S ince the mid-20th century, many countries around the globe have achieved great reductions in the burden of cervical cancer and other lower genital tract neoplasms, initially by using cervical cytology screening with follow-up of abnormal tests, and later by (1) recognizing the human papillomavirus (HPV) as the primary cause of cervical neoplasia, (2) employing laboratory tests developed to detect HPV, (3) identifying specific viral types considered high risk, and (4) developing preventive vaccines that currently reduce the risk of infection with viruses associated with several lower genital tract cancer precursors. In countries that implemented cytology-based programs, a 50%–90% reduction of cervical cancer incidence and mortality rates has been observed. Unfortunately, the application of this great health benefit has not been universal. As our knowledge expands about the burden of HPV-associated diseases among individuals in adequately resourced nations for whom limited screening and primary prevention exist, we are far behind in applying our knowledge and expertise to those in underserved nations with limited or no wellness resources. In 1957, the United States Commission on Chronic Illness defined health screening as “the presumptive identification of unrecognized disease or defect by the application of tests, examinations or other procedures that can be applied rapidly.” Thus, health screening is the use of methods to detect unrecognized health risks or diseases to permit timely intervention. Screening tests are used to distinguish apparently unaffected people from those who may have a disease or may develop it. A screening test is not intended to be diagnostic. Screening procedures are generally easier to perform and cheaper than diagnostic procedures. Their results require confirmation through definitive diagnostic tests or sometimes direct treatment based on a positive test. Even if the screening test is harmless, it can cause anxiety and the subsequent investigations and treatment may cause harm. Ensuring the safety of screening is also important because large numbers of individualswill be screened, creating a potential for greater numbers to be harmed by the process of screening. It is a coincidence that in April 2018, an article by Dobrow et al., appeared in the Canadian Medical Association Journal updating the principles of screening forged byWilson and Jungner in 1968, which have endured the test of time as a basis for making screening decisions. Briefly, Dobrow et al. conclude that Wilson and Jungner's principles retain amazing viability, but through an updated analytic process including a modified Delphi consensus process they created a group of 12 consolidated screening principles categorized as the following: (1) disease/condition, (2) test/intervention, and (3) program/system. The expanded version considers more in the direction of operational and implementation issues such as resource or system capacity, coordination of programmatic components, and their integration into the broader health care system. The implication is that the updated principles represent a more comprehensive approach for contemporary perspectives on screening and could lead to a shift in the types of evidence used to inform screening decisions, especially for addressing program and system issues. In clinical practice, the special nature of the patient/provider relationship has resulted in the need to create a core of ethical principles to govern this relationship. Screening is a preliminary process offered to a largely healthy population not seeking attention for symptoms of the disease for which the screening is being conducted and is meant to benefit the individuals being screened. An important distinction between screening and episodic care for medical diagnosis and treatment is that the screening encounter is not initiated by the subject but by the provider or the health system. This is true whether screening is offered in an organized program or opportunistically in a variety of ambulatory care settings. Those who participate in screening are not patients in the sense that they are ill and, in most situations, do not become “traditional” patients. The screener promotes the test based on evidence that screening will improve the overall health of the community. This does not mean that the condition of every screened individual will be better, but in general, this should be so. Nevertheless, providers and community health systems are responsible for minimizing the potential harms and anxiety that affect certain individuals being screened, ensuring that quality control of the screening tests is maintained, and assuring that a useful course of management is available for all individuals identified as being truly test positive.

