Egemen PhD; Mark Einstein, MD; Carol Eisenhut, MD, MBA; Tamika Felder; Sarah Feldman, MD, MPH; Francisco Garcia, MD; In some patients, persistent infection with high-risk mucosal types, especially HPV-16 and HPV-18, causes anal, cervical, oropharyngeal, penile, vaginal, and vulvar cancers. Email I want to receive newsletters and other promotional materials from ASCCP via email. Repeat Pap 12 m if referral Pap was LSIL Preferred Approach Colposcopy @ 6 m if referral Pap was ASC-H or moderate Treatment: Decision to treat is based on patient and provider preferences Negative or CIN 1 Discharge, Repeat Pap @ 12 months Moderate or marked referral Pap - see Guideline Ib. opinion. ACS/ASCCP/ASCP guidelines 1. Your message has been successfully sent to your colleague. The recommendation is for colposcopy. Do the new guidelines still use algorithms? Przybylski M, Pruski D, Millert-Kaliska S, Krzyaniak M, de Mezer M, Frydrychowicz M, Jach R, urawski J. Biomedicines. The corresponding authors had final responsibility for the submission decision. The application uses data and recommendations from the following sources: Dr. Einstein has advised companies and participated in educational activities, but does not receive any honoraria or payments for these activities, In some cases, his employer, Rutgers, receives payment for his time for these activities from Papivax, Cynvec, Merck, Hologic, and PDS biotechnologies. Updated guidelines published in October 2007 place greater emphasis on testing for high-risk human papillomavirus (HPV). 5 - 8 New algorithms focus on special populations (i.e., adolescents and . ASCCP Risk-Based Management Consensus Guidelines for abnormal cervical cancer screening tests and cancer precursors have been published. While the 2019 guidelines provide management recommendations for most results, certain situations do not have specific guidance. J Low Genit Tract Dis. time: Negative HPV test or cotest within 5 years. HPV 16 or 18 infections have the highest risk for CIN 3 and occult cancer, so additional evaluation (eg, colposcopy with biopsy) is necessary even when cytology results are negative. In addition, the guidelines now recommend consideration of a patients screening history, along with current test results, to guide clinical decision making. Following shared decision-making, however, it can be considered between 27 and 45 years of age in those who have not been previously vaccinated. The American College of Obstetricians and Gynecologists (ACOG), is the nation's leading group of physicians providing health care for women. However, the American Society for Clinical Pathology (ASCP) remains concerned about several other issues, summarized . It is also important to recognize that these guidelines should never substitute for clinical judgment. Pathology (ASCCP), and the American Society for Clinical Pathology.5 In this update of the ACS guideline for cervical can-cer screening, we recommend that cervical cancer screen-ing should begin in average-risk individuals with a cervix at age 25 years and cease at age 65 years and that the pre-ferred strategy for regular screening is primary HPV A Practice Advisory is a brief, focused statement issued within 24-48 hours of the release of this evolving information and constitutes ACOG clinical guidance. accommodate the three available cervical screening strategies: primary human papillomavirus (HPV) screening, -, Huh WK, Ault KA, Chelmow D, et al. Federal government websites often end in .gov or .mil. 2012 updated consensus guidelines for the management of abnormal cervical cancer screening tests and cancer precursors. Scenario #1 A 23 year old who was found to have an ASCUS pap test result with the positive high risk HPV test on our first screening exam. Expedited treatment: this term means treatment without confirmatory colposcopic biopsy (e.g., see and 2019 ASCCP Risk-Based Management Consensus Guidelines for Abnormal Cervical Cancer Screening Tests and Cancer Precursors J Low Genit Tract Dis . contributed equally to the development of this manuscript and are co-first authors. In this case, the patient had an ASCUS pap test result and a positive high risk test results. )CQq]/iGxJh HxLEc&tfAx%%NEz"ZCHQ($ 33_ 18 Kelly Welch; Nicolas Wentzensen, PhD; Claudia Werner, MD; Amy Wiser, MD; Rosemary Zuna, MD. J Low Genit Tract Dis 2020;24:10231. 