The College of American Pathologists (CAP) has used

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1 CAP Lortory Improvement Progrms Humn Ppillomvirus Testing nd Reporting Rtes in 2012 Results of College of Americn Pthologists Ntionl Survey Chengqun Zho, MD; Ann T. Morirty, MD; Mohieden Ghofrni, MD; Mujt Husin, MD; Rosemry H. Tmouret, MD; Rodolfo Luciric, MD; Alice Lser, MD; Andrew Fischer, MD; Idris T. Ocl, MD; Rhon J. Souers, MS; Donn K. Russell, MS, CT(ASCP); Fng Fn, MD, PhD; Brr A. Crothers, DO Context. College of Americn Pthologists (CAP) surveys re used to estlish ntionl enchmrks for lortory prmeters. Ojective. To evlute chnges in lortory humn ppillomvirus (HPV) testing ptterns in lortories incorporting HPV testing with Ppnicolou tests in Design. Dt were nlyzed from the CAP HPV Supplementl Questionnire distriuted to 1771 lortories prticipting in either CAP HPV or CAP Ppnicolou proficiency testing in Results. A totl of 1022 lortories (58%) responded. There were more high-risk (HR) HPV tests performed per institution s compred to previous surveys. There were more HPV tests performed within n institution s compred to previous surveys. Hyrid Cpture 2 (HC2) remins the most common method (42.4%, 239 of 564); Cervist nd cos methods re used in 37.2% (210 of Accepted for puliction Septemer 10, Pulished s n Erly Online Relese Decemer 1, From the Deprtment of Pthology, University of Pittsurgh Medicl Center, Pittsurgh, Pennsylvni (Dr Zho); the Deprtment of Esoteric Testing, AmeriPth Indin, Indinpolis (Dr Morirty); the Deprtment of Pthology, PeceHelth Lortories, Vncouver, Wshington (Dr Ghofrni); Clinicl Sciences, University of Centrl Florid, Orlndo (Dr Husin); the Deprtment of Pthology, Msschusetts Generl Hospitl, Boston (Dr Tmouret); the Deprtment of Pthology, Bylor College of Medicine, Houston, Texs (Dr Luciric); the Deprtment of Pthology, North Shore-LIJ Helth System, New Hyde Prk, New York (Dr Lser); the Deprtment of Pthology, University of Msschusetts Medicl School, Worcester (Dr Fischer); the Deprtment of Pthology, Myo Clinic, Scottsdle, Arizon (Dr Ocl); Biosttistics, College of Americn Pthologists, Northfield, Illinois (Ms Souers); the Deprtment of Pthology, University of Rochester Medicl Center, Rochester, New York (Ms Russell); the Deprtment of Pthology, University of Knss Medicl Center, Knss City (Dr Fn); nd the Deprtment of Pthology, Wlter Reed Ntionl Militry Medicl Center, Bethesd, Mrylnd (Dr Crothers). The uthors hve no relevnt finncil interest in the products or compnies descried in this rticle. Presented s pltform presenttion t the 2014 Annul Meeting of the United Sttes nd Cndin Acdemy of Pthology; Mrch 3, 2014; Sn Diego, Cliforni. Reprints: Chengqun Zho, MD, Deprtment of Pthology, University of Pittsurgh Medicl Center, 300 Hlket St, Pittsurgh, PA (e-mil: zhoc@upmc.edu). 564) nd 14.9% (84 of 564) of lortories, respectively. Humn ppillomvirus testing is offered s reflex test fter Ppnicolou test result of typicl squmous cells of undetermined significnce (ASC-US) in 89.6% of lortories (476 of 531); s cotest for women ged 30 yers nd older in 60.3% (404 of 531); s reflex testing fter typicl squmous cells, cnnot exclude high-grde squmous intrepithelil lesion (ASC-H) in 42.7% (320 of 531); nd s reflex testing fter typicl glndulr cells (AGC) in 27.3% (145 of 531). The HPV-positive rtes for ASC-US nd ASC-H were similr in 2012 nd Cervist (49.2%, 88 of 179) nd Roche cos (27.4%, 49 of 179) re the most common methods used for genotyping. Most lortories use the CAP Humn Ppillomvirus for Cytology Progrm for proficiency testing. Conclusions. There ws n increse in nnul volume of HR-HPV testing with shift towrd in-house HR-HPV testing. Genotyping volumes lso incresed. HC2 nd Cervist