T erms are words and compound words or multiword expressions that in specific contexts are given specific meanings. Within the clinical sciences, we use terms to describe findings, diagnoses, diseases, and treatments. Terminology is the discipline of designating termswithin a particular field. A standardized terminology provides an established comprehensive set of recommended terms. Within the clinical sciences, standardized terminologies are generally established by consensus agreement to the judgment reached by a group as a whole. The system of choosing or revising names of terms is nomenclature. Nomenclature is the naming of terms (from the Latin nomen [name] + calator [caller]). Although sometimes used as a synonym for terminology, we understand nomenclature to be the system for devising or choosing names, which are the body of named terms that belong to a specific terminology. A classification is the systematic grouping and organization of the terms of a specific terminology into classes or categories, based on characteristics in common. A clinical practice guideline is a comprehensive, consensus, or evidence-based aid for clinicians managing patients with abnormal findings, cytology, histopathology, or clinical diagnosis. Often, clinical practice guidelines use a precise nomenclature and may seek to establish a standardized terminology for a specific field of clinical science. There are many standardized terminologies within the field of anourogenital diseases. These are continuously evolving and typically updated every few years as understanding increases. Although intended to provide comprehensive and unambiguous classification, some of the terminologies overlap and may differ from one another in measuring magnitude of change from normal to abnormal. As a consequence, some clinical research was conducted at the time of 1 terminology and published after a newer standardized terminology has taken hold. Expert colleagues belonging to different specialties and cultures may not agree on the standardized terminology during a given period. Readers of journals may be confused by competing terms for similar or related conditions. As examples, the terms “Pap smear” and “Pap test” may be replaced by “cervical cytology” and the term “dysplasia” has been replaced by “intraepithelial lesion.”As 1 example, the Lower Anogenital Squamous Terminology (LAST) recommendations standardized biologically relevant histopathologic terminology for human papillomavirus– associated squamous intraepithelial lesions and superficially invasive squamous carcinomas across all lower anogenital tract sites detailed the appropriate use of specific biomarkers to clarify histologic interpretations and enhance diagnostic accuracy. A standardized terminologywill facilitate the ability of 2 or more clinicians, sites of care, healthcare systems, or countries to exchange and apply health research and information in a meaningful way for their patients. The importance of a standardized terminology is highlighted by these following aspects:

ObjectiveVaginal cancer is an uncommon cancer of the lower genital tract, and standardized screening is not recommended. Risk factors for vaginal cancer include a history of other lower genital tract neoplasia or cancer, smoking, immunosuppression, and exposure to diethylstilbestrol in utero. Although cervical cancer screening after total hysterectomy for benign disease is not recommended, many women inappropriately undergo vaginal cytology and/or human papillomavirus (HPV) tests, and clinicians are faced with managing their abnormal results. Our objectives were to review the literature on vaginal cytology and high-risk HPV (hrHPV) testing and to develop guidance for the management of abnormal vaginal screening tests. Materials and MethodsAn electronic search of the PubMed database through 2015 was performed. Articles describing vaginal cytology or vaginal hrHPV testing were reviewed, and diagnostic accuracy of these tests when available was noted. ResultsThe available literature was too limited to develop evidence-based recommendations for managing abnormal vaginal cytology and hrHPV screening tests. However, the data did show that (1) the risk of vaginal cancer in women after hysterectomy is extremely low, justifying the recommendation against routine screening, and (2) in women for whom surveillance is recommended, e.g., women posttreatment for cervical precancer or cancer, hrHPV testing may be useful in identification of vaginal cancer precursors. ConclusionsVaginal cancer is rare, and asymptomatic low-risk women should not be screened. An algorithm based on expert opinion is proposed for managing women with abnormal vaginal test results.

ObjectiveVaginal cancer is an uncommon cancer of the lower genital tract, and standardized screening is not recommended. Risk factors for vaginal cancer include a history of other lower genital tract neoplasia or cancer, smoking, immunosuppression, and exposure to diethylstilbestrol in utero. Although cervical cancer screening after total hysterectomy for benign disease is not recommended, many women inappropriately undergo vaginal cytology and/or human papillomavirus (HPV) tests, and clinicians are faced with managing their abnormal results. Our objectives were to review the literature on vaginal cytology and high-risk HPV (hrHPV) testing and to develop guidance for the management of abnormal vaginal screening tests.Materials and MethodsAn electronic search of the PubMed database through 2015 was performed. Articles describing vaginal cytology or vaginal hrHPV testing were reviewed, and diagnostic accuracy of these tests when available was noted.ResultsThe available literature was too limited to develop evidence-based recommendations for managing abnormal vaginal cytology and hrHPV screening tests. However, the data did show that (1) the risk of vaginal cancer in women after hysterectomy is extremely low, justifying the recommendation against routine screening, and (2) in women for whom surveillance is recommended, e.g., women posttreatment for cervical precancer or cancer, hrHPV testing may be useful in identification of vaginal cancer precursors.ConclusionsVaginal cancer is rare, and asymptomatic low-risk women should not be screened. An algorithm based on expert opinion is proposed for managing women with abnormal vaginal test results.

