142
a
Department of Pathology and Laboratory Medicine, Pennsylvania State University College of Medicine, Hershey, PA, USA; bDepartment of
Pharmacology, Pennsylvania State University College of Medicine, Hershey, PA, USA; cDepartments of Obstetrics, Gynecology, and
Reproductive Biology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA; dDepartment of Obstetrics and Gynecology,
McGill University Health Centre, McGill University, Montreal, QC, Canada; eDepartment of Pathology and Laboratory Medicine Service, James
A. Haley Veterans’ Hospital, Tampa, FL, USA.
*Address correspondence to this author at: Departments of Pathology and Laboratory Medicine, Pharmacology, Pennsylvania State University
College of Medicine, 500 University Dr., Mail Code H160, Hershey, PA, USA. E-mail yzhu@pennstatehealth.psu.edu.
This document was approved by the AACC Academy Content Development Committee in August 2022, the AACC Academy Council in September
2022, and the AACC Board of Directors in October 2022.
Received November 22, 2022; accepted December 08, 2022.
https://doi.org/10.1093/jalm/jfac142
© American Association for Clinical Chemistry 2023. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com
IMPACT STATEMENT
Women with persistent high-risk human papilloma virus infection account for the vast majority of cases of
cervical cancer. This guidance document addresses key questions related to cervical cancer screening and
management and introduces the most recently updated screening guidelines, risk-based management for
screening and surveillance, as well as methodologies for the diagnosis of cervical cancer. Additionally, a labora
tory report template is proposed for human papilloma virus and cervical cancer detection to facilitate inter
pretation of results and clinical decision-making. This guidance document will help clinical laboratorians
Pathology (ASCCP) guidelines recommend that the interpretation of risk to guide management is
histopathology report should include CIN 2 or CIN different.
3 qualifiers, that is, HSIL (CIN 2) and HSIL (CIN 3) (7). This guidance document introduces currently
Approaches for cervical cancer screening in available cervical cancer screening tests, testing
clude primary cervical hrHPV testing, co-testing strategies, and the most recently updated screen
of hrHPV and cervical cytology, and cytology ing guidelines as well as risk-based management
screening alone. These approaches have variable guidelines. In addition, we propose a report tem
sensitivity and specificity, which will be detailed in plate for HPV and cervical cancer detection to fa
the later sections (8). cilitate interpretation of testing results and
for detecting CIN 2/3 ranges from 90.5% to 97% and mRNA transcription-mediated amplification assay
the specificity ranges from 13% to 67.6% (15–17). targets E6/E7 genes. It covers 14 high-risk types
(16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66,
(b) The BD Onclarity™ HPV Assay (Becton,
and 68) with separate genotyping of 16, and 18/
Dickinson and Company)
45 by the Aptima 16,18/45 genotype assay. The
The FDA approved this assay in 2018 for reflex HPV HPV16 E6/7 transcript serves as an internal con
testing and co-testing with cytology as well as primary trol. The sensitivity for detecting CIN2/3 ranges
cervical cancer screening but only on SurePath from 87.5% to 98% and the specificity ranges
Specimens (see the following “Cervical Cytology from 30% to 78% (10, 15, 17, 19, 24).
mated imagers have slightly increased sensitivity Squamous intraepithelial HPV cytopathic
lesion changes
over manual screening alone; however, there is a
-LSIL
slight decrease in specificity (29–32).
-HSIL
Evaluation of slides by automated screening or
Squamous cell carcinoma
manual screening by a cytotechnologist or cyto
Glandular cells
pathologist is considered primary review. All ab
-Atypical
normal cervical Pap smears must have a
• Endocervical cells, NOS
secondary review by a cytopathologist. The report
• Endometrial cells, NOS
ing of results follows the Bethesda System for
• Glandular cells, NOS
Reporting Cervical Cytology (Table 1) (33). -Atypical
The spectrum of lesions in the cervix caused by • Endocervical cells, favor neoplastic
HPV ranges from premalignant dysplasia to inva • Glandular cells, favor neoplastic
sive carcinoma. Low-grade dysplasia or LSIL in cy -Adenocarcinoma in situ
tology may be indicative of HPV infection that can -Adenocarcinoma
be transient with regression within 2 years (34). Other malignancy Metastatic tumors,
Cytomorphologic changes of LSIL in Pap test are sarcoma,
neuroendocrine
similar to those identified as CIN 1 in cervical tissue
tumors, etc.
biopsies. Changes of LSIL can range from viral cy
NOS, not otherwise specified.