re most commonly used, with n incresing volume of Roche cos testing. The most common indiction for HPV testing mong ll lortories ws ASC-US reflex testing, ut n increse in HPV cotesting ws oserved. The dt provide n updte into persisting nd newer trends in HPV testing prctices. (Arch Pthol L Med. 2015;139: ; doi: / rp cp) The College of Americn Pthologists (CAP) hs used survey questionnires to ssess prctice ptterns in cervicovginl cytology since These surveys hve documented the widespred implementtion of the first 2 versions of The Bethesd System, reporting rtes for vrious cervicl cytology ctegories nd importnt enchmrking dt for qulity ssurnce. 1 5 Results of the Atypicl Squmous Cells of Undetermined Significnce (ASCUS) nd Low-Grde Squmous Intrepithelil Lesion (LSIL) Trige Study estlished the role of high-risk HPV (HR-HPV) testing s cost-effective trige strtegy for typicl squmous lesions nd led to development of the 2001 Americn Society for Colposcopy nd Cervicl Pthology (ASCCP) mngement guidelines. 6 The rpid doption of HPV testing y mny cytology lortories during the next few yers prompted the development Arch Pthol L Med Vol 139, June 2015 HPV Testing nd Reporting Rtes in 2012 Zho et l 757

2 Tle 1. Site of Humn Ppillomvirus Testing, Site 2012 No. (%) (n ¼ 1022) 2006 No. (%) (n ¼ 612) 2003 No. (%) (n ¼ 595) Cytology lortory in-house 150 (14.7) 55 (8.9) 35 (5.9) Another deprtment in-house 425 (41.6) 112 (18.3) 97 (16.3) Reference lortory 447 (43.7) 445 (72.7) 463 (77.8) The site frequency differs etween the 3 yers (P,.001). There is sttisticlly significnt decresing trend in testing t reference lortories (Cochrn Armitge test; P,.001). nd distriution of the 2003 CAP Supplementl Questionnire to ssess prctice ptterns in HPV testing. 5 At tht time, the prevlence of HPV in dolescent nd young women nd in postmenopusl women ws not well estlished. Bsed on dditionl studies, the negtive predictive vlue of HPV testing in conjunction with negtive Ppnicolou (Pp) test result in women ged 30 yers nd older ecme ville, leding to the puliction of interim guidnce in This ws followed y gedefined indictions of HPV testing in specil popultions, especilly dolescents nd postmenopusl women, s noted in the 2006 updte of ASCCP mngement guidelines. 8 The lst CAP survey regrding 2006 prctices for HPV testing nd reporting rtes ws distriuted in 2007 nd pulished in The most recent updte of the cervicl cncer screening guideline nd ASCCP mngement guidelines ws in 2011 nd 2012, 9,10 following dditionl informtion on performnce of HPV type-specific testing (genotyping) nd results from lrge clinicl prctice dtse. 11 The CAP survey questionnires distriuted in nd ttempted to cpture the evolving prctice ptterns relted to the updted mngement strtegies. The specific gol of the 2013 CAP HPV Supplementl Questionnire ws to evlute the 2012 lortory prctice dt from lortories incorporting HPV testing with the Pp test, to compre it to preceding survey results, nd to identify trends in HPV testing. MATERIALS AND METHODS Dt Collection In 2013, the HPV prctice supplementl questionnire ws miled to 1771 lortories enrolled in the CAP Humn Ppillomvirus for Cytology Progrm (CHPV), nd the CAP Gynecologic Cytology Proficiency Testing Progrm in Not every lortory responded to every question. Lortories were sked for their HPV testing loction, methods of testing, testing personnel, monthly test volumes, whether they provided low-risk HPV (LR-HPV) testing, nd percentge of positive HR-HPV results for the interpretive ctegories of ASC-US, ASC cnnot exclude high-grde squmous intrepithelil lesion (ASC-H), typicl glndulr cells (AGC), nd if testing ws s screening test in conjunction with the Pp test in women ged 30 yers nd older ( cotesting ). In