Persistent vulvar pain is a complex disorder that frequently is frustrating to the patient and the clinician. It can be difficult to treat and rapid resolution is unusual, even with appropriate therapy. Vulvar pain can be caused by a specific disorder or it can be idiopathic. Idiopathic vulvar pain is classified as vulvodynia. Although optimal treatment remains unclear, consider an individualized, multidisciplinary approach to address all physical and emotional aspects possibly attributable to vulvodynia. Specialists who may need to be involved include sexual counselors, clinical psychologists, physical therapists, and pain specialists. Patients may perceive this approach to mean the practitioner does not believe their pain is "real"; thus, it is important to begin any treatment approach with a detailed discussion, including an explanation of the diagnosis and determination of realistic treatment goals. Future research should aim at evaluating a multimodal approach in the treatment of vulvodynia, along with more research on the etiologies of vulvodynia.

Vaginal cancer is an uncommon cancer of the lower genital tract, and standardized screening is not recommended. Risk factors for vaginal cancer include a history of other lower genital tract neoplasia or cancer, smoking, immunosuppression, and exposure to diethylstilbestrol in utero. Although cervical cancer screening after total hysterectomy for benign disease is not recommended, many women inappropriately undergo vaginal cytology and/or human papillomavirus (HPV) tests, and clinicians are faced with managing their abnormal results. Our objectives were to review the literature on vaginal cytology and high-risk HPV (hrHPV) testing and to develop guidance for the management of abnormal vaginal screening tests.An electronic search of the PubMed database through 2015 was performed. Articles describing vaginal cytology or vaginal hrHPV testing were reviewed, and diagnostic accuracy of these tests when available was noted.The available literature was too limited to develop evidence-based recommendations for managing abnormal vaginal cytology and hrHPV screening tests. However, the data did show that (1) the risk of vaginal cancer in women after hysterectomy is extremely low, justifying the recommendation against routine screening, and (2) in women for whom surveillance is recommended, e.g., women posttreatment for cervical precancer or cancer, hrHPV testing may be useful in identification of vaginal cancer precursors.Vaginal cancer is rare, and asymptomatic low-risk women should not be screened. An algorithm based on expert opinion is proposed for managing women with abnormal vaginal test results.

In Brief Men have unique roles in eradicating the effects of human papillomavirus and other sexually transmitted carcinogenic viruses.

In 2011, the American Cancer Society, the American Society for Colposcopy and Cervical Pathology, and the American Society for Clinical Pathology updated screening guidelines for the early detection of cervical cancer and its precursors. Recommended screening strategies were cytology or cotesting (cytology in combination with high-risk human papillomavirus [hrHPV] testing). These guidelines also addressed the use of hrHPV testing alone as a primary screening approach, which was not recommended for use at that time. There is now a growing body of evidence for screening with primary hrHPV testing, including a prospective U. S.-based registration study. Thirteen experts, including representatives from the Society of Gynecologic Oncology, the American Society for Colposcopy and Cervical Pathology, the American College of Obstetricians and Gynecologists, the American Cancer Society, the American Society of Cytopathology, the College of American Pathologists, and the American Society for Clinical Pathology, convened to provide interim guidance for primary hrHPV screening. This guidance panel was specifically triggered by an application to the U. S. Food and Drug Administration (FDA) for a currently marketed HPV test to be labeled for the additional indication of primary cervical cancer screening. Guidance was based on literature review and review of data from the FDA registration study, supplemented by expert opinion. This document aims to provide information for health care providers who are interested in primary hrHPV testing and an overview of the potential advantages and disadvantages of this strategy for screening as well as to highlight areas in need of further investigation.

