What is the recommended assessment and plan for routine Pap (Papanicolau) smear and cervical cancer screening?

Cervical Cancer Screening Recommendations

The recommended approach for routine cervical cancer screening is Pap testing every 3 years for women aged 21-65 years, or for women aged 30-65 years, HPV co-testing with Pap test every 5 years is preferred. 1, 2

General Screening Guidelines

• Screening should begin at age 21 years, regardless of sexual history or other risk factors 1
• Women younger than 21 years should not be screened for cervical cancer 1
• For women aged 21-29 years, screening with cytology (Pap test) alone every 3 years is recommended 1, 2
• For women aged 30-65 years, two options are available:
  • Preferred: Co-testing with HPV DNA test and cytology every 5 years 1, 2
  • Acceptable alternative: Cytology alone every 3 years 1
• Annual screening is not recommended for any age group 1, 2
• HPV testing should not be used as a stand-alone test for screening 1, 2
• Women who have been vaccinated against HPV should follow the same screening recommendations as unvaccinated women 1

When to Discontinue Screening

• Women older than 65 years should discontinue screening if they have had adequate prior screening with normal results 1, 2
• Adequate prior screening is defined as three consecutive negative cytology results or two consecutive negative co-test results within the 10-year period before cessation of screening, with the most recent test occurring within 5 years 1
• Once screening is discontinued after age 65, it should not resume for any reason, including having a new sexual partner 1
• Women who have had a hysterectomy with removal of the cervix and who do not have a history of high-grade precancerous lesions (CIN 2/3) or cervical cancer should discontinue screening 1, 2

Special Populations

• Women at high risk for cervical cancer require more frequent screening, including those with:
  • HIV infection
  • Immunocompromised status
  • In utero exposure to diethylstilbestrol
  • Previous treatment of high-grade precancerous lesions or cervical cancer 1, 2
• Pregnant women should be screened according to the same guidelines as non-pregnant women 1

Implementation Trends and Challenges

• Despite updated guidelines, many providers continue to recommend annual cervical cancer screening 3
• Screening rates have been declining across all age groups, with an estimated 14 million women aged 21-65 not being screened within the past 3 years 4, 5
• Certain populations have lower screening rates, including recent immigrants, women without insurance, and women without a usual source of healthcare 4
• While Pap testing has decreased, HPV co-testing has increased significantly among women aged 30-65 years, suggesting growing adoption of the 2012 guidelines 5

Common Pitfalls to Avoid

• Over-screening women, which increases costs and potential harms without significantly improving cancer detection 2, 6
• Under-screening high-risk populations who require more frequent monitoring 2
• Discontinuing screening too early (before age 65) in women without adequate prior normal results 2
• Continuing screening after hysterectomy when the cervix has been removed and there is no history of high-grade lesions or cancer 2
• Screening women younger than 21 years, which can lead to unnecessary procedures and potential harm 1, 6

The evidence clearly supports the current screening intervals as providing the optimal balance between benefits and harms. More frequent screening adds minimal benefit while increasing costs and potential harms from false positives and unnecessary procedures 2, 6. Following these evidence-based recommendations will help ensure that women receive appropriate cervical cancer screening while minimizing potential harms.