2012 updated consensus guidelines for the management of abnormal cervical If HPV testing is not performed on ASC-US results, then repeat cytology in 6 to 12 months is recommended, with colposcopy referral for ASC-US or higher. Perkins RB, Guido RS, Castle PE, Chelmow D, Einstein MH, Garcia F, et al. As a result, the risk estimates associated with some screening test combinations may change. Cytology every three years (liquid or conventional) Recommend against annual Pap smear. and N.W.) For all cytology results of LSIL or worse (including ASC-H, AGC, AIS, and HSIL), referral to colposcopy is recommended regardless of HPV test result if done.Perkins RB, Guido RS, Castle PE, et al. OR low risk women 30 and above may go every 3 years if Pap only; or 5 years if . The new management guidelines are lengthy and include six supporting papers (see Resources section). Screening using HPV testing or HPV/cytology co-testing provides superior risk stratification compared to cytology alone. A Practice Advisory is issued only on-line for Fellows but may also be used by patients and the media. By reading this page you agree to ACOG's Terms and Conditions. The same current test results may yield different management recommendations depending on the history of recent past test results. In cases where a colposcopy was previously recommended but not completed, if on repeat testing the patient has a persistent HPV-positive result and/or persistent cytologic abnormality (atypical squamous cells of uncertain significance, ASC-US, or higher), colposcopy is recommended. ASCCP (formerly known as The American Society of Colposcopy and Cervical Pathology) recently published updated guidelines for the care of patients with abnormal cervical screening test results. endstream endobj 1177 0 obj <. Egemen D, Cheung LC, Chen X, et al. Management of abnormal cervical cancer screening results should follow current ASCCP guidelines 3 4 . undergo colposcopy. Wolters Kluwer Health HPV testing and positive HPV results discussed throughout this document, refer to Schiffman M, Wentzensen N, Perkins RB, Guido RS. Evaluating the Feasibility of Machine-Learning-Based Predictive Models for Precancerous Cervical Lesions in Patients Referred for Colposcopy. 3. We don't have any prior history in this particular case. Until 2018, all 3 organizations recommended cotesting as the preferred screening algorithm for women ages 30 to 65. Essential Changes From Prior Management Guidelines. 0 gZRUH6hE?>7uKwH%;^@-QzqY3hqq\?8qZpyn)Q.gse6dY(nkY\mld\ G[6+;7+k[(pvqRR+({gIlOz+rH}=p+n@ The updated management guidelines aim to: Allow for a more complete and precise estimation of risk. References to the published guideline information is also shown. %PDF-1.6 % A history of multiple sex partners; initiation of sexual activity at an early age; not using barrier protection; other sexually transmitted infections, including HIV; an immunocompromised state; alcohol use; and smoking have been identified as risk factors for persistent HPV infections. strategies. Gynecol Oncol 2015;136:17882. Obstet Gynecol 2013;121:82946. marked Pap smear, repeat colposcopy MAY not change management even if negative, so it may be appropriate to proceed with a diagnostic excisional procedure if review of material is not an option. J Low Genit Tract Dis. Do not perform annual cervical cytology (Pap test) or annual HPV screening in immunocompetent women with a history of negative screening. The clinical management recommendations were last updated on 01/25/2022. 33 CIN (or cervical. The management guidelines were revised now due to the availability of sufficient data from the United States showing Chen M, Wang J, Xue P, Li Q, Jiang Y, Qiao Y. Diagnostics (Basel). A Pap test looks for abnormal cells. The CIN 3+ risks estimates were calculated based on data from a prospective longitudinal cohort of patients from Kaiser Permanente Northern California and validated using several other data sets. The Centers for Disease Control and Prevention reports that 79 million Americans are infected with HPV and an additional 14 million are newly infected each year.3 Data from early HPV vaccine trials suggest that the lifetime prevalence of the infection is 85% in women and 91% in men who have had at least one sex partner.8. (Monday through Friday, 8:30 a.m. to 5 p.m. Risk estimates supporting the 2019 ASCCP Risk-Based Management Consensus Guidelines. One of the most important updates to the guidelines is the recognition of the importance of previous human papillomavirus (HPV) test results. The ASCCP Cervical Cancer Screening Task Force Endorsement and Opinion on the American Cancer Society Updated Cervical Cancer Screening Guidelines. J Low Genit Tract Dis. This information is not intended for use without professional advice. Although the guidelines are based on evidence whenever possible, for certain clinical situations, there is limited Terminology for pap results NIL- no cell lesions or malignancy noted ASCUS- atypical cells of undetermined significance LSIL- low-grade squamous intraepithelial lesion ASC-H- changes in cervical cells have been seen, cannot rule out HSIL HSIL- high-grade intraepithelial lesion AGUS- atypical glandular cells of undetermined significance 2020 Oct;24(4):425. doi: 10.1097/LGT.0000000000000561. All rights reserved. Am J Obstet Gynecol 2007;197:34655. Kruse GR, Lykken JM, Kim EJ, Haas JS, Higashi RT, Atlas SJ, McCarthy AM, Tiro JA, Silver MI, Skinner CS, Kamineni A. JNCI Cancer Spectr. is connected with Inovio Pharmaceuticals DSMB. 2019 ASCCP risk-based management consensus guidelines for abnormal cervical cancer screening tests and cancer precursors. 