What are the guidelines for Pap (Papanicolaou) smear and Human Papillomavirus (HPV) testing?

From the Guidelines

Cervical cancer screening guidelines recommend Pap tests (cytology) every 3 years for women ages 21-29, and for women 30-65, options include Pap testing every 3 years, HPV testing alone every 5 years, or co-testing (Pap plus HPV) every 5 years, as stated in the most recent guidelines 1. The guidelines for Pap (Papanicolaou) smear and Human Papillomavirus (HPV) testing are based on a woman’s age, her screening history, other risk factors, and the choice of screening tests.

• Screening for cervical cancer should begin at age 21 years, with cytology screening every 3 years for women ages 21-29 years, as recommended by the American Cancer Society 1.
• For women ages 30-65 years, the preferred approach is to be screened every 5 years with the combination of HPV testing and cytology (“cotesting”), although it is also acceptable to continue screening every 3 years with cytology alone 1.
• Women should discontinue screening after age 65 years if they have had 3 consecutive negative cytology tests or 2 consecutive negative cotest results within the 10-year period before ceasing screening, with the most recent test occurring within the last 5 years, as stated in the guidelines 1.
• HPV testing is not recommended for women under 30 due to the high prevalence of transient infections, but it can be used as a reflex test for women diagnosed with atypical squamous cells of undetermined significance (ASC-US) 1.
• Women with certain risk factors, such as HIV infection, immunosuppression, or history of cervical dysplasia, may need more frequent screening, as recommended by the guidelines 1.
• After hysterectomy with removal of the cervix for benign reasons, routine screening can be discontinued, as stated in the guidelines 1. These guidelines balance early detection of cervical abnormalities with avoiding overscreening, as most HPV infections clear spontaneously, especially in younger women, and the longer intervals with HPV testing are appropriate because HPV is the causative agent for cervical cancer, and negative HPV results provide strong reassurance against developing high-grade lesions in the next several years 1.

From the Research

Guidelines for Pap Smear and Human Papillomavirus (HPV) Testing

• The American College of Obstetricians and Gynecologists (ACOG), American Cancer Society (ACS), and U.S. Preventive Services Task Force (USPSTF) recommend that screening by Papanicolau (Pap) test should not be used for women aged <21 years, regardless of initiation of sexual activity 2.
• A screening interval of 3 years should be maintained for women aged 21-30 years 2.
• For women aged 30 to 65, the option of adding the HPV test (co-test) every 5 years is available 3.
• The USPSTF recommends screening women aged 21-29 years every 3 years with cervical cytology alone (Pap test), and those aged 30-65 years every 5 years with human papillomavirus (HPV) testing and cytology (cotesting) or HPV testing alone 4.

Screening Practices and Trends

• Analysis of 2000-2010 data from the Behavioral Risk Factor Surveillance System (BRFSS) for women aged 18-30 years showed that Pap testing practices for young women have been moving toward the latest guidelines 2.
• However, the data also showed a concerning trend: among women aged 22-30 years, who should be screened every 3 years, the proportion who reported never having had a Pap test increased from 6.6% to 9.0% 2.
• A 2015 U.S. National Health Interview Survey (NHIS) data examination found that 81.1% of eligible women reported having a Pap test within 3 years, but percentages declined over time among all age groups 3.
• A study using Rochester Epidemiology Project data found significant declines in Pap completion rates over time in all age groups, including an unexpected decline in 21- to 29-year-old women 5.

Impact of COVID-19 on Cervical Cancer Screening Rates

• The COVID-19 pandemic led to a substantial decrease in cervical cancer screening rates, with a 78% decline in cervical cytology screening rates per 100 person-months among women aged 21-29 years, and an 82% decrease in HPV test screening rates per 100 person-months among women aged 30-65 years 4.
• After the stay-at-home order was lifted, screening rates returned to near baseline, which might have been aided by aspects of the integrated, organized screening program 4.