See the 2010 TREATMENT GUIDELINES for the most recent treatment information.
Cervical Cancer Screening for Women Who Attend STD Clinics or Have a History of STDs
Women with a history of STDs might be at increased risk for cervical cancer, and women attending STD clinics might have other risk factors that place them at even greater risk. Prevalence studies indicate that precursor lesions for cervical cancer occur approximately five times more frequently among women attending STD clinics than among women attending family planning clinics (196). Cervical cancer screening using the Pap test is an effective, low-cost screening test for preventing invasive cervical cancer. Recommendations for cervical cancer screening intervals vary in the United States, but the American Cancer Society and American College of Obstetricians and Gynecologists guidelines recommend annual screening for women aged 21–30 years and then every 2–3 years for women aged ≥30 years if three consecutive annual Pap tests are negative (197,198).
During the appointment in which a pelvic examination for STD screening is performed, the health-care provider should inquire about the result of the patient’s most recent Pap test and discuss the following information with the patient:
- the purpose and importance of a Pap test;
- the need for regularly scheduled Pap tests between aged 21–65 years;
- whether a Pap test will be obtained during this clinic visit; and
- if a Pap test will NOT be obtained during this examination, the names of local providers or referral clinics that can perform Pap tests and adequately follow up results if indicated.
If a woman has not had a Pap test during the previous 12 months, a Pap test may be obtained as part of the routine pelvic examination. Health-care providers should be aware that many women frequently equate having a pelvic examination with having a Pap test; they believe that a Pap test was taken when they actually received only a pelvic examination. They might, therefore, over report having had a recent Pap test. Therefore, in STD clinics, having a protocol for conducting cervical cancer screening should be highly encouraged and obtaining a Pap test strongly considered during the routine clinical evaluation of women who do not have clinical-record documentation of a normal Pap test within the preceding 12 months.
A woman might benefit from receiving printed information concerning Pap tests and a report containing a statement that a Pap test was obtained during her clinic visit. If possible, a copy of the Pap test result should be provided to the patient for her records when it becomes available.
STD clinics offering cervical cancer screening are encouraged to use cytopathology laboratories that report results by using the Bethesda System of classification (199).††† If the results of the Pap test are abnormal, follow-up care should be provided according to the ASCCP Consensus Guidelines for Management of Abnormal Cervical Cytology (198), or information regarding follow-up care is available at http://www.asccp.org. If resources in STD clinics do not allow follow-up of abnormal results, protocols for referral of women needing follow-up and case management should be in place. Pap tests indicating low- or high-grade SIL should always include referral to a clinician who can perform a colposcopic examination of the lower genital tract and, if indicated, colposcopically directed biopsy. For patients with an equivocal Pap test report indicating ASC-US, three options are available for follow-up management: 1) immediate colposcopy, 2) repeat Pap tests at 6-month intervals for 3 intervals, or 3) an HPV DNA test. Women with ASC-US may be considered for immediate colposcopy if concerns for patient adherence with recommended follow-up or for other clinical indications are a factor. The presence of high grade histological changes after ASC-US Pap test reports usually is <10%.
††† The Bethesda System for Reporting Cervical/Vaginal Cytologic Results uses the terms “low-grade SIL” and “high-grade SIL” for abnormal results (199). Low-grade SIL encompasses cytological changes associated with HPV and mild dysplasia. High-grade SIL includes cytological changes associated with moderate dysplasia, severe dysplasia, and carcinoma in situ. Cytological results should be distinguished from histological results obtained from biopsy specimens.
If repeat Pap tests are used to follow ASC-US results, a test should be performed every 6 months until 3 negative results are noted before the women returns to cervical cancer screening at a normal interval for age. If subsequent Pap tests demonstrate progression to SIL, follow-up should be conducted according to ASCCP Consensus Guidelines (i.e., frequent colposcopy and directed cervical biopsy). If specific infections other than HPV are identified, the patient might need to have a repeat Pap test after appropriate treatment for those infections. In the majority of instances, even in the presence of some severe infections, Pap tests will be reported as satisfactory for evaluation, so they may be read and final reports produced without the necessity to treat and repeat the Pap test. When repeating the Pap test is necessary because of an unsatisfactory for interpretation report, the repeat test must be interpreted by the laboratory as satisfactory and also be negative before returning the woman to Pap tests at regularly scheduled intervals.
