Controversies in the management of abnormal Pap smears

Cytology is not 100% accurate. Overdiagnoses and underdiagnoses occur. Changes in classification systems and new devices have not changed the reliability of the Pap smear. The majority of squamous intraepithelial lesions will remit spontaneously and less than 1% will progress to invasive cancer. HPV-DNA testing has not provided a foolproof way to triage lesions. Therefore, the management of abnormal Pap smears is dependent on the personal experience of the physician, who must consider the following questions. What is the accuracy of your cytology laboratory? Does it overdiagnose or underdiagnose? How often has an ASCUS or LSIL become HSIL or invasive cancer on histologic evaluation? Will your patients come back for follow up? Will their health insurance cover frequent follow-up Pap smears or colposcopies? Do you have the resources to follow every patient who needs it? Do you want to avoid the development of every invasive cancer that may develop during the period of follow up?