ddition, question ws sked regrding indictions for HPV testing. Possile responses included reflex testing for ASC-US, ASC-H, LSIL, high-grde squmous intrepithelil lesion (HSIL), nd AGC; djunct to Pp test for women 30 yers nd older (contest); nd HR-HPV test performed whenever requested y provider (nonreflex requested). Some questions regrding genotyping were lso provided. The respondents were sked to se ll nswers on ctul clinicl prctice from Percentile rte tles were constructed for pproprite ctegories. Becuse severl reporting rte distriutions were not Gussin, percentile reporting rtes (frequency reporting rtes) were presented insted of mens nd stndrd devitions. Reporting rtes tht were uncler or ppered to represent impossile vlues were deleted. Reporting rtes were compred with site of HPV testing, method used, nd test volume to vlidte the reporting rtes tht were incongruously high in the presence of low Pp test volume. Likewise, those lortories reporting reflex testing without reporting HPV volumes were verified with the site of testing, method used (collection vil), nd Pp volume. The reported rtes of ASC-US testing were compred with dt received in 2006 y using v 2 test. Sttisticl nlyses for contingency tles were performed using v 2 tests. Two-sided t tests were used to test ssocitions with the monthly HPV volume. A level of.05 ws used for sttisticl significnce. All sttisticl nlyses were performed y using SAS Version 9.1 (SAS Institute Inc, Cry, North Crolin). RESULTS Of the 1771 lortories receiving the questionnire, 1022 lortories responded, representing 57.7% response rte. This response rte is incresed compred to the 2006 supplementl questionnire (42%, 679 of 1621). Compred to 2006 survey dt, 12 the 2012 survey dt show significnt decrese in the percentge of lortories referring HPV testing to outside lortories (44% [447 of 1022] in 2012 versus 73% [445 of 612] in 2006, P,.001). Conversely, there ws n increse in the percentge of lortories performing HPV testing in nother deprtment within their own institution (42% [425 of 1022] in 2012 versus 18% [112 of 612] in 2006, P,.001). The 2012 dt lso demonstrted n increse in the lortories performing HPV testing in cytology (15% [150 of 1022] in 2012 versus 9% [55 of 612] in 2006, P,.001) (Tle 1). The results from the 2012 survey re significntly different from those identified in 2003 (Tle 1). Of the lortories tht performed HPV testing in-house, 556 responded to the question out the personnel performing the HPV test. The HPV test ws performed y 75% (417 of 556) of medicl technologists, 24.1% (134 of 556) of cytotechnologists, nd 14.2% (79 of 556) of other lortory personnel. In terms of HR-HPV test volume, 440 of 496 lortories (88.7%) responded to this question. The men nd medin volumes in 2012 were 3355 nd 2284, respectively. Sixtythree of 496 lortories (12.7%) offered LR-HPV testing, Tle 2. Types of Humn Ppillomvirus (HPV) Testing nd Test Volume in 2012 (n ¼ 496) Types of HPV Test No. (% Performed) Men 10th 25th 50th 75th 90th High-risk HPV 440 (88.7) Low-risk HPV 63 (12.7) Type-specific HPV 169 (34.1) Arevition:, percentile. 758 Arch Pthol L Med Vol 139, June 2015 HPV Testing nd Reporting Rtes in 2012 Zho et l

