Cervical Cancer Screening Guidelines: The Role of Pap and HPV

SUMMARY:

The USPSTF, based on latest evidence, has released final guidelines for cervical cancer screening (August 2018). The final recommendations now include ‘HPV only’ as an option for women 30 to 65 years of age.

USPSTF recommends the following

Women ages 21 to 65 years – Recommendation Grade A (offer or provide this service)

21 to 29 years

  • The USPSTF recommends screening for cervical cancer every 3 years with cervical cytology alone

30 to 65 years

  • The USPSTF recommends screening
    • Every 3 years with cervical cytology alone or
    • Every 5 years with high-risk human papillomavirus (hrHPV) testing alone or
    • Every 5 years with hrHPV testing in combination with cytology (cotesting)

Women older than age 65 years – Recommendation Grade D (discourage the use of this service)

  • The USPSTF recommends against screening for cervical cancer in women older than age 65 years who have had adequate prior screening and are not otherwise at high risk for cervical cancer

Women younger than age 21 years – Recommendation Grade D (discourage the use of this service)

  • The USPSTF recommends against screening for cervical cancer in women younger than age 21 years

Women who have had a hysterectomy – Recommendation Grade D (discourage the use of this service)

  • The USPSTF recommends against screening for cervical cancer in women who have had a hysterectomy with removal of the cervix and do not have a history of a high-grade precancerous lesion (i.e., cervical intraepithelial neoplasia [CIN] grade 2 or 3) or cervical cancer

KEY POINTS:

  • The first three recommendations (not the recommendation related to hysterectomy) apply to women who have a cervix, regardless of their sexual history or HPV vaccination status
  • None of these recommendations apply to women who have been diagnosed with a high-grade precancerous cervical lesion or cervical cancer
  • These recommendations also do not apply to women with in utero exposure to diethylstilbestrol or women who have a compromised immune system (e.g., women living with HIV)

ACOG Practice Advisory Update (August 2018)

  • The ACOG Practice Advisory Update (endorsed by SGO and ASCCP) states

ACOG affirms its current cervical cancer screening guidelines, which encompass all three cervical cancer screening strategies (cervical cytology alone, hrHPV testing alone, and co-testing). It is appropriate to counsel average-risk women aged 30– 65 years regarding all three strategies so that they can select their preferred option.

  • The ACOG Practice Advisory Update refers to the Interim Clinical Guidance for primary hrHPV testing, based on expert panel (Obstetrics & Gynecology, 2015) evidence review
  • Panel Representation included
    • SGO | ASCCP | ACOG |ACS | American Society of Cytopathology | College of American Pathologists | American Society for Clinical Pathology
  • The ACOG Practice Advisory Update summarizes the expert opinion as follows
    • Preferred: Co-testing (cervical cytology and hrHPV testing) every 5 years
    • Acceptable: Screening with cervical cytology alone every 3 years
    • Can be considered: HrHPV testing alone as an alternative screening strategy (re-screen not more frequently than every 3 years)

American Cancer Society (2020)

  • 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 along 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

Learn More – Primary Sources:

Screening for Cervical Cancer: US Preventive Services Task Force Recommendation Statement

ACOG Practice Advisory: Cervical Cancer Screening (Update)

Use of Primary High-Risk Human Papillomavirus Testing for Cervical Cancer Screening: Interim Clinical Guidance (Obstetrics & Gynecology, 2015) 

The American Cancer Society Guidelines for the Prevention and Early Detection of Cervical Cancer