A third strategy for managing patients with ASC-US Pap test results involves testing for HPV DNA. Whereas conducting HPV testing in some STD clinics might not be possible or appropriate because of inadequate resources, such testing might be appropriate in other public health clinic settings. Only one FDA-cleared test exists, the Digene Hybrid Capture II. The HPV DNA test may be performed by 1) co-collecting a specimen; 2) using a supplied swab at the time of the Pap test, if conventional cytology is used; 3) reflex testing, if liquid-based cytology is used and enough residual material is available in the cytology test vial; or 4) scheduling a separate follow-up appointment when the Pap test report results are known. If the high-risk HPV DNA test is positive, women are referred immediately for colposcopy, and if indicated, directed cervical biopsy. Because many public health clinics, including the majority of STD clinics, cannot provide clinical follow-up of abnormal Pap tests, women with Pap tests demonstrating low or high grade SIL or ASC-US usually need a referral to other local health-care providers or clinics for colposcopy and biopsy. Clinics and health-care providers who offer Pap test screening services but cannot provide appropriate colposcopic follow-up of abnormal Pap tests should arrange referral to health-care facilities in which 1) a patient will be promptly evaluated and treated and 2) the results of the evaluation will be reported to the referring clinic or health-care provider. Clinics and health-care providers should develop protocols that identify women who miss follow-up appointments so that these women can be located and scheduled for needed studies and management, and they should reevaluate such protocols routinely. Pap test results, type and location of follow-up appointments, and results of follow-up appointments should be clearly documented in the clinic record. The establishment of colposcopy and biopsy services in local health departments, especially in circumstances in which referrals are difficult and follow-up is unlikely, should be considered if resources are available.
Other considerations in performing Pap tests include the following:
- The Pap test should not be considered a screening test for STDs.
- All women, regardless of sexual orientation (heterosexual women and those who identify themselves as lesbian or bisexual), should be considered for cervical cancer screening in an STD clinic setting.
- If a woman is menstruating, a Pap test should be postponed, and the woman should be advised to have a Pap test at the earliest opportunity.
- The presence of a mucopurulent discharge should not delay the Pap test. The test can be performed after careful removal of the discharge with a saline-soaked cotton swab.
- Women who have external genital warts do not need Pap tests more frequently than women who do not have warts, unless otherwise indicated.
- The sequence of Pap testing in relation to collection of other cervicovaginal specimens does not appear to influence Pap test results or their interpretation. Therefore, when other cultures or specimens are collected for STD diagnoses, the Pap test can be obtained last.
- Women who have had a total hysterectomy do not require a routine Pap test unless the hysterectomy was performed because of cervical cancer or its precursor lesions. In these situations, women should be advised to continue follow-up with the physician(s) who provided health care at the time of the hysterectomy, if possible. If the cervix remains after a hysterectomy, a woman should receive regularly scheduled Pap tests.
- Health-care providers who receive basic retraining on Pap test collection and clinics that use simple quality assurance measures obtain fewer unsatisfactory tests. The use of cytobrushes and brooms also improves the number of satisfactory Pap tests.
- Whereas evidence supports the option of HPV testing for the triage of women with ASC-US Pap test reports, this option might not be appropriate in an STD clinic because of limited resources. Studies to define the cost-effectiveness of HPV testing for the triage of women with ASC-US Pap tests are ongoing. The HPV test strategy that might be most cost-effective is the collection of a cervical swab placed in liquid media (i.e., liquid-based cytology or collection of a separate swab stored in HPV DNA transport media) during the initial visit when a Pap test is collected. When the Pap test report is available, an HPV DNA test can be performed on the residual material, if indicated, without the patient needing another clinic visit.
- Liquid-based cytology is an alternative to conventional Pap tests; it has a higher sensitivity for detection of SIL and can facilitate HPV testing in women with ASC-US. However, liquid-based cytology has a lower specificity, resulting in more false-positive tests and, therefore, more administrative and patient-related costs, which could reduce the cost-effectiveness of cervical cancer screening and increase the risk of patient harm because of unnecessary follow-up tests.
Pregnant women should have a Pap test as part of routine prenatal care. A cytobrush and an Ayers spatula might be used for obtaining Pap tests in pregnant women.
Several studies have documented an increased prevalence of SIL in HIV-infected women (200,201). The following recommendations for Pap test screening among HIV-infected women are consistent with other guidelines published by the U.S. Department of Health and Human Services (50) and are based partially on the opinions of professionals knowledgeable about the care and management of cervical cancer and HIV infection in women.
After obtaining a complete history of previous cervical disease, HIV-infected women should be provided a comprehensive gynecologic examination, including a pelvic examination and Pap test, as part of their initial evaluation. A Pap test should be obtained twice in the first year after diagnosis of HIV infection and, if the results are normal, annually thereafter. If the results of the Pap test are abnormal, care should be provided according to the ASCCP Consensus Guidelines for Management of Abnormal Cervical Cytology (198). Women with cytological reports of ASC-US, low or high-grade SIL or squamous cell carcinoma, regardless of CD4+ count or antiretroviral treatment status, should undergo colposcopy and directed biopsy. Colposcopy and biopsy are not indicated in HIV-positive women with negative Pap test reports.