Cervical cancer screening

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Assistant Editor-in-Chief: Nima Nasiri, M.D.[2]Monalisa Dmello, M.B,B.S., M.D. [3]

Overview

According to the American Cancer Society (ACS) (the American Society for Colposcopy and Cervical Pathology (ASCCP), and American Society for Clinical Pathology participated in the 2021 update but did not participate in this update):

"individuals with a cervix initiate cervical cancer screening at age 25 years and undergo primary human papillomavirus (HPV) testing every 5 years through age 65 years (preferred); if primary HPV testing is not available, then individuals aged 25 to 65 years should be screened with cotesting (HPV testing in combination with cytology) every 5 years or cytology alone every 3 years (acceptable) (strong recommendation).."

Importantly, self-sampling HPV testing is not yet approved by the FDA although this is a priority of the "Last Mile" initiative of the National Cancer Institute

Screening

The Pap test screening detects and prevents the progression of HPV-induced cervical cancer and other abnormalities in the female genital tract by sampling cells from the outer opening of the cervix of the uterus and the endocervix. It is generally recommended that sexually active females seek pap smear testing annually, although guidelines may vary from country to country.

Screening Guidelines

		American Cancer Society (ACS), American Society for Colposcopy and Cervical Pathology (ASCCP), and American Society for Clinical Pathology 2012 version (has since been updated in 2020	U.S. Preventive Services Task Force (USPSTF) 2018 guidelines	American College of Obstetricians and Gynecologists (ACOG)
When to start screening		Age 21. Women aged <21 years should not be screened regardless of the age of sexual initiation or other risk factors	Age 21. (A recommendation) Recommend against screening women aged <21 years (D recommendation)	Age 21 regardless of the age of onset of sexual activity. Women aged <21 years should not be screened regardless of age at sexual initiation and other behavior-related risk factors (Level A evidence)
Statement about annual screening		Women of any age should not be screened annually by any screening method	Individuals and clinicians can use the annual Pap test screening visit as an opportunity to discuss other health problems and preventive measures. Individuals, clinicians, and health systems should seek effective ways to facilitate the receipt of recommended preventive services at intervals that are beneficial to the patient. Efforts also should be made to ensure that individuals are able to seek care for additional health concerns as they present	In women aged 30–65 years, annual cervical cancer screening should not be performed. (Level A evidence) Patients should be counseled that annual well-woman visits are recommended even if cervical cancer screening is not performed at each visit
Screening method and intervals
Cytology (conventional or liquid based)	21–29 years	Every 3 years	Every 3 years (A recommendation)	Every 3 years (Level A evidence)
	30–65 years	Every 3 years	Every 3 years (A recommendation)	Every 3 years (Level A evidence)
HPV co-test (cytology + HPV test administered together)	21–29 years	HPV co-testing should not be used for women aged <30 years	Recommend against HPV co-testing in women aged <30 years (D recommendation)	HPV co-testing should not be performed in women aged <30 years. (Level A evidence )
	30–65 years	Every 5 years; this is the preferred method.	For women who want to extend their screening interval, HPV co-testing every 5 years is an option (A recommendation)	Every 5 years; this is the preferred method (Level A evidence)
Primary hrHPV f testing (as an alternative to cotesting or g cytology alone)		For women aged 30–65 years, screening by HPV testing alone is not recommended in most clinical settings	Recommend against screening for cervical cancer with HPV testing (alone or in combination with cytology) in women aged <30 years (D recommendation)	Not addressed
When to stop screening		Aged >65 years with adequate negative prior screening and no history of CIN2 or higher within the last 20 years	Aged >65 years with adequate screening history and are not otherwise at high risk for cervical cancer (D recommendation)	Aged >65 years with adequate negative prior screening* results and no history of CIN 2 or higher (Level A evidence)
When to screen after age 65 years		When to screen after age 65 years Aged >65 years with a history of CIN2 CIN2, CIN3, or adenocarcinoma in situ, routine screening should continue for at least 20 years	Women aged >65 years who have never been screened, do not meet the criteria for adequate prior screening, or for whom the adequacy of prior screening cannot be accurately accessed or documented. Routine screening should continue for at least 20 years after spontaneous regression or appropriate management of a high-grade precancerous lesion, even if this extends screening past age 65 years. Certain considerations may support screening in women aged > 65 years who are otherwise considered high risk (such as women with a highgrade precancerous lesion or cervical cancer, women with in utero exposure to diethylstilbestrol, or women who are immunocompromised)	Women aged >65 years with a history of CIN2, CIN3, or AIS should continue routine agebased screeningk for at least 20 years (Level B evidence)
Screening post-hysterectomy		Women who have had a total hysterectomy (removal of the uterus and cervix) should stop screening. Women who have had a supra-cervical hysterectomy (cervix intact) should continue screening according to guidelines	Recommend against screening in women who have had a hysterectomy (removal of the cervix) (D recommendation)	Women who have had a hysterectomy (removal of the cervix) should stop screening and not restart for any reason, (Level A evidence)
The need for a bimanual pelvic exam		Not addressed in 2012 guidelines but was addressed in 2002 ACS guidelines	Addressed in USPSTF ovarian cancer screening recommendations.	Aged <21 years, no evidence supports the routine internal examination of the healthy, asymptomatic patient. An “external-only” genital examination is acceptable. Aged ≥21 years, no evidence supports or refutes the annual pelvic examination or speculum and bimanual examination. The decision whether or not to perform a complete pelvic examination should be a shared decision after a discussion between the patient and her health care provider. Annual examination of the external genitalia should continue
Screening among those immunized against HPV 16/18		Women at any age with a history of HPV vaccination should be screened according to the age specific recommendations for the general population	The possibility that vaccination might reduce the need for screening with cytology alone or in combination with HPV testing is not established. Given these uncertainties, women who have been vaccinated should continue to be screened	Women who have received the HPV vaccine should be screened according to the same guidelines as women who have not been vaccinated (Level C evidence)

HPV = human papillomavirus; CIN = cervical intraepithelial neoplasia; AIS=adenocarcinoma in situ; hrHPV = high-risk HPV.

See also

Colposcopy