Disclaimer
Although the guidelines are based on evidence whenever possible, for certain clinical situations, there is limited
high quality evidence, and in these situations the guidelines have, by necessity, been based on consensus expert
opinion. It is also important to recognize that these guidelines should never substitute for clinical judgment.
Clinical judgment should always be used when applying a guideline to an individual patient because it is impossible
to develop guidelines that will apply to all situations.
- Sometimes cytology or pathology are not conclusive. Consider management according to the highest-grade abnormality
found when histology or cytology is inconclusive such as a result of ‘LSIL cannot rule out HSIL’.
- Note that a negative past history should be entered only when documented in the medical record and performed on
time:
- Negative HPV test or cotest within 5 years
- Colposcopic examination confirming CIN1 or less within 1 year.
Finally, both clinicians and patients need to recognize that while most cases of cervical cancer can be prevented
through a program of screening and management of cervical precancer, no screening or treatment modality is 100%
effective and invasive cervical cancer can develop in women participating in such programs.
Summary
Updated United States consensus guidelines for management of cervical screening abnormalities are needed to
accommodate the three available cervical screening strategies: primary human papillomavirus (HPV) screening,
cotesting with HPV testing and cervical cytology, and cervical cytology alone. New data indicate that a patient's
risk of developing cervical precancer or cancer can be estimated using her current screening test results and prior
screening test and biopsy results, while considering personal factors such as age and immunosuppression.
Furthermore, since prior test results affect risk, patients with prior abnormalities often require surveillance with
HPV testing or cotesting at more frequent intervals than are recommended for screening. Routine screening applies
only to patients without risk factors.
The 2012 consensus guidelines were the first to be based on the principle of equal management for equal risk,
specifically, the risk of a patient developing cervical cancer, estimated by the surrogate endpoint of the 5-year
risk of cervical intraepithelial neoplasia (CIN) grade 3 (CIN3) or more severe diagnoses (CIN3+), regardless of
which test combinations yielded this risk level. Introduction of risk- based guidelines in 2012 was a conceptual
breakthrough, but the recommendations retained a continued reliance on complicated algorithms and insufficiently
incorporated past screening history. With a more nuanced understanding of how prior results affect risk, and more
variables to consider, the 2019 guidelines further align management recommendations with current understanding of
HPV natural history and cervical carcinogenesis. More frequent surveillance, colposcopy, and treatment are
recommended for patients at progressively higher risk, while those at lower risk can defer colposcopy, undergo
follow-up at longer surveillance intervals and, when at sufficiently low risk, return to routine screening. Clearly
defined risk thresholds to guide management are designed to continue functioning appropriately when population-level
prevalence of CIN3+ decreases due to HPV vaccination, and also as new screening and triage tests are introduced. The
revised guidelines provide a framework for incorporating new data and technologies as ongoing incremental
recommendation revisions, minimizing the time needed to implement changes that are beneficial to patient care.
Frequently Asked Questions
Who developed these guidelines?
The ASCCP Risk-Based Management Consensus Guidelines represent a consensus of nearly 20 professional organizations
and patient advocates, convened by ASCCP; they are designed to safely triage individuals with abnormal cervical
cancer screening results. The last 10 years of research has shown that risk-based management allows clinicians to
better identify which patients will likely go on to develop pre-cancer and which patients may be indicated to return
to routine screening. A full list of organizations participating in
the consensus process is available.
How are these guidelines different?
The new Risk-Based Management Consensus Guidelines have several important differences from the 2012 Guidelines,
while retaining many of principles, such as the principle of equal management for equal risk. Rather than consider
test results in isolation, the new guidelines use current and past results to create individualized assessments of a
patient's risk of progressing to precancer or cancer. The goals of the ASCCP Risk-Based Management Consensus
Guidelines are to increase accuracy and reduce complexity for providers and patients.
Do the new guidelines still use algorithms?
The new guidelines rely on individualized assessment of risk taking into account past history and current results.
