From the Guidelines
Pap smear guidelines recommend that women begin cervical cancer screening at age 21, regardless of sexual activity, with a Pap test every 3 years from ages 21-29, and co-testing with both Pap and HPV every 5 years, or a Pap test every 3 years, or HPV testing alone every 5 years between ages 30-65. The guidelines are based on the most recent evidence from the American Cancer Society, which estimates that cervical cancer incidence and mortality rates have declined since the introduction of the Papanicolaou (Pap) test in the mid-20th century, and rates continue to decline to this day 1.
Key Recommendations
- Women younger than 21 years should not be screened regardless of their age of sexual initiation.
- Women at any age should not be screened annually by any screening method.
- For women ages 30 to 65 years, the preferred approach is cotesting every 5 years with cytology and HPV testing.
- Women should discontinue screening after age 65 years if they have had 3 consecutive negative cytology tests or 2 consecutive negative cotest results within the 10-year period before ceasing screening, with the most recent test occurring within the last 5 years.
Rationale
The guidelines balance the benefits of early detection against the risks of overscreening, which can lead to unnecessary procedures and anxiety 1. Regular screening is crucial because cervical cancer develops slowly, and detecting precancerous changes early allows for effective treatment before cancer develops. The American Cancer Society continues to monitor the effectiveness of primary HPV testing as a screening approach 1.
Special Considerations
- Women with a history of cervical cancer, HIV infection, immunosuppression, or DES exposure in utero may need more frequent screening.
- Those who have had a total hysterectomy (including removal of the cervix) for non-cancerous reasons can also discontinue screening.
- Recommended screening practices should not change on the basis of a woman’s HPV vaccination status 1.
From the Research
Pap Guidelines
- The US Preventive Services Task Force (USPSTF) recommends screening for cervical cancer every 3 years with cervical cytology alone in women aged 21 to 29 years 2.
- For women aged 30 to 65 years, the USPSTF recommends screening every 3 years with cervical cytology alone, every 5 years with hrHPV testing alone, or every 5 years with both tests (cotesting) 2.
- The USPSTF recommends against screening for cervical cancer in women younger than 21 years, women older than 65 years who have had adequate prior screening and are not otherwise at high risk for cervical cancer, and women who have had a hysterectomy with removal of the cervix and do not have a history of a high-grade precancerous lesion or cervical cancer 2.
Screening Strategies
- Screening with cervical cytology alone, primary hrHPV testing alone, or cotesting can detect high-grade precancerous cervical lesions and cervical cancer 2.
- The harms of screening for cervical cancer in women aged 30 to 65 years are moderate 2.
- Primary care clinicians should offer HPV vaccination to all patients between the ages of nine and 26, in addition to cervical cancer screening and follow-up guidance 3.
Follow-up and Surveillance
- Patients with an abnormal cervical cancer screening history require surveillance, which differs from routine screening for patients with normal prior screening results 3.
- Long-term surveillance is recommended for patients with CIN 2 or worse 3.
- Clinicians should conduct shared decision-making about immediate loop electrosurgical excision procedure vs. colposcopy with multiple biopsies and endocervical sampling for patients with the highest risk of cervical cancer 3.