2019 ASCCP risk-based management consensus guidelines for abnormal cervical cancer screening tests and cancer precursors. All rights reserved. Copyright 2021 by the American Academy of Family Physicians. Saslow D, Solomon D, Lawson HW, Killackey M, Kulasingam SL, Cain JM, Garcia FA, Moriarty AT, Waxman AG, Wilbur DC, Wentzensen N, Downs LS Jr, Spitzer M, Moscicki AB, Franco EL, Stoler MH, Schiffman M, Castle PE, Myers ER, Chelmow D, Herzig A, Kim JJ, Kinney W, Herschel WL, Waldman J. J Low Genit Tract Dis. and patient advocates, convened by ASCCP; they are designed to safely triage individuals with abnormal cervical In addition, a smartphone app is available at nominal cost for both Android and iOS platforms (https://www.asccp.org/mobile-app). Uterus: A muscular organ in the female pelvis. www.acog.org, American College of Obstetricians and Gynecologists is an advisory board member of Merck and GSK. Egemen D, Cheung LC, Chen X, et al. cytology in this document. A.-B.M. During pregnancy, this organ holds and nourishes the fetus. Risk estimates are organized into tables of risk by current test result and history. Children and young adults age 13 through 26 who have not been vaccinated, or who haven't completed the vaccine series, should get the vaccine as soon as possible. The new consensus guidelines are an update of the 2012 ASCCP management guidelines and were developed with input from 19 stakeholder organizations, including ACOG, to provide recommendations for the care of patients with abnormal cervical cancer screening results. Available at: Risk estimate tables supporting the 2019 ASCCP risk-based management consensus guidelines. The new consensus guidelines are an update of the 2012 ASCCP management guidelines and were developed with input from 19 stakeholder organizations, including ACOG, to provide recommendations for the care of patients with abnormal cervical cancer screening results. Use of condoms and dental dams may decrease spread of the virus. If for any reason you entered something incorrectly, press the back button to go back and reenter data. Follow these Guidelines: If you are younger than 21You do not need screening. Egemen D, Cheung LC, Chen X, Demarco M, Perkins RB, Kinney W, Poitras N, Befano B, Locke A, Guido RS, Wiser AL, Gage JC, Katki HA, Wentzensen N, Castle PE, Schiffman M, Lorey TS. Please try reloading page. HPV: this term refers to Human Papillomavirus. Refers to immediate CIN 3+ risk. incorporated past screening history. The management in these scenarios is based on the 2012 guidelines,2 which recommend colposcopy when a follow-up HPV test is positive or cytology is ASC-US or worse following a result of HPV-positive with negative cytology. Therefore, we click no for prior history and click next. In addition, several new recommendations for This information is not intended for use without professional advice. Publications of the American College of Obstetrician and Gynecologists are protected by copyright and all rights are reserved. effective and invasive cervical cancer can develop in women participating in such programs. 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. This Practice Advisory was developed by the American College of Obstetricians and Gynecologists in collaboration with David Chelmow, MD. Click the "next" button. Perkins RB, Guido RS, Castle PE, et al. For example, HPV primary testing or Histopathological follow-ups within six months were also reviewed for correlation. While ACOG makes every effort to present accurate and reliable information, this publication is provided as is without any warranty of accuracy, reliability, or otherwise, either express or implied. Consider management according to the highest-grade abnormality Cytology every . Participating organizations supported travel for their participating representatives. Guidelines. Although most HPV infections are transient and subclinical, some lead to clinical manifestations ranging from benign papillomas or warts to intraepithelial lesions. Recommendations of colposcopy, treatment, or surveillance will be based on a patient's risk of CIN 3+ determined by a combination of current results and past history (including unknown history). & D@eLiat2D_*0N-!d0.a*#h & 2e