topathic change (koilocytosis) to morphologic
changes of low-grade dysplasia. A Pap test with
atypical changes involving squamous cells that
fall short of criteria for LSIL can be reported as The cytomorphology of HSIL is similar to CIN 2 and
atypical squamous cells of undetermined signifi CIN 3 in tissue biopsy. Squamous cells with
cance (ASC-US). The ASC-US/LSIL ratio is a labora high-grade dysplasia are smaller than those with
tory quality indicator and can highlight ASC-US low-grade dysplasia. They have high nuclear to cyto
overuse. plasmic ratio and marked nuclear membrane
irregularity and can have nuclear hyperchromasia. has more prominent malignant cytomorphologic
Atypical changes that fall short of criteria for HSIL features and commonly associated degenerated
can be reported as atypical squamous cells—cannot blood and necrosis. Adenocarcinoma can be endo
exclude high-grade squamous intraepithelial lesion cervical, endometrial, or rarely metastatic in con
(ASC-H). firmatory tissue biopsy sections. Glandular and
Squamous cell carcinoma is the most common squamous abnormalities may be present in a single
malignancy of the cervix. Tissue architecture is Pap test and each interpretation should be reported.
not present in a cytology sample; however, other Publication of the 2019 ASCCP consensus
malignant features are present. Tumor cells can guidelines in April 2020 introduced a change
compared to clinician-collected samples, and ad correlation between self-collected vaginal speci
vantages and potential concerns associated with mens and clinician-collected specimens for HPV
this type of specimen. screening were conducted in the Netherlands
(16 410 total randomized patients) and in Mexico
Stability of Self-Collected Vaginal Specimens (25 061 total randomized patients), respectively.
for HPV Genotyping In the Dutch study (40), 8212 participants were
Self-collected vaginal specimens for HPV randomly allocated to the self-sampling group and
genotyping are generally collected using a “dry” 8198 to the clinician-based sampling group. 569
or lavage-based HPV self-sampling approach, (7.4%) self-collected samples and 451 (7.2%)
CIN 2 or worse in low-resource settings where re due to inadequate sampling of the squamocol
stricted infrastructure reduces the effectiveness of umnar junction.
cytology-based screening programs. (b) significant differences in screening perform
Additional, smaller-scale studies have largely ance of different self-collected vaginal speci
men collection methods
supported the conclusions from these 2 pivotal
(c) potential lack of appropriate follow-up
studies (42, 43), and a detailed meta-analysis of
(d) challenges with interpretation of results if not
self-collected vs clinician-collected samples was directly communicated to a professional care
published for studies performed prior to 2014 provider
(44). In addition, one study addressed self- vs
in individuals 25 years or older (54). Both of these uncommon, and so, on balance, cytology
tests are approved for partial HPV genotyping. It screening is felt to be adequate for detection
has been demonstrated that primary HPV screen of serious disease, while avoiding the potential
ing is more effective than screening with cytology for overevaluation associated with the highly
alone and performs similarly to and with lower sensitive HPV test in patients younger than 30
costs than screening with co-testing (9, 55). The 2 years old. Based on this data, the USPSTF re
FDA-approved tests for primary HPV screening commends that primary HPV screening only
are not available at all institutions. In many set be used for patients 30 years and older (52).
tings, co-testing will be ordered in lieu of primary An important difference in the ACS guideline is
testing until an FDA-approved primary test is the recommendation for the use of primary
available. HPV testing starting at 25 years old (53).
The USPSTF recommends that primary HPV Although based on the same data, the differ
testing not be used to screen individuals 21 to ence in interpretation reflects the balance of in
29 years old as a stand-alone test. This is due creased intervention (i.e., colposcopies) with
to the high prevalence of HPV in those under increased number of precancerous lesions
the age of 30 (56, 57), although this may change detected.
as an increasing number of people are vacci With regards to interval of screening, both orga
nated. In one study, primary HPV screening start nizations recommend screening with primary HPV
ing at 25 years of age doubled the number of not occur at intervals shorter than 3 years and not
colposcopies but resulted in a 54% greater de beyond 5 years among patients with negative
tection of CIN 3 + when compared to the same screening results. An analysis by Ronco et al. con
strategy starting at 30 years of age (58). cluded that a screening interval of at least 5 years
However, despite the increased detection of for HPV screening is safer than cytology every 3
CIN 3+, quick progression to cancer is years (59).
High-Risk HPV and Cervical Cytology HPV testing to cytology also enhances the identi
Co-Testing fication of women with adenocarcinoma of the
In co-testing, cytology and HPV testing are col cervix and its precursors (64, 65). Compared to
lected and reported together. In addition to the squamous cell cancers, cytology has been rela
two FDA-approved tests for primary HPV screen tively ineffective in decreasing the incidence of in
ing, the digene HC2 high-risk HPV DNA test, vasive adenocarcinoma of the cervix (66).
