Benchmarking CIN 3+ risk as the basis for incorporating HPV and pap cotesting into cervical screening and management guidelines

Hormuzd A. Katki, Mark Schiffman, Philip E. Castle, Barbara Fetterman, Nancy E. Poitras, Thomas Lorey, Li C. Cheung, Tina Raine-Bennett, Julia C. Gage, Walter K. Kinney

Research output: Contribution to journalArticle

122 Citations (Scopus)

Abstract

OBJECTIVE: In 2012, the US Preventive Services Task Force (USPSTF) and a consensus of 25 organizations endorsed concurrent cytology and human papillomavirus (HPV) testing ("cotesting") for cervical cancer screening. Past screening and management guidelines were implicitly based on risks defined by Pap-alone, without consideration of HPV test results. To promote management that is consistent with accepted practice, new guidelines incorporating cotesting should aim to achieve equal management of women at equal risk of cervical intraepithelial neoplasia grade 3 and cancer (CIN 3+). METHODS: We estimated cumulative 5-year risks of CIN 3+ for 965,360 women aged 30 to 64 years undergoing cotesting at Kaiser Permanente Northern California over 2003 to 2010. We calculated the implicit risk thresholds for Pap-alone and applied them for new management guidance on HPV and Pap cotesting, citing 2 examples: HPV-positive/atypical squamous cells of undetermined significance (ASC-US) and HPV-negative/Pap-negative. We call this guidance process "benchmarking." RESULTS: A low-grade squamous intraepithelial lesion result, for which immediate colposcopy is prescribed, carries a 5-year CIN 3+ risk of 5.2%, suggesting that test results with similar risks should be managed with colposcopy. Similarly, ASC-US (2.6% risk) is managed with a 6- to 12-month follow-up visit and Pap-negative (0.26% risk) is managed with a 3-year follow-up visit. The 5-year CIN 3+ risk for women with HPV-positive/ASC-US was 6.8% (95% confidence interval = 6.2%-7.6%). This is greater than the 5.2% risk implicitly leading to referral to colposcopy, consistent with current management recommendations that HPV-positive/ASC-US should be referred for immediate colposcopy. The 5-year CIN 3+ risk for women with HPV-negative/Pap-negative was 0.08% (95% confidence interval = 0.07%-0.09%), far below the 0.26% implicitly required for a 3-year return and justifying a longer (e.g., 5-year) return. CONCLUSIONS: Using the principle of "equal management of equal risks," benchmarking to implicit risk thresholds based on Pap-alone can be used to achieve safe and consistent incorporation of cotesting.

Original languageEnglish (US)
JournalJournal of Lower Genital Tract Disease
Volume17
Issue number5 SUPPL.1
DOIs
StatePublished - Apr 2013

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Benchmarking
Guidelines
Colposcopy
Confidence Intervals
Cervical Intraepithelial Neoplasia
Risk Management
Advisory Committees
Early Detection of Cancer
Practice Guidelines
Uterine Cervical Neoplasms
Cell Biology
Referral and Consultation

Keywords

  • Cancer prevention
  • Cervical intraepithelial neoplasia (CIN)
  • Human papillomavirus (HPV)
  • Pap

ASJC Scopus subject areas

  • Obstetrics and Gynecology

Cite this

Benchmarking CIN 3+ risk as the basis for incorporating HPV and pap cotesting into cervical screening and management guidelines. / Katki, Hormuzd A.; Schiffman, Mark; Castle, Philip E.; Fetterman, Barbara; Poitras, Nancy E.; Lorey, Thomas; Cheung, Li C.; Raine-Bennett, Tina; Gage, Julia C.; Kinney, Walter K.

In: Journal of Lower Genital Tract Disease, Vol. 17, No. 5 SUPPL.1, 04.2013.