3 Tle 3. significntly fewer thn the 45% of lortories (284 of 632) offering LR-HPV testing in 2006 (P,.001) (Tle 2). Thirtyfour percent of ll lortories offered type-specific HPV testing (Tle 2). There re no comprtive dt ville from the 2006 supplementl questionnire regrding typespecific HPV testing. 12 The 2013 survey prticipnts cited vriety of indictions for HPV testing, such s clinicin requests for HPV testing (nonreflex test requested nytime), s cotesting with cytology for women ged 30 yers nd older, nd reflex testing (defined s n utomtic HR-HPV testing sed on specific interprettion) (Tle 3). As in 2006, ASC-US reflex testing is still the most common indiction for HPV testing (89.6%, 476 of 531). However, there ws n increse in testing for the ctegory of women ged 30 yers nd older when compred to the 2006 survey (Tle 3). Similr to the prctice in 2006, mny lortories offered reflex testing in some other circumstnces including ASC-H, LSIL, AGC, nd HSIL in 2012, with significnt increse in the AGC ctegory. The most common HR-HPV testing method is Hyrid Cpture 2 (Qigen, Githersurg, Mrylnd) (42.4%, 239 of 564), which ws most commonly performed on specimens collected in ThinPrep preservtive (Hologic, Bedford, Msschusetts), followed y Digene Stndrd Trnsport Medium (Qigen) nd SurePth fixtive (Becton, Dickinson nd Compny, Frnklin Lkes, New Jersey) (Tle 4). These results re similr to those seen Indictions for High-Risk Humn Ppillomvirus Testing Type of Options (Multiple Responses Allowed) 2012 No. (%) (n ¼ 531) 2006 No. (%) (n ¼ 560) P Vlue ASC-US reflex 476 (89.6) 503 (89.8).92 Nonreflex test requested nytime 404 (76.1) 332 (59.3),.001 Cotest for women ged 30 y nd older 320 (60.3) 137 (24.5),.001 ASC-H reflex 227 (42.7) 269 (48.0).08 LSIL reflex 158 (29.8) 156 (27.9).49 AGC reflex 145 (27.3) 111 (19.8).003 HSIL reflex 123 (23.2) 121 (21.6).54 Arevitions: AGC, typicl glndulr cells; ASC-H, typicl squmous cells, cnnot exclude high-grde squmous intrepithelil lesion; ASC-US, typicl squmous cells of undetermined significnce; HSIL, high-grde squmous intrepithelil lesion; LSIL, low-grde intrepithelil lesion. Tle 4. Testing Methods Used for High-Risk Humn Ppillomvirus (n ¼ 564) Methods No. Percentge Qigen HC2-ll types of medi Qigen HC2-ThinPrep Qigen HC2-Stndrd Trnsport Medium Qigen HC2-SurePth Hologic Cervist Roche cos Hologic Gen-Proe APTIMA Others Polymerse chin rection Lortory-developed test Access Genetics Roche AMPLICOR Roche LINEAR ARRAY In situ hyridiztion HC2: Qigen, Githersurg, Mrylnd; ThinPrep: Hologic, Bedford, Msschusetts; SurePth: Becton, Dickinson nd Compny, Frnklin Lkes, New Jersey; Roche methods: Roche, Plesnton, Cliforni; Access Genetics: Minnepolis, Minnesot. Multiple responses were llowed. When the 3 HC2 medi types re comined, the overll usge rte is 42% (239 of 564). in the 2006 supplementl questionnire. From the response frequency it ppers most lortories tht offer nlysis of seprte Digene Stndrd Trnsport Medium lso offer other liquid-sed methods. The lortories offered Cervist HR-HPV test (Hologic) or the cos 4800 HPV Test (Roche Moleculr Systems, Plesnton, Cliforni) t rte of 37.2% (210 of 564) nd 14.9% (84 of 564), respectively, in However, these tests were not ville in The frequency of reporting HPV positivity for ASC-US (medin: 38.3%, 110 lortories); ASC-US in women ged 30 yers nd older (medin: 30.7%, 43 lortories); ASC- US in women younger thn 30 yers (medin: 51.3%, 32 lortories); ASC-H (medin: 53.8%, 103 lortories); negtive for intrepithelil lesion or mlignncy, cotested in women ged 30 yers nd older (medin: 6.5%, 81 lortories); AGC (medin: 13.2%, 90 lortories); nd LSIL in postmenopusl women (medin: 20.0%, 41 lortories) re summrized in Tle 5. The percentile distriutions from 2012 were compred to those from 2006 (Tle 6) nd the comprison demonstrtes tht the cotesting positive rte in 2012 (medin: 6.5%, 81 lortories) is sttisticlly greter thn tht in 2006 (medin: 4.0%, 29 lortories; P ¼.02). The HPV positive rtes for ASC-US nd ASC-H in 2012 re similr to those in Although the HPV positive rte for AGC in 2012 (medin: 13.2%, 90 lortories) is greter thn tht in 2006 (medin: 2.0%, 57 lortories), no sttisticl significnce ws detected (Tle 6). As shown in Tle 7, most lortories use CAP s CHPV s the proficiency test for