OBG Management: What do clinicians need in order to execute the guidelines?
Dr. Huh: Nothing. All of the information needed—the guidelines article and risk tables—are publicly available. However, to make navigation of the guidelines easier, the plan is for the app that I mentioned. I have the app on my phone and am actively beta testing it now. We’re planning on creating a web-based application as well, that will allow users to access the Internet and their electronic health record system so that they can plug in information directly from patient charts. The web-based app will be similar to the web-based Breast Cancer Surveillance Consortium’s Risk Calculator (https://tools.bcsc-scc.org/BC5yearRisk/calculator.htm). You will pull it up, plug in the requested information, including the patient’s age; their Pap smear and genotyping results; and their previous screening history.
OBG Management: When will the app be available for users?
Dr. Huh: It will be available for release on June 8.
OBG Management: Were HPV vaccination levels incorporated into the new guidelines?
Dr. Huh: We initially looked at them because human papillomavirus (HPV) vaccination hugely influences outcomes but, no, we did not include them in the guidelines. The reason is that it’s really challenging to prove whether a woman has been vaccinated. You have to have access to vaccine records. Then there is also the issue of whether a patient has had 1, 2, or 3 doses. That is a really sticky variable. So, since it is not part of the guidelines, ASCCP also did not include it as a part of the app or the website. But we do recognize that HPV vaccination plays an important role in outcomes.
OBG Management: Have recommendations regarding colposcopy changed?
Dr. Huh: Not really. About 3 years ago, we created basic colposcopy guidelines—the ASCCP Colposcopy Standards—so everything about colposcopy references back to those guidelines. Those colposcopy standards covered terminology and risk-based colposcopy, which actually aligns beautifully with these guidelines.
OBG Management: To narrow in on some changes from the prior guidelines, can colposcopy be deferred in certain patients?
Dr. Huh: Yes. Not everyone who has an abnormal screening test needs to come back for colposcopy.
OBG Management: How has guidance for expedited treatment or treatment without colposcopic biopsy changed?
Dr. Huh: This was heavily debated within not only the treatment group that I co-chaired with Richard Guido, MD, but also within the entire steering committee. The recommendation is that if the patient has an immediate risk of CIN 3 that is >60%, the patient should go straight to treatment without a colposcopic biopsy. The main reason for this is that you do not want to biopsy a patient and then lose them to follow-up.
When a woman has >60% immediate risk of CIN 3, we are fairly certain that colposcopy is not going to change management ultimately, so we recommend that patients receive treatment right away. We have already been doing this for 15 to 20 years, so this is not a new concept. It is just more formally codified here by assigning a percentage to the risk. Those who have between 25% and 60% immediate risk of CIN 3 should receive immediate colposcopy. We realize that not all clinicians have the ability to do this, so if clinicians can’t treat immediately, we recommend they do whatever they can to prevent losing the patient to follow-up.
OBG Management: How should a positive primary HPV screening test be managed?
Dr. Huh: If a woman has a positive primary HPV screening test, genotyping should be performed. If genotyping reveals HPV 16 or 18, then the patient should proceed to colposcopy. If genotyping reveals other forms of HPV, reflex cytology or a Pap smear should follow. ●