Research output: Contribution to journalArticle

Katki, HA, Schiffman, M, Castle, PE, Fetterman, B, Poitras, NE, Lorey, T, Cheung, LC, Raine-Bennett, T, Gage, JC & Kinney, WK 2013, 'Benchmarking CIN 3+ risk as the basis for incorporating HPV and pap cotesting into cervical screening and management guidelines', Journal of Lower Genital Tract Disease, vol. 17, no. 5 SUPPL.1. https://doi.org/10.1097/LGT.0b013e318285423c
Katki, Hormuzd A. ; Schiffman, Mark ; Castle, Philip E. ; Fetterman, Barbara ; Poitras, Nancy E. ; Lorey, Thomas ; Cheung, Li C. ; Raine-Bennett, Tina ; Gage, Julia C. ; Kinney, Walter K. / Benchmarking CIN 3+ risk as the basis for incorporating HPV and pap cotesting into cervical screening and management guidelines. In: Journal of Lower Genital Tract Disease. 2013 ; Vol. 17, No. 5 SUPPL.1.
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abstract = "OBJECTIVE: In 2012, the US Preventive Services Task Force (USPSTF) and a consensus of 25 organizations endorsed concurrent cytology and human papillomavirus (HPV) testing ({"}cotesting{"}) for cervical cancer screening. Past screening and management guidelines were implicitly based on risks defined by Pap-alone, without consideration of HPV test results. To promote management that is consistent with accepted practice, new guidelines incorporating cotesting should aim to achieve equal management of women at equal risk of cervical intraepithelial neoplasia grade 3 and cancer (CIN 3+). METHODS: We estimated cumulative 5-year risks of CIN 3+ for 965,360 women aged 30 to 64 years undergoing cotesting at Kaiser Permanente Northern California over 2003 to 2010. We calculated the implicit risk thresholds for Pap-alone and applied them for new management guidance on HPV and Pap cotesting, citing 2 examples: HPV-positive/atypical squamous cells of undetermined significance (ASC-US) and HPV-negative/Pap-negative. We call this guidance process {"}benchmarking.{"} RESULTS: A low-grade squamous intraepithelial lesion result, for which immediate colposcopy is prescribed, carries a 5-year CIN 3+ risk of 5.2{\%}, suggesting that test results with similar risks should be managed with colposcopy. Similarly, ASC-US (2.6{\%} risk) is managed with a 6- to 12-month follow-up visit and Pap-negative (0.26{\%} risk) is managed with a 3-year follow-up visit. The 5-year CIN 3+ risk for women with HPV-positive/ASC-US was 6.8{\%} (95{\%} confidence interval = 6.2{\%}-7.6{\%}). This is greater than the 5.2{\%} risk implicitly leading to referral to colposcopy, consistent with current management recommendations that HPV-positive/ASC-US should be referred for immediate colposcopy. The 5-year CIN 3+ risk for women with HPV-negative/Pap-negative was 0.08{\%} (95{\%} confidence interval = 0.07{\%}-0.09{\%}), far below the 0.26{\%} implicitly required for a 3-year return and justifying a longer (e.g., 5-year) return. CONCLUSIONS: Using the principle of {"}equal management of equal risks,{"} benchmarking to implicit risk thresholds based on Pap-alone can be used to achieve safe and consistent incorporation of cotesting.",
keywords = "Cancer prevention, Cervical intraepithelial neoplasia (CIN), Human papillomavirus (HPV), Pap",
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T1 - Benchmarking CIN 3+ risk as the basis for incorporating HPV and pap cotesting into cervical screening and management guidelines

AU - Katki, Hormuzd A.

AU - Schiffman, Mark

AU - Castle, Philip E.

AU - Fetterman, Barbara

AU - Poitras, Nancy E.

AU - Lorey, Thomas

AU - Cheung, Li C.

AU - Raine-Bennett, Tina

AU - Gage, Julia C.

AU - Kinney, Walter K.