HPV nlysis. Of 524 responding lortories, 214 (40.8%) performed HPV 16/18 genotype testing for women with HR-HPV positive nd cytologynegtive cotest results. HPV 16/18 genotype testing ws performed for women younger thn 30 yers with HR- HPV positive nd cytology-negtive cotest results nd for women with HR-HPV positive nd ASC-US cytology results in 35.3% (183 of 518) nd 37.3% (194 of 520) of responding lortories, respectively (Tle 8). Humn ppillomvirus genotype testing ws performed y the in-house cytology lortory in 22.9% (43 of 188) of cses, within the institution ut not in the cytology lortory in 65.4% (123 of 188), nd y reference lortory in 11.7% (22 of 188). For lortories offering HPV genotype testing, the Cervist HPV 16/18 test (Hologic) is the most commonly used method (49.2%, 88 of 179), followed y cos HPV test (Roche Moleculr Systems) (27.4%, 49 of 179) (Tle 9). COMMENT Becuse the ASCUS/LSIL Trige Study showed tht HPV testing ws cost-effective method of trige for Pp tests Arch Pthol L Med Vol 139, June 2015 HPV Testing nd Reporting Rtes in 2012 Zho et l 759

4 with n ASC-US result, HR-HPV testing ws incorported into the 2001 ASCCP Consensus Guideline s preferred method for the trige of women with ASC-US. 6 Since the most recent CAP HPV testing survey in 2006, 12 mngement guidelines regrding HPV testing hve chnged. 8,10 From Kiser Permnente s study, 11 Pp test, comined with concurrent HR-HPV test for women ged 30 yers nd older, ws recommended s preferred screening method y the recent consensus guidelines. 9 The very high negtive predictive vlue for high-grde cervicl disese when the ptient hs oth negtive Pp nd negtive HR-HPV test result llows for sfe lengthening of the intervl etween screenings The dt from this survey illustrte the current trend of lortory prctice in HPV testing. The questionnire requesting summry of 2012 HPV testing dt ws distriuted to ll prticipting lortories in the CAP PAP nd CHPV progrms in The dt were generted from rod spectrum of prctices encompssing hospitl lortories (the lrgest segment), independent nd government lortories, cdemic settings, office nd group prctices, nd the Deprtment of Defense nd Veterns hospitls. The 2012 dt were compred to the previous 2006 survey. 12 Compred to 2003 nd 2006 survey dt, 5,12 the 2012 survey dt showed tht significntly more lortories Tle 6. Comprison of High-Risk Humn Ppillomvirus Positive Rte Between 2006 nd 2012 Ctegory N Tle 5. 10th 50th 90th P Vlue ASC-US positive ASC-H positive Cotest positive AGC positive Arevitions: AGC, typicl glndulr cells; ASC-H, typicl squmous cells, cnnot exclude high-grde squmous intrepithelil lesion; ASC-US, typicl squmous cells of undetermined significnce;, percentile. Kruskl-Wllis test. High-Risk Humn Ppillomvirus (HPV) Positive Rte Percentge Ctegories N Men 10th 25th 50th 75th 90th Totl HPV tested volume reported positive ASC-US in women ged 30 y nd older (CHPV) ASC-US in women younger thn 30 y (CHPV) ASC-US (CAP PAP) ASC-H NILM Pp test cotest in women older thn 30 y AGC LSIL in postmenopusl women Arevitions: AGC, typicl glndulr cells; ASC-H, typicl squmous cells, cnnot exclude high-grde squmous intrepithelil lesion; ASC-US, typicl squmous cells of undetermined significnce; CAP, College of Americn Pthologists; CAP PAP, CAP Interlortory Comprison Progrm in Cervicovginl Cytology; CHPV, CAP Humn Ppillomvirus for Cytology Progrm; LSIL, low-grde intrepithelil lesion; NILM, negtive for intrepithelil lesion or mlignncy. prefer in-house HPV testing. Hving testing performed t the sme institution my mke issuing n integrted Pp test HPV test report esier. Testing for LR-HPV hs een shown to hve no predictive vlue for cervicl cncer precursors. The percentge of lortories offering the LR-HPV test is significntly reduced compred with the percentge in 2006, ut pproximtely 13% of lortories continue to offer LR-HPV testing. This continued vilility is proly due to finncil considertions nd ignornce regrding the lck of reltionship etween LR-HPV infection nd cervicl neoplsi. 