Clinical opinion
Oncology
Risk assessment to guide the prevention of cervical cancer

https://doi.org/10.1016/j.ajog.2007.07.049Get rights and content

Advances in screening and diagnosis make it increasingly possible to prevent cervical cancer. However, if misused or poorly understood, these new tools will only increase costs and potentially harm patients without benefit. As a framework for standardized care that maximizes patient safety and well-being, we propose that a risk model be adopted to guide clinical management now and in the future. The model would use thresholds of increasing risk for cervical precancer and treatable cancer to guide clinical decision making for screening intensity, diagnostic evaluation, or treatment. Experts would decide on these risk thresholds and stratum based on the patient risk to benefit, independent of current (eg, cytology, carcinogenic HPV testing, and colposcopy) and future methods of measuring risk. A risk management model for cervical cancer prevention, based on appropriate clinical actions that correspond to risk stratum, can result in better allocation of resources to and increased safety for women at the greatest risk and increased well-being for women at the lowest risk.

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Background

Traditionally, the Papanicolaou smear or other cytologic method has been used as the primary test for cervical cancer screening programs. A positive cytologic result led to colposcopic evaluation and directed biopsy of apparent lesions. In turn, a biopsy diagnosed as CIN2 or worse (CIN2 or greater), or sometimes CIN1, led to treatment. Repetition of the cytology/colposcopy-based program has led to substantial decreases in cervical cancer rates in countries that have sufficient resources to

Risk Stratification

The concept of risk stratification (distinguishing the few women at risk from the many who are not at risk) is the principle underlying any screening test. With regard to carcinogenic HPV DNA testing, finding carcinogenic types in cervical specimens does not provide a diagnosis of CIN3 or cancer; rather, it identifies a group of women among whom CIN3/cancer is more likely. Complementary tests may provide even more powerful risk stratification. For example, cytologically normal women who test

Risk Thresholds

Professional clinical societies and cancer prevention experts together will make the decisions as to the proper clinical responses to which risk levels, considering benefits as well as total cost, which includes financial and negative health consequences. It is worth discussing to what extent protocols versus individual clinician judgment should dictate which tests are used, when, and how they should be interpreted. In general, we believe, because screening is inherently a population-wide

The Importance of Context in Clinical Decisions

Context is another element that figures into the risk predicted by a particular set of clinical test results. A risk associated with a positive test, like a carcinogenic HPV DNA test or CIN2 biopsy, is situational. An illustrative example is as follows: young women who have recently become sexually active have a high prevalence of carcinogenic HPV but an extremely low prevalence of precancerous lesions. In fact, the positive predictive value of a carcinogenic HPV test is so low in these women

Final Comments

We emphasize that it is critical when accepting a risk-based model for cervical cancer prevention to acknowledge that a minimally acceptable risk of precancer should be defined to avoid the overscreening and overtreatment of women in an attempt to achieve the unachievable: perfect sensitivity prevention. In addition to the almost certain negative consequences of an overly aggressive cervical cancer prevention program, including the impact on fertility,21 the number of cancers spared in the

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    Cite this article as: Castle PE, Sideri M, Jeronimo J, et al. Risk assessment to guide the prevention of cervical cancer. Am J Obstet Gynecol 2007;197:356.e1-356.e6.

    This work was supported by the Intramural Research Program of the National Institutes of Health, National Cancer Institute. The financial activities of P.E.C., J.J., D.S., and M.S. are monitored by the National Cancer Institute Ethics Office.

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