What are the recommended guidelines for Pap (Papanicolau) test and HPV (Human Papillomavirus) reflex testing in cervical cancer screening?

Cervical Cancer Screening and HPV Reflex Testing Guidelines

For women aged 30-65 years, the preferred approach is co-testing with HPV and cytology every 5 years, while an acceptable alternative is cytology alone every 3 years. 1

Age-Based Screening Recommendations

Women Under 21 Years

• No screening recommended regardless of sexual activity or risk factors 2, 1
• Screening should not be performed even if sexually active 1

Women 21-29 Years

• Cervical cytology (Pap test) alone every 3 years 2, 1
• HPV testing should NOT be used for primary screening in this age group 2, 1
• HPV testing can be used as a reflex test for women with ASC-US (atypical squamous cells of undetermined significance) results 2, 1

Women 30-65 Years

• Preferred approach: Co-testing with HPV and cytology every 5 years 2, 1
• Acceptable alternative: Cytology alone every 3 years 2, 1
• Annual screening is NOT recommended for any age group 2, 1

Women Over 65 Years

• Discontinue screening if:
  • Three consecutive negative cytology tests or two consecutive negative co-tests within the past 10 years 2, 1
  • Most recent test was within the past 5 years 1
  • No history of CIN2 or more severe diagnosis in the past 20 years 2

HPV Reflex Testing Guidelines

• HPV reflex testing is recommended for women aged ≥21 years who have abnormal Pap test results (ASC-US) 2
• Women who test positive for HPV should be referred to colposcopy regardless of Pap smear result 3
• For women with ASC-US cytology, HPV testing helps determine the need for colposcopy 4
• HPV testing should not be used as a stand-alone test for screening without appropriate follow-up protocols 2

Special Populations

Post-Hysterectomy

• Women who have had a total hysterectomy (with removal of the cervix) and no history of high-grade cervical lesions should not be screened 2, 1
• Women who have had a subtotal (supracervical) hysterectomy should continue routine screening 2

High-Risk Women

• Women with a history of cervical cancer, in utero DES exposure, or who are immunocompromised (HIV infection, organ transplantation, chemotherapy, chronic corticosteroid treatment) require more frequent screening 2, 1
• Women with a history of CIN2 or more severe diagnosis should continue routine screening for at least 20 years, even if screening extends beyond age 65 2

Implementation Considerations

• HPV vaccination status does not change screening recommendations 2
• Women should be informed that a positive HPV test:
  • Does not indicate the presence of cancer 2
  • Reflects a sexually acquired infection, not necessarily a sexually transmitted disease 2
  • Is common and often transient, especially in younger women 2, 1

Clinical Pitfalls to Avoid

1. Overscreening: Annual screening is not recommended for any age group and can lead to unnecessary procedures and potential harm 2, 1, 5

2. Underscreening: Approximately 50% of cervical cancers occur in women who have never been screened or not screened in the past 5 years 1

3. Misunderstanding patient history: Many women equate having a pelvic examination with having a Pap test; verify actual screening history 2

4. Ignoring HPV positive results: All women testing positive for HPV regardless of Pap smear result should be referred to colposcopy, as persistent HPV infection is the primary risk factor for cervical cancer 3

5. Failing to follow up: Ensure proper follow-up for abnormal results according to the 2019 American Society for Colposcopy and Cervical Pathology risk-based management guidelines 1

The evidence clearly shows that implementation of these guidelines has been increasing, with a significant rise in Pap-HPV cotesting from 10.0% in 2007 to 60.8% in 2016 among women aged 30-65 years 6. However, disparities in screening based on race, ethnicity, and socioeconomic factors persist and should be addressed to improve cervical cancer prevention 6, 7.