The Hidden Risks of Cervical Cancer Screening: When Negative Cotesting May Not Be Enough

Purpose According to the 2019 ASCCP (American Society for Colposcopy and Cervical Pathology) guideline, the immediate and 5-year risks of CIN-3+ (CIN-3 or cancer) for women with unknown HPV results or with current negative HPV-DNA and Pap smear results are 0.01% and 0.12%, respectively. Cotesting is therefore recommended after 5 years. However, if the samples were taken without adequate anamnesis or reliable naked eye cervical examination during screening, are these risks still low? On another note, could self-sampling screening be a methodological trap? Our aim is to determine the immediate CIN3 + risk in patient groups whose previous HPV history is unknown, whose current cotest result is negative, and who have abnormal cervical appearance (erosion, increased vascularity, etc.) on naked eye examination or a history of postcoital bleeding. Methods Patients who underwent colposcopy biopsy at Zeynep Kamil Women and Children Diseases Education and Research Hospital, University of Health Sciences between January 2016 and December 2018 and whose cotest results were negative were examined. Patients with known previous HPV test results, history of colposcopy or excisional procedure were excluded. All biopsies were reported by gynecopathologists. IBM SPSS version 25 program was used for statistical analysis. Results Of the 112 patients included in the study, 36.6% had contact bleeding (postcoital bleeding) in their anamnesis, and 63.4% underwent colposcopic examination due to abnormal cervical appearance on naked eye examination. Of the colposcopic biopsies, CIN1 was reported in 13.4%, CIN3 in 0.9%, and invasive cancer in 0.9%. In the statistical analysis of the groups with CIN3 +  and ≤ CIN1 lesions, no difference was found regarding age, menopausal status, colposcopy indications, and findings. In total, the risk of immediate CIN3 +  lesions was calculated as 1.8%. When asymptomatic (abnormal cervical appearance) and symptomatic (contact bleeding) groups were evaluated separately, the risk of CIN3 +  lesions was 2.8% and 0.0%, respectively. Conclusion Even when cervical specimens from patients with an unknown previous HPV test result and a negative current cotest result are obtained without reliable naked-eye examination (e.g., self-sampling screening), the immediate risk of CIN3 + would not exceed the 4% threshold for requiring a colposcopy examination specified in the new guideline. However, it would be more appropriate to recommend a cotest to this patient group after 1 year instead of 5 years.