13 Other ntionl surveys hve reported LR-HPV testing nd other nonrecommended HPV testing prctices y US helth cre providers, which leds to unnecessry ptient follow-up nd incresed costs without clinicl enefit. 14 In the 2012 survey dt, type-specific HPV testing is ville in pproximtely hlf of reporting lortories, suggesting greter wreness of the importnce of HPV types (especilly HPV 16 nd HPV 18) in clinicl mngement, s recommended y current 2012 mngement consensus guidelines. 10 As in the 2006 survey, ASC-US reflex HR-HPV testing is still the most common scenrio reported y respondents in However, the rte of nonreflex testing requested nytime or s cotesting with cytology for women ged 30 yers nd older significntly incresed in 2012 compred to 2006, suggesting tht more prctitioners re dopting the current mngement guidelines tht recommend Pp nd HPV cotesting s the preferred primry screening method. Approximtely 20% to 30% of lortories offered reflex HPV testing for women with HSIL, LSIL, nd AGC Pp test results, nd 43% of lortories offered reflex HPV testing for women with ASC-H, lthough reflex HPV testing is not recommended for these norml ctegories in the consensus guidelines for the mngement of women with norml cervicl screening tests. 8,10 Tle 7. Humn Ppillomvirus Proficiency Testing Types No. Percentge CHPV New York Stte PT None Other Interlortory comprison PT CAP Virology Arevitions: CAP, College of Americn Pthologists; CHPV, CAP Humn Ppillomvirus for Cytology Progrm; PT, proficiency test. 760 Arch Pthol L Med Vol 139, June 2015 HPV Testing nd Reporting Rtes in 2012 Zho et l

5 Tle 8. Humn Ppillomvirus (HPV) 16/18 Genotyping in 2012 Ctegories Totl Response No. Performed No. Performed Percentge For women with HR- HPV positive nd Pp negtive cotesting result For women younger thn 30 y with HR-HPV positive nd Pp negtive cotesting result For women with HR- HPV positive nd ASC-US Pp result Arevitions: ASC-US, typicl squmous cells of undetermined significnce; HR-HPV, high-risk HPV; Pp, Ppnicolou. High-risk HPV medin positive rte for cotests ws 6.5% in 2012, significntly greter thn tht (4.0%) in The reson for the increse is undetermined, lthough we think differences in the testing popultion re likely to e the min cuse. In recent yers the use of cotesting for women ged 30 yers nd older hs een significntly expnded s compred to the sitution in Reltively fewer lortories (29) responded to this question in the 2006 survey, compred to 81 lortories in the current study. The rte of 6.5% seen now my reflect etter smpling of the ntionl sitution, chnges in the demogrphics of women eing screened, or some comintion of oth. The medin HR-HPV positive rtes for ASC-US nd ASC-H in 2012 re 38.3% nd 53.8% (Tle 5), respectively, similr to those in High-risk HPV positive rtes for ASC-US in the literture re vrile, minly depending on the ge of the popultions. This survey shows tht the medin HR-HPV positive rte is 51.3% in ASC-US for women younger thn 30 yers, which is significntly higher thn the rte of 30.7% in ASC-US for women ged 30 yers nd older, demonstrting the importnce of considering ge when interpreting HR-HPV testing results for women with ASC-US Pp test results. Although in the 2012 survey the most common HR-HPV testing method is still Qigen HC2, the lortories offering either Cervist HR-HPV test or Roche cos HPV test hve incresed, nd the percentge of lortories offering the Cervist HR HPV test pproximtes the percentge of lortories offering