What are the guidelines for cervical cancer screening?

Cervical Cancer Screening Guidelines

Primary HPV testing every 5 years is the preferred screening method for cervical cancer, starting at age 25 and continuing through age 65, with no screening recommended for individuals under 25 years of age. 1

Recommended Screening Approaches by Age

Under 21 Years

• No screening recommended regardless of sexual history or HPV vaccination status 1, 2

Ages 21-24 Years

• Cytology (Pap smear) alone every 3 years 1
• Note: The American Cancer Society's 2020 guideline update recommends starting screening at age 25 instead of 21 2

Ages 25-29 Years

• Primary HPV testing every 5 years (preferred) 2, 1
• Cytology alone every 3 years (acceptable alternative) 2, 1

Ages 30-65 Years

• Primary HPV testing every 5 years (preferred) 2, 1
• Co-testing (HPV + cytology) every 5 years (acceptable alternative) 2, 1
• Cytology alone every 3 years (acceptable alternative) 2, 1

Over 65 Years

• Discontinue screening if:
  • No history of cervical intraepithelial neoplasia grade 2 (CIN2) or more severe diagnosis in the past 25 years 2, 1
  • Documented adequate negative prior screening in the past 10 years 2, 1
  • Adequate negative prior screening is defined as 2 consecutive negative HPV tests, 2 negative cotests, or 3 negative cytology tests within the past 10 years, with the most recent test occurring within the recommended interval 2

Important Considerations

Benefits of HPV-Based Screening

• HPV-based screening provides 60-70% greater protection against invasive cervical cancer compared to cytology-based screening 1
• Primary HPV testing has higher sensitivity for detecting precancerous lesions and better detection of adenocarcinoma and its precursors 1

Screening Intervals

• Annual screening is NOT recommended due to increased false positives with minimal benefit 1
• Screening every 3 years with cytology is associated with approximately 760 colposcopies per 1000 women over a lifetime, while annual screening nearly triples this to about 2000 colposcopies 1

Special Populations

• These recommendations do not apply to individuals at increased risk:
  • Immunocompromised individuals (HIV infection, organ transplantation, chronic corticosteroid treatment)
  • History of cervical cancer
  • In utero exposure to diethylstilbestrol
  • Women who had subtotal (supracervical) hysterectomy should continue routine screening 1

Hysterectomy

• Women who have had a total hysterectomy with removal of the cervix and no history of CIN2+ in the past 25 years do not need screening 1

HPV Vaccination Status

• Screening recommendations do not change based on HPV vaccination status 2, 1

Common Pitfalls and Caveats

1. Overscreening young women: HPV testing is NOT recommended in women under 30 due to high prevalence of transient HPV infections 1

2. Annual screening: This is no longer recommended for any age group due to increased harms with minimal benefit 1

3. Discontinuing screening too early: Women over 65 without adequate prior screening should continue screening until criteria for cessation are met 2

4. Ignoring special populations: Individuals with HIV, immunosuppression, or previous treatment of high-grade lesions need individualized follow-up 1

5. Barriers to screening: Despite clear guidelines, approximately 14 million women aged 21-65 had not been screened within the past 3 years as of 2015 3. Recent immigrants, women without insurance, and women without a usual source of healthcare have lower odds of being up to date with screening 3.

6. Declining screening rates: Studies have shown declining Pap screening rates across all age groups, which is concerning, particularly among women aged 21-29 4

The evolution of cervical cancer screening guidelines reflects our improved understanding of HPV as the main causal factor for cervical cancer and the development of more sensitive testing methods. As the United States transitions to primary HPV testing, the use of cotesting or cytology alone will eventually be eliminated from future guidelines 2.