What are the recommended screening guidelines for cervical cancer?

Cervical Cancer Screening Guidelines

The preferred approach for cervical cancer screening is primary high-risk HPV (hrHPV) testing every 5 years for women aged 30-65 years, with cervical cytology alone every 3 years or cotesting every 5 years as acceptable alternatives. 1

Age-Specific Recommendations

• Women younger than 21 years should not be screened for cervical cancer, regardless of sexual history or other risk factors 2, 1
• Women aged 21-29 years should be screened every 3 years with cervical cytology (Pap test) alone 2, 1
• Women aged 30-65 years have three screening options:
  • Primary hrHPV testing alone every 5 years (preferred approach) 1
  • Cervical cytology alone every 3 years 2, 1
  • Cotesting (hrHPV testing plus cytology) every 5 years 2
• Women older than 65 years should discontinue screening if they have had adequate prior screening with normal results 2, 1

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 2, 1
• Women who have been vaccinated against HPV should follow the same screening recommendations as unvaccinated women 2, 1
• Women with specific risk factors (HIV infection, immunocompromised status, in utero exposure to diethylstilbestrol, or history of high-grade precancerous lesions or cervical cancer) may require more frequent screening and individualized follow-up 2

Screening Methods

• Liquid-based cervical cytology and conventional Papanicolaou (Pap) smears are similar in effectiveness, though liquid-based cytology allows for HPV testing on the same sample 2
• HPV testing is more sensitive but less specific than cervical cytology alone 2
• HPV testing should not be used as a stand-alone test for screening women younger than 30 years 2, 1
• Annual screening is not recommended for any age group 2, 1

Management of Abnormal Results

• Cervical cytology results are reported using the 2001 Bethesda System, with abnormalities ranging from lowest to highest risk of cancer:
  1. Atypical squamous cell of undetermined significance (ASC-US)
  2. Low-grade squamous intraepithelial lesion (LSIL)
  3. Atypical squamous cell suspicion of high-grade dysplasia (ASC-H)
  4. High-grade squamous intraepithelial lesion (HSIL)
  5. Invasive carcinoma 2
• Colposcopy with colposcopically directed biopsies is indicated for evaluating women with abnormal results such as positive HPV test results and ASC-US or worse 2
• Management should follow risk-based guidelines, with similar management for similar risks 2, 1

Benefits and Limitations

• Cervical cancer screening has significantly reduced cervical cancer incidence and mortality in the United States, with deaths declining from 2.8 to 2.3 per 100,000 women from 2000 to 2015 1, 3
• Despite the benefits, screening rates have been declining over time across all age groups, with an estimated 14 million women aged 21-65 not screened within the past 3 years 4
• Recent immigrants, women without insurance, and women without a usual source of healthcare have lower odds of being up to date with screening 4

Common Pitfalls to Avoid

• Screening women younger than 21 years can lead to unnecessary interventions for lesions that would likely regress 1
• Continuing to screen women older than 65 years who have had adequate prior negative screening results exposes them to unnecessary procedures 1
• Failure to follow recommended screening intervals—screening too frequently provides minimal additional benefit while increasing harms from false positives and unnecessary procedures 1
• Not offering appropriate screening options to women aged 30-65 years, who can benefit from the increased sensitivity of HPV testing 2, 1