What are the screening recommendations for cervical cancer using a Pap (Papanicolau) smear?

Cervical Cancer Screening Recommendations with Pap Smear

For women aged 21-65, cervical cancer screening should be performed with cytology (Pap smear) every 3 years, or for women aged 30-65 who want to lengthen the screening interval, screening with a combination of cytology and HPV testing (co-testing) every 5 years is recommended. 1

General Screening Guidelines by Age Group

• Women younger than 21 years should not be screened for cervical cancer, regardless of sexual history 1, 2
• Women aged 21-29 years should be screened with cytology (Pap smear) alone every 3 years 1, 2
• Women aged 30-65 years have two options:
  • Preferred: Co-testing with cytology and HPV testing every 5 years 1, 2
  • Acceptable alternative: Cytology (Pap smear) alone every 3 years 1, 2
• Women older than 65 years who have had adequate prior screening with normal results should discontinue screening 1, 2

Special Populations

• Women who have had a hysterectomy with removal of the cervix and who do not have a history of high-grade precancerous lesions or cervical cancer should discontinue screening 1, 2
• Women with a history of cervical cancer, HIV infection, immunocompromised status, or in utero exposure to diethylstilbestrol may require more frequent screening based on clinical judgment 1, 2
• Pregnant women should be screened according to the same guidelines as non-pregnant women 1

Definition of Adequate Prior Screening

For women older than 65 years to safely discontinue screening, they should meet the following criteria:

• No abnormal/positive cytology tests within the past 10 years 3
• Documentation that the 3 most recent Pap tests were technically satisfactory and interpreted as normal 3
• No history of CIN2+ within the last 20 years 3

Evidence Supporting Current Recommendations

• The 3-year screening interval with cytology alone provides a reasonable balance between benefits and harms 1
• More frequent screening (annually) provides little additional benefit but substantially increases harms 1, 2
• Co-testing with HPV and cytology every 5 years for women aged 30-65 years offers comparable benefits to cytology alone every 3 years, with acceptable harms 1
• Despite recommendations for extended screening intervals, studies show many physicians continue to recommend more frequent screening than guidelines suggest 4, 5

Common Pitfalls to Avoid

• Over-screening women, particularly annual screening, which increases costs and potential harms without significantly improving cancer detection 2
• Under-screening high-risk populations such as women with previous abnormal results, immunocompromised status, or HIV infection 2
• Discontinuing screening too early (before age 65) when a woman has not had adequate prior screening 2, 3
• Screening after hysterectomy in women who have had their cervix removed and have no history of high-grade lesions or cancer 1, 2
• Failing to transition to the recommended 3-year or 5-year screening intervals, as studies show declining but still significant rates of annual screening 6, 7

Medicare Coverage

Medicare covers Pap testing and pelvic examinations at three-year intervals for average-risk women. Yearly screening is allowed for women at high risk of cervical or vaginal cancer or who have had an abnormal Pap smear in the preceding three years 1.

Trends in Screening Practices

• Recent studies show increasing adoption of the 2012 guidelines, with more women aged 30-65 years receiving Pap-HPV co-testing 7
• However, there has been a concerning decline in Pap screening among women aged 21-29 years, who should be screened every 3 years with cytology alone 7
• Disparities in screening rates exist by race, ethnicity, insurance status, and access to healthcare 6