Is Human Papillomavirus (HPV) co-testing recommended for all ages?

HPV Co-testing is Not Recommended for All Ages

HPV co-testing is not recommended for all ages but should be limited to specific age groups according to current guidelines. 1

Age-Specific Recommendations for Cervical Cancer Screening

Women Under 21 Years

• No cervical cancer screening recommended regardless of method 1
• Neither cytology alone, HPV testing alone, nor co-testing should be performed 1

Women Aged 21-24 Years

• Cytology alone every 3 years is recommended 1
• HPV testing or co-testing is not recommended for this age group 1
• Higher rates of HPV positivity in younger women lead to unnecessary colposcopies with minimal benefit 1

Women Aged 25-29 Years

• According to the 2020 ACS guidelines, primary HPV testing every 5 years is preferred starting at age 25 1
• Cytology alone every 3 years is acceptable as a transitional option 1
• Co-testing is not recommended for routine screening in this age group due to high prevalence of transient HPV infections 1
• Although not recommended for screening, HPV testing may be used for management of abnormal cytology results in this age group 1

Women Aged 30-65 Years

• Primary HPV testing alone every 5 years is the preferred screening method (ACS 2020) 1
• Co-testing every 5 years is an acceptable option 1
• Cytology alone every 3 years remains acceptable where access to HPV testing is limited 1
• Co-testing in this age group has increased significantly from 5.2% in 2007 to 84.3% in 2019 2

Women Over 65 Years

• Discontinue screening if adequate negative prior screening has been documented 1
• Adequate negative prior screening is defined as 2 consecutive negative primary HPV tests, or 2 negative co-tests, or 3 negative cytology tests within the past 10 years 1
• Women without documentation of prior screening should continue screening until criteria for cessation are met 1

Benefits and Limitations of Co-testing

Benefits

• Increased detection of precancerous lesions and adenocarcinoma compared to cytology alone 1
• Lower risk conferred by a negative screening result 1
• May allow for longer screening intervals (5 years vs. 3 years with cytology alone) 1

Limitations

• Adding HPV testing to cytology for women under 30 years decreases specificity more than it increases sensitivity 3
• Higher rates of false positives and unnecessary colposcopies, especially in younger women 1
• A Swedish study found minimal benefit of adding a single co-test to HPV-based screening, with only a few additional high-grade dysplasia cases detected 4
• Co-testing is less efficient compared to primary HPV testing alone across multiple screening measures 1

Special Considerations

Post-Hysterectomy

• No screening recommended for women without a cervix and without a history of CIN2+ in the past 25 years or cervical cancer 1

HPV-Vaccinated Women

• Follow the same age-specific screening recommendations as unvaccinated individuals 1
• Cytology-based screening is less efficient in vaccinated populations as abnormal cytology disproportionately identifies minor abnormalities from lower-risk HPV types 1
• Future recommendations may need to incorporate vaccination status as evidence accumulates 1

Evolving Guidelines

• The 2020 ACS guidelines indicate a transition toward primary HPV testing as the preferred method, with co-testing considered an acceptable but transitional option 1
• The use of co-testing or cytology alone for cervical cancer screening will likely not be included in future guidelines as the US transitions to primary HPV testing 1
• Despite recommendations limiting co-testing to women aged 30-65 years, studies show some increase in co-testing among younger women, which is not currently recommended 2

In conclusion, HPV co-testing should be limited to women aged 30-65 years as an acceptable but not preferred screening option, with primary HPV testing emerging as the preferred method for this age group. Co-testing is explicitly not recommended for women under 30 years of age.