Chief Medical Officer, American Society for Colposcopy and Cervical Pathology; and Acting Editor-in-Chief, Journal of Lower Genital Tract Disease. Correspondence to: Herschel W Lawson, MD, 1530 Tilco DR, Suite C, Frederick, MD, 21704-6726. E-mail: [email protected] The author has declared that there are no conflicts of interest

Vulvodynia is a complex disorder that can be difficult to treat. Most patients describe it as burning, stinging, irritation, or rawness. Vulvodynia is a costly disease both economically and on its negative impact on patient quality of life. Although many treatment options are available, no one treatment is effective for all patients, thus the need to individualize management. Measures such as gentle vulvar care, medication, biofeedback training, physical therapy, sexual counseling and surgery, as well as complementary and alternative therapies are available to treat the condition with varying success.

A group of 47 experts representing 23 professional societies, national and international health organizations, and federal agencies met in Bethesda, MD, September 14-15, 2012, to revise the 2006 American Society for Colposcopy and Cervical Pathology Consensus Guidelines. The group's goal was to provide revised evidence-based consensus guidelines for managing women with abnormal cervical cancer screening tests, cervical intraepithelial neoplasia (CIN) and adenocarcinoma in situ (AIS) following adoption of cervical cancer screening guidelines incorporating longer screening intervals and co-testing. In addition to literature review, data from almost 1.4 million women in the Kaiser Permanente Northern California Medical Care Plan provided evidence on risk after abnormal tests. Where data were available, guidelines prescribed similar management for women with similar risks for CIN 3, AIS, and cancer. Most prior guidelines were reaffirmed. Examples of updates include: Human papillomavirus-negative atypical squamous cells of undetermined significance results are followed with co-testing at 3 years before return to routine screening and are not sufficient for exiting women from screening at age 65 years; women aged 21-24 years need less invasive management, especially for minor abnormalities; postcolposcopy management strategies incorporate co-testing; endocervical sampling reported as CIN 1 should be managed as CIN 1; unsatisfactory cytology should be repeated in most circumstances, even when HPV results from co-testing are known, while most cases of negative cytology with absent or insufficient endocervical cells or transformation zone component can be managed without intensive follow-up.

An update to the American Cancer Society (ACS) guideline regarding screening for the early detection of cervical precancerous lesions and cancer is presented. The guidelines are based on a systematic evidence review, contributions from 6 working groups, and a recent symposium cosponsored by the ACS, the American Society for Colposcopy and Cervical Pathology, and the American Society for Clinical Pathology, which was attended by 25 organizations. The new screening recommendations address age-appropriate screening strategies, including the use of cytology and high-risk human papillomavirus (HPV) testing, follow-up (eg, the management of screen positives and screening intervals for screen negatives) of women after screening, the age at which to exit screening, future considerations regarding HPV testing alone as a primary screening approach, and screening strategies for women vaccinated against HPV16 and HPV18 infections.

In March 2012, the College of American Pathologists and American Society for Colposcopy and Cervical Pathology, in collaboration with 35 stakeholder organizations, convened a consensus conference called the Lower Anogenital Squamous Terminology (LAST) Project. The recommendations of this project include using a uniform, two-tiered terminology to describe the histology of human papillomavirus-associated squamous disease across all anogenital tract tissues: vulva, vagina, cervix, penis, perianus, and anus. The recommended terminology is "low-grade" or "high-grade squamous intraepithelial lesion (SIL)." This terminology is familiar to clinicians, because it parallels the terminology of the Bethesda System cytologic reports. Biopsy results using SIL terminology may be further qualified using "intraepithelial neoplasia" (IN) terminology in parentheses. Laboratory p16 tissue immunostaining is recommended to better classify histopathology lesions that morphologically would earlier have been diagnosed as IN 2. p16 is also recommended for differentiating between high-grade squamous intraepithelial lesions and benign mimics. The LAST Project recommendations potentially affect the application of current guidelines for managing cervical squamous intraepithelial lesions. The authors offer interim guidance for managing cervical lesions diagnosed using this new terminology with special attention paid to managing young women with cervical high-grade squamous intraepithelial lesions on biopsy. Clinicians should be aware of the LAST Project recommendations, which include important changes from prior terminology.

