Page 21 - Screening for Cervical Cancer: Systematic Evidence Review

Chapter I. Introduction

spectrum of cervical abnormalities detected by cytology, from low-grade changes to carcinoma

in situ, is a particular challenge. HSIL warrants immediate evaluation by colposcopy, biopsy,

and endocervical curettage. Patients with CIN 3/CIS receive definitive intervention, such as

conization by loop electrosurgical excision procedure (LEEP), laser, or cold knife, to remove the

transformation zone and confirm that no invasive disease is present. Patients with CIN 2 may be

treated with conization or ablative procedures to remove or destroy the transformation zone.

Appropriate intervention for atypical squamous cells of uncertain significance (ASCUS) and

LSIL are active areas of research focused on determinants of progression, stability, and

regression.

Current clinical care of ASCUS and LSIL increases the vigilance of follow-up and results

in colposcopic evaluation for the majority of women with these diagnoses. Evaluation of

ASCUS is guided by the cytologic clarification that accompanies the diagnosis: (a) reactive

processes are followed with repeat Paps every 6 months until 3 normals; (b) inflammation

prompts evaluation for infection, followed by repeat Pap; (c) atrophic changes are treated with

topical estrogen, followed by repeat Pap; and (d) ASCUS favoring atypia is evaluated in a

fashion comparable to the degree of atypia suggested (i.e., “ASCUS favor LSIL” is evaluated as

LSIL). LSIL, in a patient who will be compliant with follow-up and is comfortable with

expectant management, can be followed with repeat Paps every 6 months until 3 consecutive

negative smears are obtained or progression is noted. Colposcopy and biopsy is preferred for

high-risk patients (characteristically broadly defined and not clearly specified) and required for

those with immune compromise or prior dysplasia.

As women are screened at younger ages and in larger numbers, and as tests are

increasingly sensitive for detecting low-grade changes such as ASCUS and CIN 1, the

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