Management of Women with Atypical Pap Tests of Undetermined Significance
Abstract & Commentary
Synopsis: There is a lack of consensus among gynecologists regarding the best method for the management of ASCUS and AGUS Pap smears.
Source: Smith-McCune K, et al. Am J Obstet Gynecol. 2001;185:551-556.
The Bethesda System (TBS) for reporting cervical cytology has been in widespread use in the United States for more than a decade. At the present time, virtually all cytology laboratories use TBS for reporting. Unfortunately, there appears to be no consensus concerning the appropriate management of ASCUS and AGUS reports among gynecologists. The purpose of this study was to quantify the spectrum of management of patients with these results among board-certified gynecologists practicing in all areas of the United States.
Smith-McCune and associates used the ACOG Directory of Fellows to obtain a random sample and mailed a questionnaire to 491 physicians in April 1998. Their report was based on 213 completed surveys. Appropriate statistical analyses were performed on the data.
Each physician received a questionnaire that included 9 multiple choice questions. For the management of patients with ASCUS, a clinical scenario was presented in which a patient had an ASCUS smear for the first time after many normal Pap smears. Several management options were provided. The physician was then asked about options if a patient had a repeat ASCUS smear. Similar questions were asked for AGUS, but the management choices were increased considerably for this type of report. A question concerning management of high-grade reports was included for internal validation.
About one quarter of respondents stated that when they have a first ASCUS report on a patient they immediately perform or refer for a colposcopy. The remaining three quarters would repeat the Pap smear at various intervals including about 25% who would repeat the Pap smear in less than 3 months.
When given that a patient had a repeat ASCUS smear, about 90% would perform or refer for colposcopy. The management of initial or repeat ASCUS smears did not correspond with the number of years since board certification.
When given an AGUS scenario, 21% of the respondents would only repeat the Pap smear. About 51% would perform colposcopy, many with the addition of an endocervical sample and/or an endometrial biopsy. Twenty-five percent would perform only a biopsy procedure (without colposcopy). These biopsies might be an ECC, an endometrial biopsy or some combination of 1 of these samples plus a Pap smear.
When the physicians were given that a patient had a recurrent AGUS smear, almost half would perform colposcopy and about one-quarter would perform an excisional procedure.
Smith-McCune et al conclude that ". . .compared with published guidelines, practitioners undermanage patients with AGUS and overmanage patients with ASCUS." They further suggest that additional physician education might be useful.
Comment by Kenneth L. Noller, MD
While it was very interesting to read this paper and see the various ways ASCUS and AGUS Pap smear reports are managed by practicing gynecologists, I was not at all surprised by the results. While Smith-McCune et al conclude that physicians are not practicing according to "published guidelines," I would have a slightly different interpretation. I believe that clinicians are confused by the myriad of opinions they have heard and read regarding the appropriate management of patients with these cytologic diagnoses. I suspect that they choose to follow the practice of the paper, or expert, they most believe. Since there is no uniformity of opinion concerning management in either guidelines or among experts, it would be surprising if the results of the survey showed anything other than multiple management practices.
I think it is safe to say that up to present time there has been no clear-cut preferred management of women with AGUS Pap smear reports. While the results of the NCI-funded randomized trial (ALTS) have not been published yet, verbal reports indicate that there may be defendable algorithms that can be used by practicing physicians. Certainly, these results have not yet been transmitted to the majority of individuals practicing gynecology.
There has been more uniformity regarding the best method to manage AGUS Pap smears. The literature has consistently supported the fact that women with AGUS reports (particularly if they are older than age 35) have a significant risk of invasive cancer. Unfortunately, Smith-McCune et al did not provide scenarios for women younger or older than age 35. Thus, some of their results are not meaningful. Nonetheless, only half of the gynecologists would perform colposcopy when a first AGUS smear is reported. Virtually all experts and guidelines agreed that colposcopy is indicated for all of these patients.
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