Cervista HPV HR assay, Cervista HPV 16/18 assay,
Cervical Cytology Alone
Aptima HPV assay, and Aptima HPV 1618/45 as
say are all approved by the FDA as of March When cervical cytology alone is used, the cer
cytology (i.e., cytology alone or reflex HPV testing, + was less than 1% in the next 5 to 10 years (63, 64,
0.30–0.76 per 1000) (69). 75–78). Meta-analysis indicated that, compared
With respect to detection, a systematic review with cytology-based testing, screening with HPV
found that primary HPV testing among individuals testing (mainly with co-testing) was associated
25 to 65 years compared with cytology alone was with a lower incident of cervical cancer at a median
associated with increased detection of CIN 3 + in follow up of 6.5 years (rate ratio 0.60, 95%CI, 0.40–
the initial round of screening (relative risk range, 0.89) (59). Consistent with the low risk associated
1.61 [95% CI, 1.09–2.37]) to 7.46 (95% CI, 1.02– with negative co-testing, modeling studies found
54.66) (8). Colposcopy rates were higher for primary that co-testing every 5 years was as effective as
it is uncertain what level of vaccine uptake in the screening in the past 10 years with normal results
general population will achieve the level of indi and no history of CIN2 + within the past 25 years
vidual protection and herd immunity that would discontinue screening (53). Those with a history
warrant changes in screening protocols for all of precancer or cancer should continue to have
women or for those with documented vaccin testing for at least 25 years after diagnosis even
ation history (53). if the testing goes past age 65. The evidence for
As noted, the USPSTF recommends screening discontinuation of screening is based primarily
at 21 years and older with cytology every 3 years on a single modeling study with a model of contin
(52) based on a meta-analysis of randomized ued screening up to age 90 (69). A prolonged
demonstrate how a patient’s risk is evaluated, irre long-term surveillance (i.e., annual cytology or
spective of which of the 3 screening strategies is every 3-year co-testing) (7).
used. • Clinical signs or symptoms of bleeding, dis
To determine if an individual meets criteria for charge, and/or pain: It is important to note that
symptomatic patients of any age should undergo
routine screening, the following should be elicited
diagnostic evaluation regardless of prior or cur
from clinical history: rent screening results. Signs and symptoms of
cervical disease could include abnormal dis
• History of immunosuppression: Patients with HIV charge, abnormal bleeding, postcoital bleeding,
as well as solid organ transplant, allogeneic hem pelvic pain, change in bladder or bowel function,
atopoietic stem cell transplant, inflammatory bo
YES
Does the pa!ent have all normal PAP and nega!ve HPV within the past 25 years?
NO
No Yes
Fig. 1. Triage algorithm for cervical cancer screening, surveillance, and diagnosis. This flow diagram in
corporates the ACS and USPSTF recommendations for those who meet criteria for routine screening as
well as risk-based management guidelines from ASCCP. References for the following special popula
tions and who do not qualify for routine screening are provided: (A), history of immunosuppression
(95); (B), history of vulvar or vaginal dysplasia (96–98); (C), history of hysterectomy with removal of cer
vix (7, 99); (D), patients with any signs and/or symptoms should undergo further evaluation; (E), for
those with prior abnormal results and recent testing results is not available, surveillance based on risk-
based estimates provided by ASCCP is recommended (9).
action recommendation includes the patient’s age registrational trials (102, 103), the New Mexico
and current test results, recognizing that prior HPV Pap Registry (104, 105), and the Centers for
screening history might not be available. Disease Control and Prevention’s National Breast
However, ideally, prior cytology, HPV and path and Cervical Cancer Early Detection Program
ology data are entered into the risk calculator in (106). Patients with an immediate risk of CIN 3 +
order to create a personal risk score for the pa that is less than 4% undergo surveillance, and
tient, which determines management. Data tables based on their 5-year risk of CIN 3+, the interval
of risk estimates are to guide management clinical may be 1, 3, or 5 years. Those with an immediate
action thresholds under the principle of “equal CIN 3 + risk of greater than or equal to 4% are re
management for equal risk” (9). The estimates ferred to diagnostic evaluation, which may include
are based on data from Kaiser Permanente colposcopic evaluation and/or excisional
Northern California (64), the BD Onclarity procedure.
