What are the guidelines for cervical cancer screening?

Cervical Cancer Screening Guidelines

Primary HPV testing every 5 years is the preferred screening method for women aged 25-65 years, with cytology alone every 3 years or cotesting every 5 years as acceptable alternatives during the transition to primary HPV testing. 1, 2

Age-Specific Recommendations

Under 21 Years

• No screening is recommended for women under 21 years of age, regardless of sexual history or other risk factors 3, 2
• Screening women younger than 21 years can lead to unnecessary interventions for lesions that would likely regress spontaneously 3

Ages 21-24 Years

• Cytology (Pap test) alone every 3 years is recommended 3, 2
• HPV testing or cotesting is not recommended for this age group 2

Ages 25-29 Years

• Primary HPV testing every 5 years is the preferred screening method 1, 2
• Cytology alone every 3 years is an acceptable transitional option 2
• Cotesting is acceptable where access to primary HPV testing is limited 1

Ages 30-65 Years

• Primary HPV testing alone every 5 years is the preferred screening method 1, 3, 2
• Cotesting (HPV plus cytology) every 5 years is an acceptable alternative 1, 2
• Cytology alone every 3 years is acceptable where access to HPV testing is limited 1
• Annual screening is not recommended for any age group as it provides minimal additional benefit while increasing harms from false positives 3, 4

Over 65 Years

• Discontinue screening if adequate negative prior screening has been documented and the woman is not otherwise at high risk for cervical cancer 1, 3, 2
• Adequate negative prior screening is defined as:
  • 2 consecutive negative primary HPV tests, or
  • 2 negative cotests, or
  • 3 negative cytology tests within the past 10 years, with the most recent test occurring within the past 3-5 years 1, 2
• Women over 65 years without documentation of prior screening should continue screening until criteria for cessation are met 1
• Continuing screening in women over 65 with adequate prior negative screening results exposes them to unnecessary procedures 3

Special Populations

After Hysterectomy

• Women who have had a hysterectomy with removal of the cervix and no history of high-grade precancerous lesions (CIN2+) in the past 25 years or cervical cancer should not be screened 1, 3, 2

HPV-Vaccinated Women

• HPV-vaccinated women should follow the same age-specific screening recommendations as unvaccinated individuals 1, 3, 2
• Cytology-based screening is less efficient in vaccinated populations, as abnormal cytology disproportionately identifies minor abnormalities resulting from HPV types associated with lower cancer risk 1, 2

Management of Abnormal Results

• For management of positive results and subsequent surveillance, refer to the American Society of Colposcopy and Cervical Pathology (ASCCP) 2020 Risk-Based Management Consensus Guidelines 1
• Women with abnormal screening results should be managed according to risk-based guidelines 3
• Colposcopy is recommended for women with high-grade squamous intraepithelial lesion (HSIL), HPV-positive HSIL, HPV-positive atypical squamous cells cannot exclude HSIL (ASC-H), or atypical glandular cells (AGC) 3

Benefits and Limitations

• Cervical cancer screening has significantly reduced cervical cancer incidence and mortality in the United States 3, 5
• The number of deaths from cervical cancer in the United States has decreased from 2.8 to 2.3 deaths per 100,000 women from 2000 to 2015 5
• Cotesting has increased detection of precancerous lesions and adenocarcinoma compared to cytology alone 2
• Cotesting may allow for longer screening intervals but has higher rates of false positives and unnecessary colposcopies, especially in younger women 2

Common Pitfalls to Avoid

• Screening too frequently (annually) provides minimal additional benefit while increasing harms from false positives and unnecessary procedures 3, 4
• Despite recommendations for less frequent screening, many women continue to be screened annually - 55% of women with no history of abnormal smears reported annual screening in earlier studies 4
• Screening rates have been declining in all age groups, including an unexpected decline in 21- to 29-year-old women, which is concerning 6
• Disparities in screening exist by race, ethnicity, smoking status, and comorbidity level 6
• Recent immigrants to the United States, women without insurance, and women without a usual source of healthcare have lower odds of being up to date with screening 7