CLINICAL ACTIONS: 

In the case of an average woman who is being seen for cervical cancer screening:

• Begin screening average risk women at age 21
  • Screen every 3 years with cytology, with reflex human papillomavirus (HPV) if the cytology results in an abnormal Pap smear result
  • Do not perform HPV testing routinely
• Women age 30-65 can be screened
  • Every 5 years ‘cotesting’ with cytology plus HPV (preferred)
  • Every 3 years with cytology only (acceptable)
  • Primary screening with hrHPV testing alone can be considered as an alternative to the above
    • Expert interim guidance (2015): Re-screen no sooner than 3 years
    • USPSTF guidance (2018): Every 5 years
  • Changes in risk factors, including a new sexual partner may warrant more frequent screening
• Stop screening average-risk women older than 65 for cervical cancer IF
  • They have had 3 consecutive negative cytology results or 2 negative cytology with negative HPV results within 10 years
  • AND the most recent Pap test was within 5 years
• Do not screen average risk women of any age for cervical cancer if they have had a hysterectomy with removal of the cervix (i.e. you can’t get cervical cancer without a cervix)

SYNOPSIS:

Cervical cancer rates in the United States are low, 7.8 cases per 100,000 women per year due largely to access to effective screening.  Cervical cancer is believed with a high degree of certainty, to be the delayed consequence of infection with high risk or oncogenic human papillomavirus (HPV).  The majority of HPV infections are transient and do not progress to cervical cancer.  The consequences of cervical treatment harms can be significant and excisional procedures (LEEP, cervical cone biopsy) may increase the risk of a subsequent preterm birth.

KEY POINTS:

• The goal of cervical cancer screening is to minimize harm and maximize benefit
• New guidelines focus on increasing the age at which to begin screening, lengthening the screening interval and discontinuing screening women at low risk for future cervical cancer
• The above action items refer to average risk women
• Women at increased risk for cervical cancer require a higher level of surveillance and include those who are:
  • Immunocompromised (HIV positive, organ transplant recipient, chronic steroid use)
  • Sex workers
  • Women with multiple partners or high risk partners
  • Women with a history of abnormal Pap smear  or precancerous genital conditions
  • Smokers
  • Women with a history of sexually transmitted diseases
• American Cancer Society (2020) has recommended the use of HPV testing in isolation
  • 25 to 65 years of age: ‘Primary’ HPV testing every 5 years
  • If HPV testing is not available, other acceptable screening methods: HPV and cervical cytology every 5 years or cervical cytology alone every 3 years
  • Women >65: Stop screening if patient meets the following criteria
    Regular screening in the past 10 years with normal results and no history of CIN2 or higher in the past 25 years
  • Total hysterectomy: Stop screening (unless surgery was for cervical cancer or pre-cancer)
  • Supra-cervical hysterectomy: Continue screening
  • Patients who have had HPV vaccine: Continue to screen based on guidelines
• Diagnosis Codes:
  • Z01.411 encounter for routine gyn exam with abnormal findings
  • Z01.412 encounter for routine gyn exam with normal findings
  • Z01.42 encounter for exam to confirm normal smear after history of abnormal cervical cytology

Learn More – Primary Sources:

ACOG Practice Bulletin 168: Cervical Cancer Screening and Prevention

Cancer Screening in Average-Risk Women: Best Practice Advice from the Clinical Guidelines Committee of the American College of Physicians

ASCCP Management Guidelines and Algorithms

USPSTF (2018): Cervical Cancer Screening

Cervical cancer screening for individuals at average risk: 2020 guideline update from the American Cancer Society

Locate a GYN Oncology Specialist:

Gyn Oncology Locator – SGO

Related ObG Topics:

Cervical Cancer Screening Guidelines – Including ‘HPV Only’ Option

ACOG, AAFP & USPSTF Guidance: Still a Role for the Annual Pelvic Exam?

Colposcopy Results: Follow-Up and Management