What is the recommended approach for a routine pap smear that includes cytology and Human Papillomavirus (HPV) testing?

From the Guidelines

The recommended approach for a routine pap smear with cytology and HPV testing is to begin screening at age 21, with different intervals based on age and risk factors, as outlined in the most recent guidelines 1. For women aged 21-29, cytology alone should be performed every 3 years, as HPV testing is not recommended for this age group, except as a reflex test for women diagnosed with atypical squamous cells of undetermined significance (ASC-US) 1.

• The procedure involves collecting cells from the cervix using a speculum examination, with samples taken from both the ectocervix (using a spatula) and endocervix (using a brush).
• Both samples are placed in liquid-based cytology media for laboratory analysis.
• Patients should avoid douching, sexual intercourse, and inserting anything into the vagina for 24-48 hours before the test to ensure accurate results. For women aged 30-65, co-testing with both cytology and HPV testing every 5 years is preferred, though cytology alone every 3 years is also acceptable 1.
• This approach allows for the detection of both cellular abnormalities through cytology and the presence of high-risk HPV types that may lead to cervical cancer, enabling early intervention when precancerous changes are identified. Screening can generally be discontinued after age 65 if there is a history of adequate negative screening results, with 3 consecutive negative cytology tests or 2 consecutive negative co-test results within the 10-year period before ceasing screening, and the most recent test occurring within the last 5 years 1.
• The American Cancer Society (ACS) recommends that women with an HPV-negative ASC-US result should return for screening in 3 years rather than 5 years, consistent with the American Society for Colposcopy and Cervical Pathology recommendation 1.

From the Research

Routine Pap Smear Approach

For a routine pap smear that includes cytology and Human Papillomavirus (HPV) testing, the recommended approach is as follows:

• Concurrent testing for HPV and cervical cytology (co-testing) is an approved alternative to cytology alone in women aged 30 years and older 2.
• Co-testing can identify women at high risk of cervical cancer or cervical intraepithelial neoplasia grade 3 (CIN3) or worse over 5 years 2.
• For women aged 30 years and older who are negative by co-testing (both HPV and cytology), 3-year screening intervals are safe because a single negative test for HPV is sufficient to reassure against cervical cancer over 5 years 2.

HPV Testing and Cytology

• HPV testing without adjunctive cytology might be sufficiently sensitive for primary screening for cervical cancer 2.
• Women who consecutively test positive for high-risk HPV without and minor changes on reflex cytology (atypical squamous cells of undetermined significance [ASC-US] or low-grade squamous intraepithelial lesion [LSIL]) or dysplasia on cervical colposcopy-oriented biopsy are always referred to colposcopy 3.
• Colposcopy remains the reference technique to assess patients with abnormal cytological test results, especially those with ASC-H, LSIL, HSIL, and AGC 4.

Colposcopy and Management

• Cytology identifies the women who are at higher risk of harboring high-grade cervical premalignant lesions or invasive cancer, and colposcopy is crucial for localization of the abnormality, confirmation of diagnosis, and appropriate management 5.
• The management of women who have equivocal or borderline cytology of low-grade abnormalities (ASCUS/LSIL) is still under deliberation, but it is generally agreed to have an HPV triage for women with equivocal cytology 5.
• The accuracy of p16/Ki-67 and HPV test in the detection of CIN2/3 in women diagnosed with ASC-US or LSIL has been compared, and both methods showed similar performance in predicting high-grade cervical intraepithelial neoplasia among women with ASC-US 6.