Table 19.2 (Continued )
Atypical endocervical cells, favor neoplastic  glandular cells, favor neoplastic
Suggestions should be concise and consistent with clinical follow-up guidelines published by professional organizations (references to relevant publications may be included).
From Solomon D, Davey D, Kurman R, et al. The 2001 Bethesda System: terminology for reporting results of cervical cytology. JAMA 2002; 287:2114–2119. Available online at: www.bethesda2001.cancer.gov w ww.cancer.gov/newscenter/pressreleases/2002/bethesda2001 otherwise specified, depending on the presumptive origin, or modified to atypical glandular cells favor neoplasia in the presence of evidence of their origin (Table 19.2).
Guidelines based on the literature were developed to guide cervical cancer screening, follow-up, and treatment. The evolving state of the science and our improved understanding of HPV and cervical carcinogenesis, and clinical practice and liability considerations, occasionally lead to subtle differences in the interpretation of these guidelines. Ultimately guidelines cannot substitute for an informed discussion of risks and benefits between a patient and health care provider in order to make decisions about treatment.
The 2002 American Cancer Society (ACS) recommended that screening with conventional Pap testing should occur every year. If liquid-based cytology is being used, screening can be extended to every 2 years. Beginning at the age of 30, women may be screened every 3 years using a combination of cytology and a high-risk HPV DNA test. Screening should begin at the age of 21 or within 3 years of the onset of sexual activity, and screening can stop at age 70 if there were no abnormal Pap test result in the previous 10 years. Under these recommendations, screening after hysterectomy for benign (non-HPV related) disease is not necessary (61).
The American College of Obstetricians and Gynecologists (ACOG) updated its guidelines (62). The ACOG recommends that women not initiate cervical cancer screening until they are 21, regardless of the onset of sexual activity. This acknowledges the very low prevalence of invasive cancer in very young women, the long multiyear process of cervical carcinogenesis, and the very low but real risks for preterm birth associated with outpatient excisional procedures. Likewise screening frequency was revised to every 2 years from age 21 to 29 (with either conventional slide or liquid-based cytology), and every 3 years for women after age 30 years if three consecutive negative, i.e., negative for intraepithelial lesion or malignancy (NILM) Pap tests can be documented. More frequent screening continues to be recommended for HIV-positive women (twice first year and annually after), those who are immune-suppressed, diethylstilbestrol (DES) daughters, and for those with a history of CIN 2 or greater (screen annually for 20 years). Discontinuation of screening is reasonable between 65 to 70 years, with reassessment of risk factors annually to determine if reinitiating screening is appropriate. Likewise in the setting of posthysterectomy for benign indications it is reasonable to discontinue screening in the absence of a history of high-grade CIN or cancer (Table 19.3).
Table 19.3 Comparison of Screening Guidelines from the American Cancer Society and the American College of Obstetricians and Gynecologists
Comparison of Cervical Cytology Screening