What are the guidelines for Pap (Papanicolau) smears for cervical cancer screening?

Guidelines for Cervical Cancer Screening

The current recommendation for cervical cancer screening is to screen women aged 21 to 65 years with cytology (Pap smear) every 3 years or, for women aged 30 to 65 years who want to lengthen the screening interval, screening with a combination of cytology and HPV testing every 5 years. 1

General Screening Recommendations

• Screening should begin at age 21 regardless of sexual history 1
• Annual screening is not recommended for any age group 1
• For women aged 21-29 years: Screening with cervical cytology alone every 3 years 1
• For women aged 30-65 years: Two acceptable approaches 1
  • Cytology (Pap test) alone every 3 years, OR
  • Cytology plus HPV testing (cotesting) every 5 years (preferred)
• HPV testing should not be used as a stand-alone test for screening 1
• Women who have been vaccinated against HPV need to be screened using the same recommendations as unvaccinated women 1

When to Stop Screening

• Screening is not recommended in women aged 65 years and older if they have had adequate prior screening with normal results 1
• Adequate prior screening is defined as three consecutive negative cytology results or two consecutive negative cotests within the past 10 years, with the most recent test occurring within the past 5 years 1, 2
• Women should continue screening until age 70 years if they are in good health, after which they may elect to stop if they have had no abnormal/positive cytology tests within the 10-year period prior to age 70 years, and if there is documentation that the 3 most recent Pap tests were technically satisfactory and interpreted as normal 1

Special Populations

Women Under 21 Years

• Women younger than 21 years should not be screened for cervical cancer 1

Women After Hysterectomy

• Women who have had a hysterectomy with removal of the cervix and who do not have a history of a high-grade precancerous lesion or cervical cancer should not be screened 1

High-Risk Populations

• Women with a history of cervical cancer or in utero exposure to diethylstilbestrol (DES) should follow the same guidelines as average-risk women before age 30 years, and should continue with that protocol after age 30 years 1
• Women who are immunocompromised (including those who are HIV positive, have organ transplantation, are on chemotherapy, or chronic corticosteroid treatment) should receive more frequent screening 1

Pregnant Women

• Pregnant women should be screened according to the same guidelines as non-pregnant women 1
• If CIN3 is detected during pregnancy, treatment can wait until after delivery unless invasive cancer is suspected 1

Patient Education

When discussing HPV testing with patients, they should be informed that:

• HPV infection is very common and usually not harmful 1
• Almost everyone who has had sexual intercourse has been exposed to HPV 1
• A positive HPV test result does not indicate the presence of a sexually transmitted disease, but rather a sexually acquired infection 1
• A positive HPV test result does not indicate the presence of cancer, and the majority of women who test positive for HPV will not develop advanced cervical neoplasia 1

Common Pitfalls to Avoid

• Over-screening: Annual screening is not recommended for any age group and may lead to unnecessary procedures 1, 3
• Under-screening: An estimated 14 million women aged 21-65 have not been screened within the past 3 years 4
• Inappropriate use of HPV testing in women under 30 years: HPV testing is not recommended for screening in women younger than 30 years 1
• Discontinuing screening too early: Women should not stop screening at age 65 if they have not had adequate prior screening 1, 2
• Continuing screening unnecessarily after hysterectomy: Women who have had a hysterectomy with removal of the cervix and no history of high-grade lesions do not need continued screening 1

Trends in Screening Practices

• There has been a decline in screening rates among all age groups in recent years, which is concerning 4, 5
• Adoption of cotesting (Pap plus HPV) has increased significantly among women aged 30-65 years, from 10.0% in 2007 to 60.8% in 2016 5
• Geographic variations exist in screening modalities across the United States, with Midwestern and Southern states having the lowest uptake of cotesting 6

The evolution of cervical cancer screening guidelines reflects the growing understanding of HPV's role in cervical cancer development and the benefits of risk-based screening approaches that can reduce unnecessary procedures while maintaining effective cancer prevention 3.