Risk estimation will use technology, such as a smartphone application or website. Because the new Risk-Based
Management Guidelines will be electronic, updates and new technologies will be incorporated at a much faster rate
than in previous iterations of guidelines. The ability to adjust to the rapidly emerging science is critical for the
long-term utility of the guidelines. There will be an option available at no cost.
Why were the guidelines revised now?
The management guidelines were revised now due to the availability of sufficient data from the United States showing
that incorporation of the risk-based approach can provide more appropriate and personalized management for an
individual patient based on their current results and past history. In addition, several new recommendations for
cervical cancer screening have come out since 2012, such as primary HPV as a screening option for patients 25 years
of age and older. Updated guidelines were needed to incorporate these changes. In addition, changing the paradigm of
management from one that is based on specific test results to one that is based on a patient's risk will allow for
incorporation of future technologies as well.
Clinical Situations
Routine Screening (within past 5 years): Management of HPV and/or cytology results obtained during routine cervical cancer screening and for patients where prior screening results did not result in colposcopy, but where risk was too high to return to routine screening.
Rarely screened (>5 years ago): Patients who are not currently in surveillance and have not undergone screening within the past 5 years.
Evaluation of a colposcopic biopsy: Management of biopsy results after colposcopy.
Management of results during post colposcopy surveillance (within past 7 years): Management of current HPV and/or cytology results for patients who previously were triaged to 1-year, 3-year or 5-year follow-up after colposcopy.
Follow-up after treatment: Management of current HPV and/or cytology results for patients who have previously been treated for dysplasia.
Glossary
CIN2+: this term includes CIN2, CIN3, AIS, and cancer
CIN3+: this term includes CIN3, AIS, and cancer
Clinical Action Threshold: this term refers to risk levels that prompt different clinical management
strategies. For example, an immediate CIN3+ risk of 4% is the Clinical Action Threshold for colposcopy; risks below
this threshold undergo surveillance, while risks above this threshold, but below the expedited treatment threshold,
undergo colposcopy.
Colposcopy standards: this term refers to the ASCCP Colposcopy Standards that provide evidence-based
recommendations for the practice of colposcopy.
Cotesting: this term refers to screening or surveillance performed with both cytology and HPV testing.
Expedited treatment: this term means treatment without confirmatory colposcopic biopsy (e.g., see and
treat).
Excisional treatment: this term includes procedures that remove the transformation zone and produce a
specimen for histologic analysis, such as Loop Electrosurgical Excision Procedure (LEEP), Large Loop Excision of the
Transformation Zone (LLETZ), and cold knife conization.
HPV: this term refers to Human Papillomavirus. Within this text, HPV refers specifically to high-risk HPV as
defined by IARC, including the 12 types that are considered Class 1 carcinogens, plus type 68 which is considered a
Class 2A carcinogen (i.e., HPV types 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, and 68).
HPV-based testing: this term is used in this document to describe the use of either cotesting or primary HPV
screening for surveillance after abnormalities. It does not apply to reflex HPV testing for triage of ASC-US
cytology in this document. HPV testing and positive HPV results discussed throughout this document, refer to
high-risk HPV types only.
Lower Anogenital Squamous Terminology (LAST): this term refers to two-tiered pathology criteria for
evaluating histologic specimens obtained via colposcopic biopsy.
Primary HPV testing: testing with HPV testing alone as a screening or surveillance test.
Reflex testing: this means that laboratories should perform a specific additional triage test in the setting
of a positive screening test to inform the next steps in management. For example, an ASC-US cytology should trigger
a reflex HPV test. New for these guidelines, a positive screening HPV test should trigger both a reflex genotyping
test (to determine the presence/absence of HPV 16/18), and also a reflex cytology test to determine whether the
patient would be a candidate for expedited management.
