What are the guidelines for cervical cancer screening?

Cervical Cancer Screening Guidelines

For women aged 21-65 years, cervical cancer screening should be performed every 3 years with cervical cytology alone, or for women aged 30-65 years, screening can be done every 5 years with high-risk HPV testing alone or with HPV-cytology cotesting. 1

Age-Specific Recommendations

• No screening is recommended for women younger than 21 years, regardless of sexual history or other risk factors 1
• For women aged 21-29 years:
  • Screen every 3 years with cervical cytology (Pap test) alone 1
  • HPV testing or cotesting is not recommended for this age group 1
• For women aged 30-65 years:
  • Preferred approach: Screen every 5 years with high-risk HPV testing alone 1, 2
  • Acceptable alternatives: Screen every 5 years with HPV-cytology cotesting or every 3 years with cytology alone 1
• For women older than 65 years:
  • Discontinue screening if they have had adequate prior screening and are not otherwise at high risk for cervical cancer 1
  • Adequate prior screening is defined as three consecutive negative cytology results or two consecutive negative HPV tests or cotests within the past 10 years, with the most recent test occurring within the past 5 years 1, 2

Special Populations

• Women who have had a hysterectomy with removal of the cervix and no history of high-grade precancerous lesions or cervical cancer should not be screened 1
• Women who have been vaccinated against HPV should follow the same screening recommendations as unvaccinated women 1
• Women with a history of cervical cancer, in utero exposure to diethylstilbestrol (DES), or who are immunocompromised (including those with HIV) require more frequent screening and should not follow these general guidelines 1, 2

Management of Abnormal Results

• Women with abnormal screening results should be managed according to risk-based guidelines 1
• Results are reported using the 2001 Bethesda System, with abnormalities ranging from lowest to highest risk: ASC-US, LSIL, ASC-H, HSIL, and invasive carcinoma 1
• For women aged 21-24 years with abnormal results, more conservative management is recommended as many lesions in this age group may regress 1
• Colposcopy is recommended for women with HSIL, HPV-positive HSIL, HPV-positive ASC-H, or atypical glandular cells (AGC) 1

Benefits and Limitations

• Cervical cancer screening has significantly reduced cervical cancer incidence and mortality in the United States 1
• Most cases of cervical cancer occur among women who have not been adequately screened 1
• Annual screening is not recommended for any age group as it provides minimal additional benefit while increasing harms from false positives and unnecessary procedures 1
• HPV testing is more sensitive than cytology alone but less specific, potentially leading to more follow-up testing 1

Common Pitfalls to Avoid

• Screening women younger than 21 years can lead to unnecessary interventions for lesions that would likely regress 1
• Over-screening (more frequently than recommended) increases costs and potential harms without improving outcomes 3, 4
• Despite guidelines recommending longer intervals, studies show many women still undergo annual screening 3, 5
• Failure to discontinue screening in women over 65 with adequate prior negative screening results exposes them to unnecessary procedures 1
• Continuing to screen women who have had a hysterectomy with removal of the cervix (and no history of high-grade lesions) provides no benefit 1

Trends in Screening Practices

• Despite recommendations for less frequent screening, many women continue to be screened annually 3, 5
• There has been a gradual shift toward HPV-cytology cotesting among women aged 30-65 years, from 10% in 2007 to 60.8% in 2016 5
• Screening rates vary by demographic factors, with disparities observed by race, ethnicity, insurance status, and access to healthcare 6, 5