TRIAGE OF WOMEN WITH ASCUS AND LSIL ON PAP SMEAR REPORTS - MANAGEMENTBY REPEAT PAP SMEAR, HPV DNA TESTING, OR COLPOSCOPY

BACKGROUND. The purpose of this study was to determine the efficacy of a repeat Papanicolaou (Pap) smear and the Hybrid Capture tube-based ( HCT) HPV DNA test for detecting cervical intraepithelial neoplasia (CI N) grade 2 or 3 in women with recent atypical squamous cells of undete rmined significance (ASCUS) or low-grade squamous intraepithelial lesi on (LSIL) Pap smear reports. METHODS. Women with a recent Pap smear re port of ASCUS (n=169) or LSIL (n=110) had a repeat Pap smear, sampling of the cervix for HCT HPV DNA assay and a colposcopy examination. Dat a were evaluated using three different triage thresholds for colposcop y examination: a repeat Pap smear of persistent ASCUS or more severe d ysplasia, a finding of persistent LSIL or more severe dysplasia, and a carcinogenic HPV test result. RESULTS. The sensitivity specificity, a nd positive and negative predictive values for detecting CIN 2/3 were 70%, 45%, 7%, and 96% for a repeat Pap smear using an ASCUS-positive t hreshold and 20%, 86%, 8%, and 94% for a repeat Pap smear using an LSI L-positive threshold, respectively, when women with an initial ASCUS P ap smear were considered. HPV testing for carcinogenic viruses alone o l in combination with a repeat Pap smear (using ASCUS as a positive th reshold) yielded results of 50%, 67%, 9%, and 96%, respectively, and 7 0%, 37%, 7%, and 95%, respectively, for detecting CIN 2/3. In women wi th an initial LSIL Pap smear, respective values for detecting CIN 2/3 by a repeat Pap smear with an ASCUS threshold were 92%, 26%, 14%, and 96%, and for an LSIL threshold 23%, 64%, 8%, and 86%, respectively. Hy brid Capture HPV testing alone or in combination with a repeat Pap sme ar yielded 69%, 43%, 14%, and 91%, respectively, and 100%, 21%, 14%, a nd 100%, respectively. CONCLUSIONS. A Pap smear triage threshold restr icted to LSIL or more severe dysplasia for women with prior ASCUS or L SIL Pap smear results was clearly ineffective for detecting high-grade cervical precancerous lesions. In contrast, when the repeat Pap smear triage threshold was expanded to include persistent ASCUS as abnormal , 83% of the women with CIN 2/3 were detected. Detection of carcinogen ic HPV DNA using the HCT test was almost as sensitive for detecting CI N 2/3 as a solitary repeat Pap smear using an ASCUS or more severe pos itive threshold. Combining the HPV test with a repeat Pap smear did no t significantly improve the sensitivity of cytology for detecting high -grade CIN. This study suggests that women with ASCUS and particularly LSIL Pap smears should be referred for a colposcopy examination until better triage methods become available.