OBJECTIVE: To quantify repeat Pap testing and colposcopic biopsies among women in the National Breast and Cervical Cancer Early Detection Program between 2003 and 2006 (N=955,494). METHODS: Rates of repeat Pap testing (two tests within 9 months) and colposcopic biopsies were estimated along with 95% confidence intervals (CIs). Odds ratios and 95% CIs for receipt of colposcopic biopsy compared with repeat Pap testing were estimated from multivariable logistic regression models. Finally, we estimated positive predictive values and 95% CIs of cervical intraepithelial neoplasia (CIN) 2 or worse (CIN 3, carcinoma in situ, invasive cancer) for two strategies: 1) repeat Pap testing followed by colposcopic biopsy and 2) colposcopic biopsy alone. RESULTS: There were 39,583 and 53,880 women with repeat Pap testing and colposcopic biopsy, respectively, from 2003 to 2006. Overall, age-standardized rates of repeat Pap testing and colposcopic biopsies were 37.2 per 1,000 women and 39.3 per 1,000 women, respectively. Younger women, Hispanic women, and African-American women were more likely to receive colposcopic biopsies compared with repeat Pap tests. Positive predictive values of colposcopic biopsy were highest after abnormal Pap test results (27% after a result of atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion, 70% after a result of high-grade squamous intraepithelial lesion/squamous cell cancer). CONCLUSION: Colposcopic biopsies are common among young women after being screened for cervical cancer and, except among those with the most severe Pap test results, may not be efficient in detecting serious disease. These results conflict with current recommendations for less aggressive follow-up for most young women. LEVEL OF EVIDENCE: II

The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention. Address for reprints: Vicki B. Benard, PhD, Epidemiology and Applied Research Branch, Division of Cancer Prevention and Control, Mailstop K-55, NCCDPHP, CDC, 4770 Buford Hwy NE, Atlanta, GA 30341; Fax: (770) 488-4639; E-mail: vdb9@ cdc.gov *This article is a US government work and, as such, is in the public domain in the United States of America.

BACKGROUND. This study examined the association between county-level measures of socioeconomic status (SES) and the incidence rate of human papillomavirus(HPV)-associated cancers, including cervical, vulvar, vaginal, anal, penile, and oral cavity and oropharyngeal cancers.METHODS. The authors collected data from cancer registries for site-specific invasive cancer diagnoses between 1998 and 2003, inclusive, among adults aged >20 years at the time of diagnosis. County-level variables that included education, income, and poverty status were used as factors for socioeconomic status. Measures of rural-urban status, the percentage of the population that currently smoked, and the percentage of women who reported having ever had a Papanicolaou (Pap) test were also studied.RESULTS. Lower education and higher poverty were found to be associated with increased penile, cervical, and vaginal invasive cancer incidence rates. Higher education was associated with increased incidence of vulvar cancer, male and female anal cancer, and male and female oral cavity and oropharyngeal cancers. Race was an independent predictor of the development of these potentially HPV-associated cancers.CONCLUSIONS. These findings illustrate the association between SES variables and the development of HPV-associated cancers. The findings also highlight the importance of considering SES factors when developing policies to increase access to medical care and reduce cancer disparities in the United States. Cancer 2008; 113(10 suppl):2910-8. Published 2008 411 the American Cancer Society.*