substantial fraction of cases with features that are for the diagnosis of CIN 2 (117, 119), which is often
not clearly high or low grade. For example, while difficult to distinguish from CIN 1 and CIN
reproducibility is good for the distinction between 3. Consistency in diagnosis has been aided by
CIN 1 and CIN 3 (117, 118), reproducibility is poor the addition of immunohistochemistry for p16, a
protein product of the cell cycle gene CDKN2A. This THE IDEAL LABORATORY REPORT
marker is sensitive for high-grade lesions but is
also expressed in a substantial subset of low- Based on the previous discussion of the import
grade lesions. Expression of p16 is particularly ance of specifying the indication for testing (i.e.,
high in low-grade lesions driven by high-risk HPV screening, surveillance, or diagnosis) and the test
types, with diffuse expression of p16 seen in near used, we propose the following report template
ly 90% of hrHPV-positive LSIL in one study (120). (Table 3) to facilitate results interpretation and
CIN 1 lesions that are p16-positive progress to clinical decision-making. While this template can
CIN 2 or higher in 10% to 35% of cases, while those be modified for local needs, we believe it incorpo
the appropriate use and interpretation of tests. For screening intervals. Furthermore, the ACS and
example, the intervals of 1-, 3-, and 5-year dis USPSTF guidelines were developed prior to the
cussed within the ASCCP guidelines are surveillance ASCCP guidelines, and nuanced differences may
intervals whereas the 3- and 5- year intervals dis be noted, specifically with updates to the use of pri
cussed in the ACS and USPSTF guidelines refer to mary HPV testing. For example, the ASCCP
guidelines recommend that when primary HPV calculation. Ideally, standardized reports would in
screening is used as the initial test alone, additional clude HPV test used, genotype information, cy
reflex triage test (e.g., reflex cytology) for all positive tology, and histology using common terminology
HPV tests be performed regardless of genotype (7); (e.g., Lower Anogenital Squamous Terminology) in
this is a change from the 2015 interim guidelines tegrated with other clinical information from a pa
(58). However, if primary HPV screening test geno tient’s electronic health record. This would not only
typing results are HPV 16- or HPV 18-positive and allow for accurate risk estimates but also establish a
reflex triage testing from the same laboratory spe reliable tracking and reminder system to facilitate
cimen is not feasible, patients should proceed dir communication, improve patient safety and quality
Nonstandard Abbreviations: ACS, American Cancer Society; ASCCP, American Society for Colposcopy and Cervical Pathology;
AGC, atypical glandular cells; ASC-H, atypical squamous cells—cannot exclude high-grade squamous intraepithelial lesion;
ASC-US, atypical squamous cells of undetermined significance; CIN, cervical intraepithelial neoplasia; FDA, Food and Drug
Administration; HSIL, high-grade squamous intraepithelial lesion; hrHPV, high risk human papilloma virus; HPV, human papil
loma virus; LBC, liquid-based cytology; LSIL, low-grade squamous intraepithelial lesion; USPSTF, US Preventative Services
Task Force.
Author Contributions: The corresponding author takes full responsibility that all authors on this publication have met the following
required criteria of eligibility for authorship: (a) significant contributions to the conception and design, acquisition of data, or analysis
and interpretation of data; (b) drafting or revising the article for intellectual content; (c) final approval of the published article; and (d)
agreement to be accountable for all aspects of the article thus ensuring that questions related to the accuracy or integrity of any part
of the article are appropriately investigated and resolved. Nobody who qualifies for authorship has been omitted from the list.
Authors’ Disclosures or Potential Conflicts of Interest: Upon manuscript submission, all authors completed the author disclosure
form. Disclosures and/or potential conflicts of interest: Employment or Leadership: S.O.A. Leung, American College of Obstetricians
and Gynecologists, District I Quebec Section Fellow Vice Chair, International Papillomavirus Policy Committee Member, American
Cancer Society Cervical Cancer Screening Initiative, Provider Needs Workgroup Member; S. Feldman, Board of IPVS. Consultant
or Advisory Role: None declared. Stock Ownership: None declared. Honoraria: S. Feldman, Indian Health Service, post-graduate
courses at Harvard Medical School. Research Funding: Y. Zhu, funding from Abbott Laboratories to institution; M.H. Creer, Abbott
Clinical Diagnostics, Siemens Clinical Diagnostics, Fujirebio; S. Feldman, funding from National Cancer Institute/National Institutes of
Health and Society to Improve Diagnosis in Medicine to institution, gift to institution from Glyciome. Expert Testimony: None
declared. Patents: None declared. Other Remuneration: S. Feldman, royalties from Uptodate, payment for travel from American
Cancer Society and ASCCP.
Role of Sponsor: The funding organizations played no role in the design of study, choice of enrolled patients, review and inter
pretation of data, preparation of manuscript, or final approval of manuscript.
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