OBJECTIVES: Our goals were to assess adherence to the National Cancer Institute clinical practice guideline (CPG) for the management of atypical squamous cells of uncertain significance (ASCUS) Papanicolaou (Pap) test results in a community at high risk of cervical cancer and to identify predictors of adherence to the CPG.
STUDY DESIGN: We used a historical cohort and collected data by chart abstraction.
POPULATION: Our study included women receiving care in 7 urban community health centers who had an initial ASCUS or atypical Pap test result in 1996. We excluded women with a history of cervical dysplasia or human immunodeficiency virus infection, yielding a final sample of 387 women.
OUTCOMES MEASURED: The outcome was the level of adherence to the CPG, defined as falling within 1 of 3 mutually exclusive categories (complete, moderate, or low).
RESULTS: Providers recommended colposcopy after an initial atypical Pap test result in 12% of women and repeat cytology in 67% of women. Failure to document a plan for management was found in 19% of women. Complete adherence was achieved for 27% of subjects, moderate for 28%, and low for 45%. The factors associated with complete versus moderate or low adherence included site of care, description of the abnormality (ASCUS vs atypia), availability of onsite colposcopy, and discussing the plan at a visit.
CONCLUSIONS: Adherence with the CPG in this setting was disappointing and varied substantially by site. Factors amenable to change that may improve follow-up include good communication of results and providing colposcopy at the site of primary care.
KEY POINTS
- Adherence with the National Cancer Institute clinical practice guideline for the management of atypical squamous cells of uncertain significance (ASCUS) Papanicolaou test results is disappointing in an urban primary care setting.
- The manner in which cytology results are reported is important; optimal follow-up is more likely when results are reported as ASCUS rather than “atypia.”
- Factors amenable to change that may improve follow-up include good communication of results and providing colposcopy at the site of primary care.
Approximately 50 million Papanicolaou (Pap) tests are performed annually in the United States, of which approximately 5% will require further evaluation because of an abnormality.1 The Bethesda System for reporting cervical/vaginal cytologic diagnoses,2 developed in 1988 and revised in 1991, provides uniform diagnostic terminology to improve consistency of reporting. The Bethesda System introduced new terminology for atypical cytology, creating the label “atypical squamous cells of uncertain significance” (ASCUS). Pap test results labelled ASCUS encompass a spectrum of cellular change reflecting a variety of pathologic processes that cannot be more specifically categorized, including reactive changes, inflammation, human papillomavirus (HPV) related changes, suggested dysplasia, and less than optimal slide preparation.2 Because studies have consistently shown a small but real risk that an ASCUS Pap result represents an underlying high-grade lesion,3-6 there has been much debate about their management. Uncertainty about optimal management led to the development of clinical practice guidelines (CPG).7-9
The National Cancer Institute7 (NCI) and a Canadian expert pane18 suggest that ASCUS and low-grade squamous intraepithelial lesions can be managed either by immediate colposcopy or by repeating cervical cytology. Clinicians may, if they choose, reserve referral to colposcopy for those patients with persistent abnormality on subsequent cytology. This conservative strategy is based on several assumptions:10 (1) conditions that mimic dysplasia, including reactive changes, are common; (2) spontaneous regression occurs in at least 50% of low-grade lesions; (3) the rate of progression is relatively slow; (4) the chance of carcinoma in situ with an ASCUS Pap test result is low; and (5) persistently negative follow-up Pap results are unlikely to be false negatives. The current practice guideline suggests that if clinicians opt for cytologic follow-up of ASCUS, repeat Pap tests should be done every 4 to 6 months until 3 consecutive normal test results have been obtained. Colposcopy should be performed if there is a subsequent abnormal Pap test result.7 The 1996 statement of the American College of Obstetricians and Gynecologists is similar, with the addition that colposcopy be performed for women with a single ASCUS Pap result if they also have any of the following high-risk factors: HPV infection, human immunodeficiency virus (HIV) infection, smoking, or multiple sexual partners.9
A disproportionate share of the cervical cancer burden in this country, in terms of both incidence and mortality, is shouldered by low-income minority women.11-13 Minority and low-income populations have the highest rates of nonadherence with repeat Pap test or colposcopy.14-18 Thus, the women who are at the highest risk of cervical intraepithelial neoplasia (CIN) may also be the most at risk for suboptimal management after an abnormal Pap test result is obtained. This project assessed current management of ASCUS Pap results in a diverse community at high risk of cervical cancer by comparing actual practice to the NCI guideline. In addition to assessing levels of follow-up in this community, we sought to identify predictors of adherence to that guideline.