Professional clinical societies and cancer prevention experts together will make the decisions regarding the proper clinical responses to risk levels, considering benefits as well as total cost, which includes both financial and negative health consequences. In general, we believe that because screening is inherently a populationwide intervention among predominantly well women, the costs and benefits of a screening test or program should be described on a population basis. Evaluation of women with abnormal screening results, decisions on treatment, and proper posttreatment follow-up require increasing degrees of individualization and clinical judgment as risk becomes more clearly defined.
Basically, there are currently 4 options for management: 1) routine screening interval; 2) more intensive follow-up with shorter interval to screening; 3) colposcopy and biopsy; and 4) treatment. To promote discussion, we can provide some possible thresholds for risk of CIN3/cancer, as illustrated in the Figure, based on examples from currently used management strategies. Given that there is no such thing as zero risk, the first principle is to acknowledge that there is an acceptable low level of risk that does not trigger more intensive follow-up.
Women with a <2% risk of precancer within the subsequent 2–3 years (eg, women who test carcinogenic HPV negative in routine screening) may be at an acceptable low risk to remain in regular interval screening. Regular screening may include 1- to 2-year screening with cytology alone or every 3 years with cytology and carcinogenic HPV co-testing for women 30 and over. Women with a 2% to <10% risk (eg, women with negative cytology who test carcinogenic HPV positive in screening or women with atypical cells of undetermined significance [ASCUS] cytology unqualified by carcinogenic HPV testing) might warrant rescreening in a year. Women with a ≥10% risk (eg, women with low-grade squamous intraepithelial lesion [LSIL] cytology or carcinogenic HPV-positive ASCUS) may warrant immediate colposcopic evaluation, including multiple biopsies to maximize the sensitivity of colposcopy in high-risk women.
More controversial is the suggestion that women identified with a risk of precancer above a certain threshold may warrant treatment even if an initial colposcopic evaluation and directed biopsy, because of imperfect sensitivity, does not identify a precancerous lesion on that day. We should recognize that the current treatment threshold of CIN2 results in significant overtreatment of many women whose lesions would regress spontaneously; we already accept this overtreatment in order to provide a margin of safety against misclassification of diagnosis and risk.
With informed decision making between patient and clinician that takes into account patient well-being, it may be more cost effective and less invasive to immediately treat women with very high-risk profiles than to require 2 or more clinical visits, including an intensive follow-up with multiple biopsies to find the precancerous lesion that is probably present before it invades, followed by treatment.