This supplement, known as the ABHACUS (Assessing the Burden of HPV-Associated Cancers in the United States) supplement, contains 22 articles. Together, these articles provide a comprehensive snapshot of data related to the occurrence and control of multiple cancers that have been associated with the human papillomavirus (HPV). These analyses highlight the burden of HPV-associated cancers in the US population as a whole and among vulnerable population subgroups. We anticipate that these findings will be an important resource for enhancing existing strategies for the prevention and control of HPV-associated cancers. HPV is estimated to be responsible for 5.2% of the cancers diagnosed worldwide.1 Virtually 100% of cervical cancers are causally associated with HPV, and there is increasing evidence of the role that HPV plays in other anogenital cancers and oropharyngeal cancers. With the recent approval and recommendation of an HPV vaccine that contains HPV–16 and HPV–18, interest in quantifying the spectrum and burden of cancers is heightened. The International Agency for Research on Cancer (IARC) has determined that there is sufficient evidence for the carcinogenicity of HPV–16 in the cervix, vulva, vagina, penis, anus, oral cavity, and oropharynx.2 The IARC has found sufficient evidence of the role HPV–18 plays in cervical cancer, with limited or no evidence in other sites. Together, cervical cancer combined with the other HPV-associated cancers potentially afflicts an additional 25,000 persons every year in the US. Worldwide and in the US, the excitement and concern surrounding the HPV vaccine has been profound. The excitement derives from the potential of the vaccine to reduce the burden of cervical cancer in countries that have no screening infrastructure as well as in countries such as the US, in which nearly 11,000 women each year are told they have invasive cervical cancer and 4000 die from this disease, despite the availability of screening. The HPV vaccine also has the potential to impact a significant proportion of other cancers for which there typically is no routine screening. Conversely, the concern is that vaccine recipients may not continue to undergo screening for cervical cancer. Yet another concern is that if vaccine uptake is lower in those groups at highest risk of developing cervical cancer, current racial/ethnic or geographic disparities could increase. We hope that the articles in this supplement will highlight the burden and disparities associated with these cancers before vaccine implementation. This supplement includes an in-depth analysis of cancer incidence and mortality data from population-based central cancer registries that house high-quality data. Fourteen articles are based mainly on cancer occurrence, using incidence data from population-based central cancer registries that participate in the Centers for Disease Control and Prevention (CDC)'s National Program of Cancer Registries (NPCR) and/or the National Cancer Institute (NCI)'s Surveillance, Epidemiology, and End Results (SEER) program. The NPCR program, which was established through the Cancer Registries Amendment Act passed by the US Congress in 1992, began providing financial support and technical assistance to population-based central cancer registries in 1994. This program currently supports central registries in 45 states, the District of Columbia, and 3 US territories; these registries cover approximately 96% of the US population. The SEER program, which was established as a result of the National Cancer Act of 1971, currently supports 14 such registries and 3 supplemental registries, covering approximately 26% of the US population. The population-based central cancer registries collect information on all reportable cancer cases within a state or another defined geographic area. Today, the NPCR and SEER programs together cover 100% of the US population, and data regarding more than 1 million new invasive cancer cases are added each year. Medical records are the primary source of the data. Both the NPCR and SEER data are collected and reported with the use of uniform data items and codes, as documented by the North American Association of Central Cancer Registries.3 The Institute of Medicine has recognized the importance of these 2 programs as valuable resources for studies on cancer.4 National and regional population coverage of cancer registry data has been achieved only within the last few years. Such coverage now allows for the unprecedented examination of rare cancers, as well as a focus on cancer burden by age, sex, race, histology, geography, and other variables. This supplement leverages US population-based cancer registries by demonstrating the current burden of disease for all 6 HPV-associated cancers in each of the individual site-specific chapters (cervical, vaginal, vulvar, anal, penile, and oropharyngeal cancers).5-10 Before engaging in any analyses, the steering committee spent a considerable amount of time establishing common definitions. Watson et al describe the registries in more detail and provide some standardized analytic criteria used in the site-specific analyses.11 Benard et al highlight some of the applications of cancer registry data, augmented with linked census-based socioeconomic data, thereby to our knowledge underscoring for the first time general patterns that are observed for each of the HPV-associated cancers.12 Ryerson et al focus on the HPV-associated cancer burden for oral cavity and oropharyngeal cancers, using anatomic subsites as a proxy for HPV association.5 Several articles take advantage of the unique attributes of certain central cancer registries or go beyond the description of cancer occurrence. For example, data from the California Cancer Registry allow for the computation of cancer incidence rates for Asian subpopulations, some of which have been known to have the highest incidence of cervical cancer in the US.13 Despite the 1996 recommendation to discontinue the collection of data regarding carcinoma in situ (CIS) of the cervix, the Michigan Cancer Surveillance System continued to collect these data; Copeland et al present current trends related to cervical CIS.14 Hopehayn et al and Coughlin et al examine the burden of cervical cancer in areas with disproportionate burdens: Appalachia and those states bordering Mexico.15, 16 Additional articles use cancer registry data to examine treatment patterns for female HPV-associated cancers and the risk of other HPV-associated cancers among cervical cancer survivors.17 Finally, an examination of the years of potential life lost and mortality-related productivity costs of all HPV-associated cancers is presented.18 Because of the importance of primary prevention and screening for cancer control, another aim of this supplement is to update the reader with pertinent information related to vaccination and screening. Dunne et al describe the epidemiology of HPV and the HPV vaccine.19 Tiro et al examine various national behavioral surveillance systems related to cervical cancer screening and vaccination.20 Castle et al comment on the potential impact of the HPV vaccine on cervical cancer screening in the years to come.21 Whiteside et al present an overview of what is known concerning the molecular mechanisms involved in HPV oncogenesis to help readers interpret data regarding HPV causality in noncervical cancers and understand the new molecular markers proposed for screening.22 Gillison et al discuss the role of HPV in noncervical cancers and apply worldwide and US estimates of attributable fractions to further define the burden of HPV-associated cancers.22 Another article comments on the role the cancer registries can play in monitoring the impact of the HPV vaccine.23 Lastly, Khan et al describe 2 key CDC programs related to cervical cancer prevention (the Vaccines for Children Program) and screening (the National Breast and Cervical Cancer Early Detection Program) that target uninsured individuals and other vulnerable populations.24 A few years ago, the National Coordinating Council for Cancer Surveillance developed a national framework for cancer surveillance in the US.25 This supplement represents the application of this cancer surveillance framework to HPV-associated cancers. To be effective, cancer surveillance requires coordination and cooperation among government, professional, nonprofit, and private organizations, and the articles contained in this supplement demonstrate the success that can be achieved through such collective efforts. Greater than 100 investigators and 30 peer reviewers from various divisions at the CDC, various parts of the NCI, population-based cancer registries (Arkansas, Arizona, California, Florida, Idaho, Illinois, Kansas, Kentucky, Louisiana, Maine, Michigan, New Mexico, New York, South Dakota, Tennessee, Texas, and Washington DC), academic institutions, and the American Cancer Society worked diligently and collaboratively over the past year and a half to produce this supplement. We wish to express our deepest gratitude to them.