Surveillance: this term refers to repeat testing (HPV primary screening, cotesting, or cytology alone), that
occurs at shorter intervals than those recommended for routine screening. For example, HPV primary testing or
cotesting at intervals <5 years, or cytology alone at intervals <3 years.
Acknowledgments
The guidelines effort received support from ASCCP and the National Cancer Institute. Participating organizations
supported travel for their participating representatives. All participating consensus organizations, including the
primary funders, had equal and balanced roles in the consensus process including data analysis and interpretation,
writing of manuscript, and decision to submit for publication. No industry funds were used in the development of
these guidelines. The corresponding authors had final responsibility for the submission decision.
The Steering Committee, Working Group members, and additional contributing authors for the ASCCP Risk Based
Management Consensus Guidelines Committee includes:
Deborah Arrindell; Pelin Batur, MD; Alicia Carter, MD; Patty Cason, MS, FNP; Philip Castle, PhD; David Chelmow, MD;
Xiaojian Chen MS; Li Cheung PhD; Kim Choma, DNP; Megan Clarke, PhD; Christine Conageski, MD; Miriam Cremer, MD, MPH;
Barbara Crothers, DO; Teresa Darragh, MD; Maria Demarco, PhD; Eileen Duffey-Lind, MSN; Ysabel Duron, BA; Didem
Egemen PhD; Mark Einstein, MD; Carol Eisenhut, MD, MBA; Tamika Felder; Sarah Feldman, MD, MPH; Francisco Garcia, MD;
Michael Gold, MD; Robert Goulart, MD; Richard Guido, MD; Paul Han, MD; Sally Hersh, DNP; Aimee Holland, DNP; Eric
Huang, MD; Warner Huh, MD; Michelle Khan, MD, MPH; Jane Kim, PhD; Rachel Kupets, MD; Margaret Long, MD; Thomas Lorey
MD; Jennifer Loukissas, MPP; Anna-Barbara Moscicki, MD; Jeanne Murphy, PhD; Amber Naresh, MD, MPH; Ritu Nayar, MD;
Erin Nelson, MD; Akiva Novetsky, MD, MS; Rebecca Perkins, MD; Jeffrey Quinlan, MD; Mona Saraiya, MD; Debbie Saslow,
PhD; George Sawaya, MD; Mark Schiffman, MD; Kathryn Sharpless, MD, PhD; Katie Smith, MD, MS; Elizabeth Stier, MD;
Colleen Stockdale, MD, MS; Sana Tabbara, MD; Deanna Teoh, MD, MS; Elizabeth Unger, PhD, MD; Alan Waxman, MD, MPH;
Kelly Welch; Nicolas Wentzensen, PhD; Claudia Werner, MD; Amy Wiser, MD; Rosemary Zuna, MD
The ASCCP Management Guidelines applications were developed by ASCCP. No industry funds were used in the
development of the applications.
The application uses data and recommendations from the following sources:
1. Perkins RB, Guido RS, Castle PE, et al. 2019 ASCCP risk-based management consensus guidelines for abnormal
cervical cancer screening tests and cancer precursors. J Low Genit Tract Dis 2020;24:102-31.
2. Egemen D, Cheung LC, Chen X, et al. Risk estimates supporting the 2019 ASCCP Risk-Based Management Consensus
Guidelines. J Low Genit Tract Dis 2020;24:132-43.
3. Demarco M, Egemen D, Raine-Bennett TR, et al. A study of partial human papillomavirus genotyping in support of
the 2019 ASCCP risk-based management consensus guidelines. J Low Genit Tract Dis 2020;24:144-7.
4. Risk estimates supporting the 2019 ASCCP Risk-Based Management Consensus Guidelines. https://cervixca.nlm.nih.gov/RiskTables/
5. Massad SL, Einstein MH, Huh WK, et al. 2012 updated consensus guidelines for the management of abnormal cervical
cancer screening tests and cancer precursors. J Low Genit Tract Dis 2013; 17: S1-S27.
The clinical management recommendations were last updated on 11/06/2023.