the HC2 test. In summry, most lortories experienced incresed volumes of HR-HPV testing with shift towrd in-house HR-HPV testing including HPV genotyping. Qigen HC2 nd Cervist HR HPV test continue to e the most common tests with n incresing volume of the Roche cos 4800 HPV test. Most HPV tests re requested for reflex testing, ut HPV-Pp cotests re lso incresing. These dt provide n updte into persisting nd newer trends in HPV testing prctices. Tle 9. Humn Ppillomvirus (HPV) 16/18 Genotyping Methods in 2012 Methods No. Percentge Hologic Cervist HPV 16/ Roche cos PCR (other thn Roche) Others Totl Arevition: PCR, polymerse chin rection. Bedford, Msschusetts. Plesnton, Cliforni. The study ws supported y the College of Americn Pthologists (CAP), ut conceptulized y memers of the CAP Cytopthology Committee. References 1. Dvey DD, Nryshkin S, Nielsen ML, Kline TS. Atypicl squmous cells of undetermined significnce: interlortory comprison nd qulity ssurnce monitors. Dign Cytopthol. 1994;11(4): Dvey DD, Nielsen ML, Nryshkin S, Ro JA, Cohen T, Kline TS. Atypicl squmous cells of undetermined significnce: current lortory prctices of prticipnts in the College of Americn Pthologists Interlortory Comprison Progrm in Cervicovginl Cytology. Arch Pthol L Med. 1996;120(5): Dvey DD, Nielsen ML, Rosenstock W, Kline TS. Terminology nd specimen dequcy in cervicovginl cytology: the College of Americn Pthologists Interlortory Comprison Progrm experience. Arch Pthol L Med. 1992;116(9): Dvey DD, Woodhouse S, Styer P, Ststny J, Mody D. Atypicl epithelil cells nd specimen dequcy: current lortory prctices of prticipnts in the College of Americn Pthologists Interlortory Comprison Progrm in Cervicovginl Cytology. Arch Pthol L Med. 2000;124(2): Dvey DD, Nel MH, Wilur DC, Colgn TJ, Styer PE, Mody DR. Bethesd 2001 implementtion nd reporting rtes: 2003 prctices of prticipnts in the College of Americn Pthologists Interlortory Comprison Progrm in Cervicovginl Cytology. Arch Pthol L Med. 2004;128(11): Wright TC, Cox JT, Mssd LS, Twiggs LB, Wilkinson EJ consensus guidelines for the mngement of women with cervicl cytologicl normlities. JAMA. 2002;287(16): Wright TC, Schiffmn M, Solomon D, et l. Interim guidnce for the use of humn ppillomvirus DNA testing s n djunct to cervicl cytology for screening. Ostet Gynecol. 2004;103(2): Wright TC Jr, Mssd LS, Dunton CJ, Spitzer M, Wilkinson EJ, Solomon D consensus guidelines for the mngement of women with norml cervicl screening tests. J Low Genit Trct Dis. 2007;11(4): Sslow D, Solomon D, Lwson HW, et l. Americn Cncer Society, Americn Society for Colposcopy nd Cervicl Pthology, nd Americn Society for Clinicl Pthology screening guidelines for the prevention nd erly detection of cervicl cncer. J Low Genit Trct Dis. 2012;16(3): Mssd LS, Einstein MH, Huh WK, et l updted consensus guidelines for the mngement of norml cervicl cncer screening tests nd cncer precursors. Ostet Gynecol. 2013;121(4): Ktki HA, Kinney WK, Fettermn B, et l. Cervicl cncer risk for women undergoing concurrent testing for humn ppillomvirus nd cervicl cytology: popultion-sed study in routine clinicl prctice. Lncet Oncol. 2011;12(7): Morirty AT, Schwrtz MR, Eversole G, et l. Humn ppillomvirus testing nd reporting rtes: prctices of prticipnts in the College of Americn Pthologists Interlortory Comprison Progrm in Gynecologic Cytology in Arch Pthol L Med. 2008;132(8): Morirty AT. A rock nd hrd plce: HPV testing nd finncil gin. Dign Cytopthol. 2007;35(8): Lee JW, Berkowitz Z, Sriy M. Low-risk humn ppillomvirus testing nd other nonrecommended humn ppillomvirus testing prctices mong US helth cre providers. Ostet Gynecol. 2011;118(1):4 13. Arch Pthol L Med Vol 139, June 2015 HPV Testing nd Reporting Rtes in 2012 Zho et l 761