PY - 2013/4

Y1 - 2013/4

N2 - OBJECTIVE: In 2012, the US Preventive Services Task Force (USPSTF) and a consensus of 25 organizations endorsed concurrent cytology and human papillomavirus (HPV) testing ("cotesting") for cervical cancer screening. Past screening and management guidelines were implicitly based on risks defined by Pap-alone, without consideration of HPV test results. To promote management that is consistent with accepted practice, new guidelines incorporating cotesting should aim to achieve equal management of women at equal risk of cervical intraepithelial neoplasia grade 3 and cancer (CIN 3+). METHODS: We estimated cumulative 5-year risks of CIN 3+ for 965,360 women aged 30 to 64 years undergoing cotesting at Kaiser Permanente Northern California over 2003 to 2010. We calculated the implicit risk thresholds for Pap-alone and applied them for new management guidance on HPV and Pap cotesting, citing 2 examples: HPV-positive/atypical squamous cells of undetermined significance (ASC-US) and HPV-negative/Pap-negative. We call this guidance process "benchmarking." RESULTS: A low-grade squamous intraepithelial lesion result, for which immediate colposcopy is prescribed, carries a 5-year CIN 3+ risk of 5.2%, suggesting that test results with similar risks should be managed with colposcopy. Similarly, ASC-US (2.6% risk) is managed with a 6- to 12-month follow-up visit and Pap-negative (0.26% risk) is managed with a 3-year follow-up visit. The 5-year CIN 3+ risk for women with HPV-positive/ASC-US was 6.8% (95% confidence interval = 6.2%-7.6%). This is greater than the 5.2% risk implicitly leading to referral to colposcopy, consistent with current management recommendations that HPV-positive/ASC-US should be referred for immediate colposcopy. The 5-year CIN 3+ risk for women with HPV-negative/Pap-negative was 0.08% (95% confidence interval = 0.07%-0.09%), far below the 0.26% implicitly required for a 3-year return and justifying a longer (e.g., 5-year) return. CONCLUSIONS: Using the principle of "equal management of equal risks," benchmarking to implicit risk thresholds based on Pap-alone can be used to achieve safe and consistent incorporation of cotesting.

AB - OBJECTIVE: In 2012, the US Preventive Services Task Force (USPSTF) and a consensus of 25 organizations endorsed concurrent cytology and human papillomavirus (HPV) testing ("cotesting") for cervical cancer screening. Past screening and management guidelines were implicitly based on risks defined by Pap-alone, without consideration of HPV test results. To promote management that is consistent with accepted practice, new guidelines incorporating cotesting should aim to achieve equal management of women at equal risk of cervical intraepithelial neoplasia grade 3 and cancer (CIN 3+). METHODS: We estimated cumulative 5-year risks of CIN 3+ for 965,360 women aged 30 to 64 years undergoing cotesting at Kaiser Permanente Northern California over 2003 to 2010. We calculated the implicit risk thresholds for Pap-alone and applied them for new management guidance on HPV and Pap cotesting, citing 2 examples: HPV-positive/atypical squamous cells of undetermined significance (ASC-US) and HPV-negative/Pap-negative. We call this guidance process "benchmarking." RESULTS: A low-grade squamous intraepithelial lesion result, for which immediate colposcopy is prescribed, carries a 5-year CIN 3+ risk of 5.2%, suggesting that test results with similar risks should be managed with colposcopy. Similarly, ASC-US (2.6% risk) is managed with a 6- to 12-month follow-up visit and Pap-negative (0.26% risk) is managed with a 3-year follow-up visit. The 5-year CIN 3+ risk for women with HPV-positive/ASC-US was 6.8% (95% confidence interval = 6.2%-7.6%). This is greater than the 5.2% risk implicitly leading to referral to colposcopy, consistent with current management recommendations that HPV-positive/ASC-US should be referred for immediate colposcopy. The 5-year CIN 3+ risk for women with HPV-negative/Pap-negative was 0.08% (95% confidence interval = 0.07%-0.09%), far below the 0.26% implicitly required for a 3-year return and justifying a longer (e.g., 5-year) return. CONCLUSIONS: Using the principle of "equal management of equal risks," benchmarking to implicit risk thresholds based on Pap-alone can be used to achieve safe and consistent incorporation of cotesting.

KW - Cancer prevention

KW - Cervical intraepithelial neoplasia (CIN)

KW - Human papillomavirus (HPV)

KW - Pap

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