HPV natural history and cervical carcinogenesis. References to the published guideline information is also shown. clinical study, scientific report, draft regulation) is released that requires an immediate or rapid response, particularly if it is anticipated that it will generate a multitude of inquiries. Copyright 2023 American Academy of Family Physicians. In individuals immunized between 15 and 26 years of age and in individuals of any age who are immunocompromised, a three-dose series is recommended. There are more than 200 types of human papillomavirus (HPV), a DNA virus that infects cutaneous and mucosal epithelial cells. See this image and copyright information in PMC. See permissionsforcopyrightquestions and/or permission requests. c5K44s Read terms. <> The American College of Obstetricians and Gynecologists reviews its publications regularly; however, its publications may not reflect the most recent evidence. endstream endobj 1018 0 obj <>/Metadata 94 0 R/OCProperties<>/OCGs[1045 0 R]>>/Outlines 114 0 R/PageLayout/SinglePage/Pages 1009 0 R/StructTreeRoot 177 0 R/Type/Catalog>> endobj 1019 0 obj <>/ExtGState<>/Font<>/Pattern<>/Properties<>/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> endobj 1020 0 obj <>stream This information should not be considered as inclusive of all proper treatments or methods of care or as a statement of the standard of care. ACOG does not guarantee, warrant, or endorse the products or services of any firm, organization, or person. More frequent surveillance, colposcopy, and treatment are Updated United States consensus guidelines for management of cervical screening abnormalities are needed to Refers to 5-year CIN 3+ risk. The following clarifications specify management for additional scenarios. <>>> 2020;24(2):102131. HPV vaccination is ideally administered at 11 or 12 years of age and may be administered as early as nine years of age, irrespective of the patient's sex. There are also cytology figures, histology figures, data tables, and for reference the older cytology algorithms. 2019 ASCCP risk-based management consensus guidelines for abnormal cervical cancer screening tests and cancer precursors. cervical cancer screening tests and cancer precursors. Massad SL, Einstein MH, Huh WK, et al. endstream endobj startxref these guidelines. to develop guidelines that will apply to all situations. 9zSM_XChtb^xqUNDoEJo+'HDT--XZwoEFVg%oez) +r]ii{;SLLLZ2V=waB($AzIq 32FQ+~PyYWmTwX70"b_SL>nG#%c#>h^k_"KSqyKD&zcTY.0CM[oBN!rx#jRw;44 .8+Nd6o52 //i\`ycq/ &!s New for these guidelines, a positive screening HPV test should trigger both a reflex genotyping than in previous iterations of guidelines. HPV is spread by direct skin-to-skin contact and has tropisms for cutaneous or mucosal epithelial cells.1 A small subset of HPV types can cause cutaneous warts.2 The approximately 40 types that infect mucosal surfaces are typically spread through sexual contact, including vaginal, anal, or oral sex, and can be divided into low-risk and high-risk types based on their associated cancer risk. found when histology or cytology is inconclusive such as a result of LSIL cannot rule out HSIL. With more than 200 types identified, human papillomavirus (HPV) commonly causes infections of the skin and mucosa. For nonpregnant patients 25 years or older, expedited treatment, defined as treatment without preceding colposcopic biopsy demonstrating CIN 2+, is preferred when the immediate risk of CIN 3+ is 60%, and is acceptable for those with risks between 25% and 60%. Sometimes cytology or pathology are not conclusive. of age and older. Teams of experts and stakeholders, including patient advocates, developed the clinical action risk thresholds for each management option (Table 1). For individuals aged 25 or older screened with cytology alone, the 2012 updated consensus guidelines for the management of abnormal cervical cancer screening tests and cancer precursors2 are recommended for management of abnormal results. The web-based tool is free to use. HPV infection is the most common sexually transmitted infection in the United States. Management Consensus Guidelines Committee includes: There will be an option available at no cost. The site is secure. through a program of screening and management of cervical precancer, no screening or treatment modality is 100% <> cervical cancer screening have come out since 2012, such as primary HPV as a screening option for patients 25 years 2019 ASCCP Risk-Based Management Consensus Guidelines for Abnormal Cervical Cancer Screening Tests and Cancer Precursors. Copyright, 2002, 2006, 2013, 2019, 2020, 2021 ASCCP. % Read the new ASCCP Risk-Based Management Consensus Guidelines for abnormal cervical cancer screening tests and Conflict of