Obstetrics Gynecol：美国更新宫颈癌筛查指南

　　近日，美国阴道和子宫颈癌协会发布宫颈癌筛查异常和癌前病变处理指南。总体来看，目前的宫颈癌筛查间隔较长，30~64 岁女性每5 年筛查一次，应接受细胞学和人乳头状瘤病毒（HPV）检测。新版指南强调两种方法联合应用，旨在限制随访检查次数。该指南建议，风险相似的人群应采取相似的筛查策略。

　　该指南强调了筛查策略的安全性。指南不推荐对21~24 岁、细胞学检查异常程度较低的女性进行积极评估和治疗，因这类人群的患癌风险较低。对于宫颈上皮内瘤变（CIN）2 度病变者，指南也不主张给予较强治疗，因这类病变有较高的自愈率。新指南还有一个显著的改变是，最常见的异常发现——性质不明的不典型性鳞状细胞（ASC-US）与HPV 感染无关，进展为浸润性病变的风险较低。目前指南推荐，HPV 阴性、细胞学检查结果为ASC-US 者应接受细胞学和HPV 联合检查，间隔为每3年而不是每5 年检查一次。而细胞学检查为ASC-UC 但无HPV检测结果的人群，只需1 年后重复进行细胞学检查，而不是在第6 个月和第12 个月时均进行检查。若1 年检查结果为阴性，那么此后每3 年检查一次。年龄≥ 65 岁、ASC-US 阳性但HPV阴性的人群应在1 年后重复检查，而不是不再接受常规筛查。新指南还有一个修订是，当细胞学样本不理想，比如检查结果阴性、但样本中缺少宫颈内/ 转化区成分时，仍可继续接受常规筛查，因为她们发生CIN 3 的风险不高。如果细胞学检查不满意（通常由于鳞状细胞量不足），即使HPV 检查结果阴性，也建议重复检查。

　　指南指出，检查结果为CIN 1者应在1年后接受重复联合检查，如HPV 和细胞学检查结果均为阴性，则此后每3 年筛查一次。指南建议，因CIN 2+ 病变接受治疗的女性应在第1 年和第2 年接受两种方法联合筛查；若1 年和2年检查结果均为阴性，则此后可每3 年筛查一次，若检查结果仍为阴性，可维持每3 年筛查一次。

　　指南强调，HPV 分型可帮助筛选发生CIN 3 病变的高危人群，这些高危亚型感染的人群较早接受阴道镜检查。在无完善的证据和共识的情况下，组织病理学检查结果若为低度上皮内鳞变（LSIL），应按CIN 1 病变对待，高度上皮内鳞变（HSIL）则按CIN 2 病变和CIN 3 病变对待。指南指出，应进一步开展研究明确因CIN 2 或CIN 3 接受治疗人群的理想筛查间隔。此外，应开展大样本队列研究来探讨HPV 疫苗接种的效果。最后，指南制定专家指出，应将根据以往筛查和治疗史做出的风险评估结果纳入治疗决策，以更好地、更个体化地权衡风险和获益，而不单纯依靠指南推荐，这样更合理。

与宫颈相关的拓展阅读：

• 美国阴道镜检查和宫颈病理学会公布2013版宫颈癌筛查和癌前病变管理指南
• SGO:无铂化疗不能提高宫颈癌患者生存率
• 美国女性宫颈涂片筛查方式趋于合理
• Br J Cancer：原发宫颈癌普查中HPV DNA检查较液基细胞学检查有优越性
• 我国宫颈癌发病呈年轻化趋势
  
• 更多信息请点击：有关宫颈更多资讯

New Guidance for Management of Women with Abnormal Cervical Cancer Screening Results
In 2012, the American Cancer Society, American Society for Clinical Pathology, and American Society for Colposcopy and Cervical Pathology (ASCCP) issued new guidelines for cervical cancer screening (JW Women's Health Apr 12, 2012). Now, the ASCCP has updated its recommendations (first published in 2006) for managing women with abnormal cervical cancer screening tests and cancer precursors. This guidance was developed based on a literature review, input from 23 professional societies, and clinical experience with 1.4 million women seen at Kaiser Permanente Northern California. The 19 algorithms cover clinical scenarios ranging from unsatisfactory cytology to various grades of squamous and glandular intraepithelial neoplasia. They are timely, given that co-testing (cytology plus assessment for high-risk human papillomavirus [HPV]) has become increasingly common.
One notable algorithm concerns management of women aged 21 to 24 with cytology indicating either atypical squamous cells of undetermined significance (ASCUS) or low-grade squamous intraepithelial lesion (LSIL). The 2006 guidelines recommended colposcopy with cervical biopsy for women with ASCUS plus positive reflex HPV test results, as well as for those with LSIL. The current guidelines do not recommend initial colposcopy for women in this age range. Instead, when HPV reflex testing is negative in women with ASCUS cytology, routine screening should resume. If the initial screen reveals ASCUS with positive HPV — or LSIL — repeat cytology is recommended at 12 months. The results of this 12-month cytology then determine whether colposcopy or repeat cytology at 12 months is indicated.
A second noteworthy algorithm relates to management of women with LSIL (for whom colposcopy had been recommended under the 2006 guidance). If LSIL is found during the course of co-testing and the HPV result is negative, repeat co-testing in 12 months is now the preferred action. In contrast, if LSIL is not accompanied by an HPV test — or if such testing is positive — colposcopy continues to be recommended.
Comment: Many clinicians may find the 19 algorithms too complicated to memorize. I plan to keep a copy handy whenever I see patients; other clinicians who evaluate women with abnormal cervical cancer screening results might choose to do the same.