Guidance Update: Professional Organizations Align on Cervical Cancer Screening

SUMMARY:

ACOG has joined ASCCP and the SGO in endorsing the USPSTF cervical cancer screening recommendations. The ACOG practice document states that

Consistent with prior guidance, screening should begin at age 21 years, and screening recommendations remain unchanged for average-risk individuals aged 21–29 years and those who are older than 65 years

Management of abnormal cervical cancer screening results should follow current ASCCP guidelines

CLINICAL ACTIONS: 

The USPSTF recommends the following (Grade A – “Offer or Provide this Service”) 

• Begin screening at age 21
  • Screen every 3 years with cytology alone
  • Do not perform HPV testing routinely
• Age 30 to 65 can be screened
  • Every 5 years ‘cotesting’ with cytology plus HPV
  • Every 3 years with cytology only
  • every 5 years with high-risk human papillomavirus (hrHPV) testing alone

The USPSTF recommends against the following (Grade D – Discourage the use of this service)

• <21 years
  • Do not offer screening
• >65 years
  • Do not offer screening in the setting of adequate prior screening and otherwise not at high risk for cervical cancer
•  Do not offer screening following hysterectomy if
  • Cervix was removed and
  • There is no history of a high-grade precancerous lesion (ie, cervical intraepithelial neoplasia [CIN] grade 2 or 3) or cervical cancer

SYNOPSIS:

Cervical cancer rates in the United States are low 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.  However, the consequences of missing precancerous or early cancerous lesions are potentially lethal and should be avoidable with appropriate screening.

KEY POINTS:

• The goal of cervical cancer screening is to minimize harm and maximize benefit
• 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
• ACOG has responded to the American Cancer Society (2020) recommendation that hrHPV testing in isolation every 5 years should be prioritized for women 25 to 65 years of age
  • hrHPV alone has demonstrated efficacy and efficiency
  • However, the ACOG Practice Advisory notes significant limitations regarding current healthcare infrastructure, including

Limited access to primary hrHPV testing is of particular concern in rural and under-resourced communities and among communities of color, which have disproportionately high rates of cervical cancer incidence, morbidity, and mortality

Although HPV self-sampling has the potential to greatly improve access to cervical cancer screening, and there is an increasing body of evidence to support its efficacy and utility, it is still investigational in the United States

Learn More – Primary Sources:

ACOG: Updated Cervical Cancer Screening Guidelines

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