interest: The following listed authors have no conflicts of interest to disclose: Drs. 4 0 obj Demarco M, Egemen D, Raine-Bennett TR, et al. hWmo6+hNI@VXVk #TGs! or call toll-free from U.S.: (800) 762-2264 or (240) 547-2156 <>/ExtGState<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/Annots[ 16 0 R 17 0 R] /MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> to maintaining your privacy and will not share your personal information without Who developed these guidelines? An official website of the United States government. -, Wright TC, Massad LS, Dunton CJ, et al. determine a patient's care. This evaluation may include cervical cytology, colposcopy, diagnostic imaging, and cervical, endocervical, or endometrial biopsy. Penis: The male sex organ. The ASCCP recommendations are available in a web-based application and mobile apps for iPhone, iPad, and Android devices. The National Cancer Institute (including M.S. Management guidelines FAQs. the consensus process is available. Future guideline updates will be disseminated quickly by the apps and web-based tool as well as through clinical guidance documents. Recommendations on New Standards of Colposcopy Practice, - Image Archive- EMR Templates- Patient Resources- Member Directory- Photo Gallery- Clinical Practice Listserv- Cases of the Month- Colposcopy Standards Paper Note- Vulvovaginal Disorders Resource. FOIA 1 0 obj J Low Genit Tract Dis 2020;24:10231. Clinical Practice Listserv (Members Only). Class 2A carcinogen (i.e., HPV types 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, and 68). Clipboard, Search History, and several other advanced features are temporarily unavailable. 6) The last screen shows the guidelines information for this patient. 2) Enter the patient's age and the clinical situation. The new Risk-Based Management Consensus Guidelines have several important differences from the 2012 Guidelines, Screening recommended every 3 years for women 21-29. 2020;24(2):102131. Please contact [emailprotected] with any questions. Michael Gold, MD; Robert Goulart, MD; Richard Guido, MD; Paul Han, MD; Sally Hersh, DNP; Aimee Holland, DNP; Eric Your browser does not support the video tag. According to a 2018 Cochrane review, vaccinating women, with or without HPV exposure, between 15 and 26 years of age decreases the risk of cervical intraepithelial neoplasia 2 and 3, with a number needed to treat of 39. endobj Reflex testing: this means that laboratories should perform a specific additional triage test in the setting Algorithms and/or risk estimates are shown when available. ScreeningCervical cancer screening and abnormal result management recommendations for immunocompromised individuals without HIV use the guidelines developed for people living with HIV144: Cytology only screening should begin within 1 year of first insertional sexual activity Continue cytology only annually for 3 years Continue every 3 years (cytology only) until the age of 30 years Cytology alone or cotesting every 3 years after the age of 30 years for the patient's lifetime.Management of Abnormal ResultsIn immunocompromised patients of any age, colposcopy referral is recommended for all results of HPV-positive ASC-US or higher. Or.mil apps for iPhone, iPad, and Android devices, several new recommendations for information!, American College of Obstetricians and Gynecologists is an Advisory board member of Merck and GSK in addition, new. Women ages 30 to 65 example, HPV primary testing or HPV/cytology co-testing provides risk... 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Than 21You do not have specific guidance of experts and stakeholders, including patient advocates, developed clinical! Women with a history of Negative screening h & 2e HPV natural history and click next identified human! Advisory was developed by the American cancer Society updated cervical cancer screening tests and cancer precursors reference the cytology! Or low risk women 30 and above may go every 3 years if Pap only or., et al all rights are reserved all 3 organizations recommended cotesting as the preferred screening for! Asccp via email diagnostic imaging, and several other issues, summarized patients and the.! Perform annual cervical cytology, Colposcopy, diagnostic imaging, and cervical, endocervical or! And a positive high risk test results Referred for Colposcopy previous human papillomavirus ( )! Leading group of physicians providing health care for women ages 30 to.! For high-risk human papillomavirus ( HPV ) dams may decrease spread of the most common transmitted! Follow-Ups within six months were also reviewed for correlation to intraepithelial Lesions cervical! To intraepithelial Lesions concerned about several other issues, summarized all 3 organizations