ALTS was a clinical trial to find the best way to help women and their doctors decide what to do about the mildly abnormal and very common Pap test results known as ASCUS and LSIL. About three million women in the United States are diagnosed with ASCUS and LSIL each year. Organized and funded by the National Cancer Institute, ALTS included more than 5,000 women. It began in November 1996 and concluded at the end of 2000. Data analysis of the trial's findings is ongoing.
ASCUS stands for atypical squamous cells of undetermined significance and LSIL for low-grade squamous intraepithelial lesions. Most of these mild abnormalities will go away without treatment, but some may signal a precancerous condition or, rarely, cancer, ALTS looked at three ways to manage these abnormalities:
- immediate colposcopy (magnified viewing and testing of the cervix)
- repeat Pap tests
- testing for human papillomavirus (HPV), an infection linked to cervical cancer
Approximately 55 million Pap smears are performed each year in the United States. The vast majority of results are negative (no abnormality identified) but about 5% to 8% are reported as abnormal. Most low-grade changes regress spontaneously; only a minority of such lesions would progress to a cancer precursor without treatment. However, currently there is no way to determine morphologically which patients are at risk of progression. Therefore, both high- and low-grade lesions are often managed with colposcopy and directed biopsy. Determining alternative management strategies could yield important potential benefits including fewer medical complications from overtreatment, reduced patient anxiety associated with referral for cytologic abnormalities, as well as cost savings.
Epidemiologic, virologic and molecular studies have clearly demonstrated that human papillomavirus (HPV) is the central cause of cervical cancer. The motivation for the ALTS trial was to use the information we have gained about the role of HPV to design better treatment and prevention strategies to reduce the burden of cervical cancer and its precursors.
ALTS consisted of three management strategies: (1) immediate colposcopy of all women; (2) repeat cytology with colposcopy only if the results show a high grade lesion; and (3) HPV testing and repeat cytology in combination, with referral to colposcopy if either the HPV test is positive or the cytology shows a high grade lesion. Four Clinical Centers - University of Alabama, Birmingham AL; Magee-Womens Hospital, Pittsburgh PA; University of Oklahoma, Oklahoma City OK; and University of Washington, Seattle WA - enrolled approximately 5,000 women with a recent diagnosis of ASCUS or LSIL. Participants were followed at six month intervals for a total of 2 years. ALTS is comparing the efficacy and cost-effectiveness of the different strategies in the early detection of high-grade lesions.
The trial design and methods are described in: Schiffman, M. and Adrianza, E., ASCUS-LSIL Triage Study: Design, Methods and Characteristics of Trial Participants, Acta Cytologica, Sep-Oct 2000:44(5):726-42.
Study centers that participated in ALTS were:
- University of Alabama at Birmingham - Investigators: Edward E. Partridge, MD, Professor and Vice Chairman of the Department of Obstetrics; Larry Clinton Kilgore, MD, Associate Professor in the UAB Division of Gynecologic Oncology; Ronald David Alvarez, MD, Associate Professor in the UAB Division of Gynecologic Oncology; Mack Nathaniel Barnes, III, MD, Assistant Professor in the Division of Gynecologic Oncology; Study Manager: Shirley Hester, MSN CRNP
- University of Oklahoma - Investigators: Joan L. Walker, MD, Associate Professor and Chief of the Gynecologic Oncology Section; Gary A. Johnson, MD
- Magee-Womens Hospital of the University of Pittsburgh Medical Center Health System - Investigators: Richard S. Guido, MD, Assistant Professor in the Department of Obstetrics and Gynecology; Kathleen McIntyre-Seltman, MD, Associate Professor in the Department of Obstetrics and Gynecology; Study Manager: Judy Gruss, RN
- University of Washington at Seattle - Investigators: Nancy Kiviat, MD, Professor of Pathology; Laura Koutsky, PhD, Associate Professor of Epidemiology at the University of Washington; Study Manager: Joanna Haug, MPH
HPV testing is sensitive in detecting underlying precancerous lesions among women with a Pap test diagnosis of ASCUS.