Objetivo. Evaluar la conducta aplicada en el National Breast and Cervical Cancer Early Detection Program de EEUU para las lesiones intraepiteliales escamosas de bajo grado (LSIL) antes y después de la publicación en 2002 de las directrices relativas a la citología anormal de la American Society for Colposcopy and Cervical Pathology (ASCCP). Material y métodos. Examinamos el seguimiento de 22.342 mujeres con LSIL durante 2 períodos: 2000-2002 y 2003-2005. Resultados. El porcentaje de profesionales de la salud que siguieron las directrices recomendadas, con colposcopia para un resultado de LSIL en la citología de cribado aumentó en un 9% al comparar el periodo pre-ASCCP con el post- ASCCP. Se observó un aumento para todas las edades y grupos raciales/étnicos. Las mujeres más jóvenes (< 30 años) y las mujeres blancas tenían una probabilidad de seguimiento mediante colposcopia en vez de la repetición de la citología superior a la de los grupos de comparación. Conclusiones. El aumento del porcentaje de mujeres a las que se practicó una colposcopia en 2003, 1 año después de la publicación de las nuevas directrices, sugiere un cambio en las prácticas aplicadas por los profesionales de la salud que concuerda con lo indicado en las directrices. ▪

OBJECTIVE:To assess the management of women in the National Breast and Cervical Cancer Early Detection Program with low-grade squamous intraepithelial lesions (LSIL) before and after the American Society for Colposcopy and Cervical Pathology (ASCCP) guidelines for management of abnormal cytology were published in 2002.MATERIALS AND METHODS:We examined the follow-up for 22,342 women with LSIL during 2 periods: 2000-2002 and 2003-2005.RESULTS:The percentage of providers who followed the recommended guidelines with colposcopy for an LSIL Pap test result increased by 9% from the pre-ASCCP to the post-ASCCP period. An increase was seen in every age and racial/ethnic group. Younger women (<30 years) and white women were more likely than comparison groups to be followed by colposcopy rather than a repeat Pap test.CONCLUSIONS:The increase in percentage of women having colposcopy in 2003, 1 year after the new guidelines were published, suggests a change in provider practices consistent with those guidelines.