Colposcopy is the centerpiece of most cervical cancer screening programs. In screen-positive women, colposcopic impression and biopsy results determine further management or treatment. Colposcopy-biopsy practice ranges from taking single biopsies from the worst appearing lesion to routinely taking multiple random biopsies independent of colposcopy impression.
There is a wide range of risk of cervical precancer among women who are referred to colposcopy, suggesting that colposcopy-biopsy procedures could be adapted to the underlying risk. Several test results, including cytology, HPV genotype, and biomarkers like p16/Ki-67 cytology may be available at colposcopy. Together with colposcopy impression, they can provide strong risk stratification in a colposcopy population. We evaluated this approach in the Biopsy Study among 700 women referred to colposcopy at the University of Oklahoma.
In strata defined by HPV testing, cytology, and colposcopy impression, the absolute risk of precancer ranged from 2.4% for women with <HSIL cytology, no HPV16 and normal colposcopy impression to 75.9% for women with HSIL, HPV16 and high grade colposcopy impression. When restricting to cytology and colposcopy impression, the absolute risk ranged from 3.2% for women with <HSIL cytology and normal colposcopy impression to 71.2% for women with HSIL and high grade colposcopy impression. Similarly, when using HPV genotype and colpo impression, the absolute risk ranged from 5.1% for women without HPV16 and normal colposcopy impression to 76.1% for women with HPV16 and high grade colposcopy impression. We observed similar risk stratification for combinations of p16/Ki-67 cytology and colposcopy impression (range from 1.4%-68.8%).
Risk assessment at colposcopy can inform colposcopy-biopsy practice, including optimal number of biopsies, and guide management. In a low-risk group, a normal colposcopy confers higher reassurance that CIN3+ is not present. In the highest risk groups, immediate treatment without biopsy confirmation could be considered according to current guidelines. In the future, colposcopy populations will change when primary HPV screening and new triage strategies are implemented. Furthermore, with HPV-vaccinated women increasingly entering the screening age, women referred to colposcopy generally will have a lower risk of precancer. A risk-based approach will allow developing evidence-based guidelines for colposcopy that anticipates the changing populations.
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