This study looked at the ALTS patients with ASCUS who were found to have a precancerous lesion when they underwent colposcopy and biopsy. Its purpose was to find out how sensitive HPV testing was at identifying these women compared to repeat Pap testing. The study found that HPV testing was 96-percent sensitive - that is, identified 96% of the women with ASCUS who had a precancerous lesion. The authors concluded that HPV testing is a viable option for the management of ASCUS. Reference: D. Solomon, M. Schiffman, R. Tarone for the ALTS Group, Comparison of Three Management Strategies for Patients With Atypical Squamous Cells of Undetermined Significance: Baseline Results From a Randomized Trial, Journal of the National Cancer Institute, Feb 21, 2001:92(12):293-299).
HPV testing is not useful for women with a Pap test diagnosis of LSIL.
This study focused on the 642 women in the ALTS study who had an LSIL diagnosis, seeking to determine whether HPV testing could be used to decide which of them needed to undergo colposcopy and which could wait, pending the outcome of repeat testing. The authors found that 82.9 percent of women with LSIL tested positive for HPV. They conclude that this high prevalence of HPV limits the usefulness of HPV testing in deciding how to manage LSIL. Reference: Human Papillomavirus Testing for Triage of Women With Cytologic Evidence of Low-Grade Squamous Intraepithelial Lesions: Baseline Data From a Randomized Trial. The ASCUS/LSIL Study (ALTS) Group, Journal of the National Cancer Institute, Mar 1, 2000: 92 (5):397-402.
Expert interpretations of Pap tests vary substantially.
The purpose of this analysis was to determine how often pathologists agree in their interpretations of both Pap tests and cervical biopsy specimens. The researchers compared different pathologists' diagnoses of the thin-layer Pap tests and biopsy specimens that were collected when women enrolled in ALTS. They found substantial differences among expert pathologists in interpreting both thin-layer Pap tests and biopsies; agreement (reproducibility) was only moderate. They conclude that variability among experts in interpreting Pap tests and biopsies should be taken into consideration when using these interpretations and when developing standards of practice. Reference: Stoler, M.H. and Schiffman, M., Interobserver Reproducibility of Cervical Cytologic and Histologic Interpretations: Realistic Estimates From the ASCUS-LSIL Triage Study, Journal of the American Medical Association, Mar. 21, 2001: 285(11),1500-1505.
- Gage K. Schiffman M, Solomon D, Wheeler CM, Castle PE. Comparison of measurements of human papillomavirus persistence for postcolposcopic surveillance for cervical precancerous lesions. Cancer Epidemiol Biomarkers Prev. 2010 19(7):1668-74.
- Porras C, Bennett C, Safaeian M, Coseo S, Rodriguez AC, Gonzalez P, et al. Determinants of seropositivity among HPV-16/18 DNA positive young women. BMC Infect Dis. 2010 10:238.
- Rodriguez AC, Schiffman M, Herrero R, Hildesheim A, Bratti C, Sherman ME, Solomon D, Guillen D, Alfaro M, Morales J, Hutchinson M, Katki H, Cheung L, Wacholder S, Burk RD. Longitudinal study of human papillomavirus persistence and cervical intraepithelial neoplasia grade 2/3: critical role of duration of infection. J Natl Cancer Inst. 2010 102(24):315-324.
- Schiffman M, Solomon D. Liquid-based cytology vs. conventional cytology in detecting cervical cancer. Reply to Letter to the Editor. JAMA. 2010 303(11):1034-1035.
- Wacholder S, Chen BE, Wilcox A, Macones G, Gonzales P, Befano B, Hildesheim A, Rodriguez AC, Solomon D, Herrero R, Schiffman M, for the CVT Group. Risk of miscarriage in two randomized controlled trials of a bivalent accine against human papillomavirus types 16 and 18. Br Med J. 2010 340:c1666.