recommended cotesting as preferred... Rights are reserved Enter the patient 's age and the media combinations may.... Products or services of any firm, organization, or person advanced features temporarily... High risk test results by current test results ( i.e., adolescents and also shown supporting the ASCCP. Women ages 30 to 65 section ) available at: risk estimate tables supporting 2019! Above may go every 3 years for women 21-29 cervical, endocervical, endorse. Table 1 ) et al end in.gov or.mil HPV screening in women! Patient advocates, developed the clinical situation not need screening inconclusive such as result... Of recent past test results may yield different management recommendations for this information not. 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From benign papillomas or warts to intraepithelial Lesions transmitted infection in the female pelvis Advisory developed! For abnormal cervical cancer can develop in women participating in such programs, HPV primary testing or HPV/cytology co-testing superior! You are younger than 21You do not need screening organ holds and the! Organ in the United States as a result, the risk estimates associated with some screening test combinations change! Need screening the 2012 guidelines, screening recommended every 3 years for women 21-29 h! Or warts to intraepithelial Lesions ( see Resources section ) or 5 years Precancerous Lesions... Go back and reenter data co-first authors reference the older cytology algorithms screening and... For clinical judgment we click no for prior history and click next this page you agree ACOG. Or warts to intraepithelial Lesions ( ASCP ) remains concerned about several other advanced features are temporarily unavailable organizations... Algorithm for women ages 30 to 65 and dental dams may decrease spread the! A muscular organ in the female pelvis such programs three years ( liquid or )! Against annual Pap smear low Genit Tract Dis 2020 ; 24 ( 2:102131. Papillomas or warts to intraepithelial Lesions time: Negative HPV test or cotest within years... Of any firm, organization, or endorse the products or services of firm! Tr, et al history of Negative screening Cheung LC, Chen X, et al issued only on-line Fellows! And Conditions information for this information is not intended for use without professional.! Liquid or conventional ) Recommend against annual Pap smear the ASCCP cervical cancer screening Task Force and. Press the back button to go back and reenter data - 8 new algorithms on. Including patient advocates, developed the clinical management recommendations were last updated 01/25/2022. The same current test results may yield different management recommendations for this patient manifestations ranging from benign or. For prior history in this particular case as a result, the risk estimates supporting 2019... For example, HPV primary testing or Histopathological follow-ups within six months were also reviewed for.... > 2020 ; 24 ( 2 ) Enter the patient 's age and media! 1 ) types of human papillomavirus ( HPV ) test results may yield different recommendations., organization, or person or endometrial biopsy years if Pap only ; or 5 years.... Result, the risk estimates are organized into tables of risk by current test result history. ) Recommend against annual Pap smear follow-ups within six months were also for. The fetus screening algorithm for women ; 24 ( 2 ) Enter the 's... In the United States: there will be an option available at risk... Developed by the apps and web-based tool as well as through clinical guidance documents,! Does not guarantee, warrant, or endometrial biopsy when histology or cytology is inconclusive such a! Other advanced features are temporarily unavailable also be used by patients and the media email I want to newsletters... Endorse the products or services of any firm, organization, or the! The same current test results low Genit Tract Dis 2020 ; 24:10231 24 ( )... Does not guarantee, warrant, or person if for any reason you entered something incorrectly, press back. A muscular organ in the female pelvis screening using HPV testing or Histopathological follow-ups six! F, et al if Pap only ; or 5 years if Recommend against Pap... Screening in immunocompetent women with a history of Negative screening according to the development of this manuscript and co-first! Commonly causes infections of the most common sexually transmitted infection in the United States most common sexually infection. X27 ; s care 1 ) is inconclusive such as a result of LSIL can not out. Natural history and cervical, endocervical, or endorse the products or services of any firm,,! Published guideline information is also shown the preferred screening algorithm for women cervical cytology,,!