- Castle PE, Rodriguez AC, Burk RD, Herrero R, Hildesheim A, Solomon D, Sherman ME, Jeronimo J, Alfaro M, Morales J, Gullen D, Htuchinson ML, Wacholoder S, Schiffman M. Neither one-time negative screening tests nor negative colposcopy provides absolute reassurance against cervical cancer. Int J Cancer. 2009 Oct 1; 125(7):1649-56.
- Castle PE, Schiffman M, Wheeler CM, Solomon D. Evidence for frequent regression of cervical intraepithelial neoplasia grade 2, the clinical threshold for treatment in cervical cancer screening programs. Obstet Gynecol. 2009 113:18-25.
- Hildesheim A, Schiffman M, Solomon D, Wacholder S, Herrero R, Rodriguez AC. Response to analysis of adverse events of potential autoimmune aetiology in a large integrated safety database of AS04 adjuvanted vaccines by Verstraeten et al. Vaccine. 2009 April 28;27(19):2529.
- Katki HA, Wacholder S, Solomon D, Castle PE, Schiffman M. Risk estimation for the next generation of prevention programmes for cervical cancer. Keynote Comment. Lancet Oncol. 2009 Nov;10(11):1022-3.
- Massad LS, Einstein M, Myers E, Wheeler C, Wentzensen N, Solomon D. The impact of human papillomavirus vaccination on cervical cancer prevention efforts. Gynecol Oncol. 2009 114:360-364.
- Safaeian M, Schiffman M, Gage J, Solomon D, Wheeler CM, Castle PE. Detection of precancerous cervical lesions is differential by human papillomavirus type. Cancer Res. 2009 Apr 15;69(8):3262-6.
- Schiffman M, Solomon D. Screening and prevention methods for cervical cancer. JAMA. 2009 October 28:302:1809-10.
- Solomon D, Castle P, Hildesheim A, Katki HA, Schiffman M, Wacholder S. HPV vaccination in women aged 24-45 years. Letter to the editor. Lancet. 2009 Oct 10;374(9697):1239.
- Solomon D, Papillo J, Davey D. Statement on human papillomavirus DNA test utilization. Cancer Cytopathol. Commentary. 2009 154-156.
- Castle PE, Cox JT, Jeronimo J, Solomon D, Wheeler CM, Gravitt PE, Schiffman M. An analysis of high-risk human papillomavirus DNA-negative cervical precancers in the ASCUS-LSISL Triage Study (ALTS). Obstet Gynecol. 2008 111:847-856.
- Castle P, Cox JT, Schiffman M, Wheeler C, Solomon D. Factors influencing histologic confirmation of high-grade disease. Obstet Gynecol. 2008 112:637-645.
- Castle P, Solomon D, Saslow D, Schiffman M. Commentary: predicting the effect of successful HPV vaccination on existing US cervical cancer prevention programs in the United States. Cancer. 2008 113:3031-5.
- Castle PE, Solomon D, Wheeler CM, Gravitt PE, Wacholder S, Schiffman M. Human papillomavirus genotype specificity of hybrid capture 2. J Clin Microbiol. 2008;46:2595-604.
- Castle PE, Gravitt PE, Solomon D, Wheeler CM, Schiffman M. Comparison of linear array and line blot assay for detection of human papillomavirus and diagnosis of cervical precancer and cancer in ALTS. J Clin Microbiol. 2008 46:109-117.
- Galgano MT, Castle PE, Stoler MH, Solomon D, Schiffman M. Can HPV-16 genotyping provide a benchmark for cervical biopsy specimen interpretation? Am J Clin Pathol. 2008 130:65-70.
- Herrero R, Hildesheim A, Rodriguez AC, Wacholder S, Bratti C, Solomon D et al. Rationale and design of a community-based double-blind randomized clinical trial of an HPV 16 and 18 vaccine in Guanacaste, Costa Rica. Vaccine. 2008 26:4795-4808.
- Lowy DR, Solomon D, Hildesheim A, Schiller JT, Schiffman M. Human papillomavirus infection and the primary and secondary prevention of cervical cancer. Cancer. 2008 113:1980-1993.
- Nayar R, Solomon D. From the authors of the Bethesda System. Letter to the Editor. Cytopathology. 2008 19:399-400.
- Rodriguez AC, Schiffman M, Herrero R, Wacholder S, Hildesheim A, Castle PE, Solomon D, Burk R. Rapid clearance of human papillomavirus and implications for clinical focus on persistent infections. J Natl Cancer Inst. 2008 100:513-517.
- Carreon J, Sherman ME, Guillen D, Solomon D, Herrero R, et.a. CIN2 is a much less reproducible and less valid diagnosis than CIN3: results from a histological review of population-based cervical samples. International J Gyn Pathol. 2007 26:441-446.
- Castle P, Sideri M, Jeronimo J, Solomon D, Schiffman M. Risk management to guide the prevention of cervical cancer. 2007 Am J Obstet Gynecol 2007 197:356-358.
- Castle PE, Stoler MH, Solomon D, Schiffman M. Relationship of community biopsy-diagnosed cervical intraepithelial neoplasia grade 2 (CIN2) to the quality control pathology reviewed diagnoses: an ALTS report. Am J Clin Pathol. 2007 127:805-815.
- Hildesheim A, Herrero R, Wacholder S, Rodrigues AC, Solomon D, et al. Effect of human papillomavirus 16/18 L1 viruslike particle vaccine among young women with preexisting infection. JAMA 2007 298:743-753.
- Sherman ME, das Gupta A, Schiffman M, Nayar R, Solomon D. Bethesda Interobserver Reproducibility Study (BIRST). Cancer Cytopathol. 2007 111:15-25.
- Safeian M, Solomon D, Castle PE. Cervical cancer prevention – cervical screening: science in evolution. Obstet Gynecol Clin North Am 2007 34:739-760.
- Safaeian M, Solomon D, Wacholder S, Schiffman M, Castle P. Risk of precancer and follow-up management strategies for women with HPV-negative atypical squamous cells of undetermined significance. Obstet Gynecol. 2007 Jun;109(6):1325-31.
- Solomon D, Breen N, McNeel T. Cervical cancer screening rates and potential impact of implementation of screening guidelines. CA Cancer J Clin. 2007 57:105-111.
- Solomon D, Stoler M, Jeronimo J, Khan M, Castle P, Schiffman M. Diagnostic utility of endocervical curettage in women undergoing colposcopy for equivocal or low grade cytologic abnormalities. Obstet Gynecol. 2007 110:288-295.
- Stoler MH, Castle PE, Solomon D, Schiffman M. The expanded use of HPV testing in gynecologic practice per ASCCP-guided management requires the use of well-validated assays. Am J Clin Pathol. 2007 127:335-337.
- Wright TC, Massad LS, Dunton CJ, Spitzer M, Wilkinson EJ, Solomon D. for the 2006 ASCCP consensus conference. 2006 consensus guidelines for the management of women with cervical intraepithelial neoplasia or adenocarcinoma in situ. Am J Obstet Gynecol 2007 197:340-345
- Wright TC, Massad LS, Dunton CJ, Spitzer M, Wilkinson EJ, Solomon D. for the 2006 ASCCP consensus conference. 2006 consensus guidelines for the management of women with abnormal cervical cancer screening tests. Am J Obstet Gynecol 2007 197:346-355
- Atkins KA, Jeronimo J, Stoler MH. Description of patients with squamous cell carcinoma in the atypical squamous cells of undetermined significance/low-grade squamous intraepithelial lesion triage study. Cancer. 2006 Aug 25;108(4):212-21.
- Ferris DG, Litaker MS; ALTS Group. Prediction of cervical histologic results using an abbreviated Reid Colposcopic Index during ALTS. Am J Obstet Gynecol. 2006 Mar;194(3):704-10.
- Gage JC, Hanson VW, Abbey K, Dippery S, Gardner S, Kubota J, Schiffman M, Solomon D, Jeronimo J for the ALTS Group. Evidence that taking more cervical biopsies substantially improves the sensitivity of colposcopically-guided biopsies. Obstet Gynecol. 2006 108:264-72.
- Kreimer AR, Guido RS, Solomon D, Schiffman M, et al. Human papillomavirus testing following loop electrosurgical excision procedure identifies women at risk for posttreatment cervical intraepithelial neoplasia grade 2 or 3 disease. Cancer Epidemiol Biomarkers Prev. 2006 May;15(5):908-14.
- Kulasingam SL, Kim JJ, Lawrence WF, Mandelblatt JS, Myers ER, Schiffman M, Solomon D, Goldie SJ; ALTS Group. Cost-effectiveness analysis based on the atypical squamous cells of undetermined significance/low-grade squamous intraepithelial lesion Triage Study (ALTS). J Natl Cancer Inst. 2006 Jan 18;98(2):92-100.
- Sherman ME, Carreon JD, Schiffman M. Performance of cytology and human papillomavirus testing in relation to the menstrual cycle. Br J Cancer. 2006 Jun 5;94(11):1690-6.
- Sherman ME, Castle PE, Solomon D. Cervical cytology of atypical squamous cells-cannot exclude high-grade squamous intraepithelial lesion (ASC-H): characteristics and histologic outcomes. Cancer. 2006 Oct 25;108(5):298-305.
- Walker JL, Wang SS, Schiffman M, Solomon D for the ALTS Group. Predicting absolute risk of CIN3 during post-colposcopic follow-up: results from the ASCUS/LSIL Triage Study. Letter to the Editor. Am J Obstet Gynecol. 2006 Aug;195(2):341-8. Comment in: Am J Obstet Gynecol. 2007 May;196(5):e58; author reply e58-9.
- Castle, PE. HPV type 16 infections and 2-year absolute risk of cervical precancer among women with equivocal or mild cytologic abnormalities. J Natl Cancer Inst. 2005 97:1066-71.
- Castle PE, Walker JL, Schiffman M, Wheeler CM. Hormonal contraceptive use, pregnancy and parity, and the risk of cervical intraepithelial neoplasia 3 among oncogenic HPV DNA-positive women with equivocal or mildly abnormal cytology. Int J Cancer. 2005 Dec 20;117(6):1007-12.
- Ferris DG, Litaker M; ALTS Group. Interobserver agreement for colposcopy quality control using digitized colposcopic images during the ALTS trial. J Low Genit Tract Dis. 2005 Jan; 9(1):29-35.
- Guido RS, Jeronimo J, Schiffman M, Solomon D; ALTS Group. The distribution of neoplasia arising on the cervix: results from the ALTS trial. Am J Obstet Gynecol. 2005 Oct;193(4):1331-7.
- Jeronimo J, Khan MJ, Schiffman M, Solomon D; ALTS Group. Does the interval between papanicolaou tests influence the quality of cytology? Cancer. 2005 Jun 25;105(3):133-8.
- Khan MJ, Partridge EE, Wang SS, Schiffman M. Socioeconomic status and the risk of cervical intraepithelial neoplasia grade 3 among oncogenic human papillomavirus DNA-positive women with equivocal or mildly abnormal cytology. Cancer. 2005 Jul 1;104(1):61-70.
- McIntyre-Seltman K, Castle PE, Guido R, Schiffman M, Wheeler CM; ALTS Group. Smoking is a risk factor for cervical intraepithelial neoplasia grade 3 among oncogenic human papillomavirus DNA-positive women with equivocal or mildly abnormal cytology. Cancer Epidemiol Biomarkers Prev. 2005 May;14(5):1165-70.
- Schiffman M, Khan MJ, Solomon D, Herrero R, Wacholder S, Hildesheim A, Rodriguez AC, Bratti MC, Wheeler CM, Burk RD; PEG Group; ALTS Group. A study of the impact of adding HPV types to cervical cancer screening and triage tests. J Natl Cancer Inst. 2005 Jan 19;97(2):147-50.
- Schiffman M, Wheeler CM, Dasgupta A, Solomon D, Castle PE; The ALTS Group. A comparison of a prototype PCR assay and hybrid capture 2 for detection of carcinogenic human papillomavirus DNA in women with equivocal or mildly abnormal papanicolaou smears. Am J Clin Pathol. 2005 Nov;124(5):722-32.
- Srodon M, Parry Dilworth H, Ronnett BM. Atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion: diagnostic performance, human papillomavirus testing, and follow-up results. Cancer. 2006 Feb 25;108(1):32-8.
- Wang SS. Medication use, medical conditions and the risk of human papillomavirus infection and subsequent CIN3 among women with mild cytologic abnormalities. Cancer Epidemiol Biomarkers Prev. 2005;14:542-5.
- Wang SS. Estimating the risk of CIN3 using a combination of cytologic, virologic, and visual methods Cancer Epidemiol Biomarkers Prev. 2005;14:2665-8.
- Zuna RE, Wang SS, Rosenthal DL, Jeronimo J, Schiffman M, Solomon D; ALTS Group. Determinants of human papillomavirus-negative, low-grade squamous intraepithelial lesions in the atypical squamous cells of undetermined significance/low-grade squamous intraepithelial lesions triage study (ALTS). Cancer Cytopathology. 2005 Oct 25;105(5):253-62.
- Castle PE, Wheeler CM, Solomon D, Schiffman M, Peyton CL; ALTS Group. Interlaboratory reliability of hybrid capture 2. Am J Clin Pathol. 2004 Aug;122(2):238-45.
- Castle PE, Schiffman M, Wheeler CM. Hybrid Capture 2 viral load and the 2-year cumulative risk of CIN 3 or cancer. Am J Obstet Gynecol. 2004 Nov;191(5):1590-7.
- Ferris DG, Litaker MS; ASCUS/LSIL Triage Study (ALTS) Group. Colposcopy quality control by remote review of digitized colposcopic images. Am J Obstet Gynecol. 2004 Dec;191(6):1934-41.
- Piyathilake C. Folate (one-carbon metabolism biomarkers) as a co-factor, based on blood, questionnaire, and related polymorphisms. Cancer Res. 2004;64:8788-93.
- ASCUS-LSIL Traige Study (ALTS) Group. A randomized trial on the management of low-grade squamous intraepithelial lesion cytology interpretations. Am J Obstet Gynecol. 2003 Jun;188(6):1393-400.
- ASCUS-LSIL Traige Study (ALTS) Group. Results of a randomized trial on the management of cytology interpretations of atypical squamous cells of undetermined significance. Am J Obstet Gynecol. 2003 Jun;188(6):1383-92.
- Cox JT; American Society for Colposcopy and Cervical Pathology. The clinician's view: role of human papillomavirus testing in the American Society for Colposcopy and Cervical Pathology Guidelines for the management of abnormal cervical cytology and cervical cancer precursors. Arch Pathol Lab Med. 2003 Aug;127(8):950-8.
- Cox JT, Schiffman M, Solomon D; ASCUS-LSIL Triage Study (ALTS) Group. Prospective follow-up suggests similar risk of subsequent cervical intraepithelial neoplasia grade 2 or 3 among women with cervical intraepithelial neoplasia grade 1 or negative colposcopy and directed biopsy. Am J Obstet Gynecol. 2003 Jun;188(6):1406-12.
- Guido R, Schiffman M, Solomon D, Burke L; ASCUS LSIL Triage Study (ALTS) Group. Postcolposcopy management strategies for women referred with low-grade squamous intraepithelial lesions or human papillomavirus DNA-positive atypical squamous cells of undetermined significance: a two-year prospective study. Am J Obstet Gynecol. 2003 Jun;188(6):1401-5.
- Lorincz AT. Screening for cervical cancer: new alternatives and research. Salud Publica Mex. 2003 45 Suppl 3:S376-87. Review.
- Monk BJ, Brewster WR. Does the ALTS trial apply to the community-based practitioner? Am J Obstet Gynecol. 2003 Jun;188(6):1381-2.
- Schiffman M, Solomon D. Findings to date from the ASCUS-LSIL Triage Study (ALTS). Arch Pathol Lab Med. 2003 Aug;127(8):946-9. Review.
- Sherman ME, Wang SS, Tarone R, Rich L, Schiffman M. Histopathologic extent of CIN 3 lesions in the ASCUS LSIL Triage Study (ALTS): implications for subject safety and lead-time bias. Cancer Epidemiol Biomarkers Prev. 2003 Apr;12(4):372-9.
- Stoler MH. Testing for human papillomavirus: data driven implications for cervical neoplasia management. Clin Lab Med. 2003 Sep;23(3):569-83. Review.
- Castle PE, Hildesheim A, Bowman FP, Strickler HD, Walker JL, Pustilnik T, Edwards RP, Crowley-Nowick PA. Cervical concentrations of interleukin-10 and interleukin-12 do not correlate with plasma levels. J Clin Immunol. 2002 Jan;22(1):23-7.
- Sherman ME, Schiffman M, Cox JT; Atypical Squamous Cells of Undetermined Significance/Low-Grade Squamous Intraepithelial Lesion Triage Study Group. Effects of age and human papilloma viral load on colposcopy triage: data from the randomized Atypical Squamous Cells of Undetermined Significance/Low-Grade Squamous Intraepithelial Lesion Triage Study (ALTS). J Natl Cancer Inst. 2002 Jan 16;94(2):102-7.
- Solomon D, Schiffman M, Tarone R. ASCUS LSIL Triage Study (ALTS) conclusions reaffirmed: response to a November 2001 commentary. Obstet Gynecol. 2002 Apr;99(4):671-4. No abstract available.
- Ferris DG, Schiffman M, Litaker MS. Cervicography for triage of women with mildly abnormal cervical cytology results. Am J Obstet Gynecol. 2001 Oct;185(4):939-43.
- Herbst AL, Pickett KE, Follen M, Noller KL. The management of ASCUS cervical cytologic abnormalities and HPV testing: a cautionary note. Obstet Gynecol. 2001 Nov;98(5 Pt 1):849-51.
- Solomon D, Schiffman M, Tarone R; ALTS Study group. Comparison of three management strategies for patients with atypical squamous cells of undetermined significance: baseline results from a randomized trial. J Natl Cancer Inst. 2001 Feb 21;93(4):293-9.
- Stoler MH, Schiffman M; Atypical Squamous Cells of Undetermined Significance-Low-grade Squamous Intraepithelial Lesion Triage Study (ALTS) Group. Interobserver reproducibility of cervical cytologic and histologic interpretations: realistic estimates from the ASCUS-LSIL Triage Study. JAMA. 2001 Mar 21;285(11):1500-5.
- Human papillomavirus testing for triage of women with cytologic evidence of low-grade squamous intraepithelial lesions: baseline data from a randomized trial. The Atypical Squamous Cells of Undetermined Significance/Low-Grade Squamous Intraepithelial Lesions Triage Study (ALTS) Group. J Natl Cancer Inst. 2000 Mar 1;92(5):397-402.
- Schiffman M, Adrianza ME. ASCUS-LSIL Triage Study. Design, methods and characteristics of trial participants. Acta Cytol. 2000 Sep-Oct;44(5):726-42.