What are the guidelines for Pap smear screening for Human Papillomavirus (HPV)?

From the Guidelines

Pap screening for HPV should begin at age 25 years and undergo primary human papillomavirus (HPV) testing every 5 years through age 65 years. This is based on the most recent guidelines from the American Cancer Society, which recommends primary HPV testing as the preferred screening strategy for individuals with a cervix at average risk 1. The guidelines also state that if primary HPV testing is not available, then individuals aged 25 to 65 years should be screened with cotesting (HPV testing in combination with cytology) every 5 years or cytology alone every 3 years.

Some key points to consider when implementing these guidelines include:

• The recommended age to start screening is 25 years, rather than 21 years, as previously recommended
• Primary HPV testing is recommended as the preferred screening strategy, with cotesting and cytology alone as acceptable alternatives where access to primary HPV testing is limited
• Screening can be discontinued after age 65 if there is adequate negative prior screening and no history of cervical intraepithelial neoplasia grade 2 or more severe disease within the past 25 years, as stated in the guidelines 1
• HPV vaccination status does not change screening recommendations, and individuals who have had a total hysterectomy with removal of the cervix and no history of high-grade precancer or cervical cancer can discontinue screening.

The American Cancer Society guidelines aim to balance early detection of cervical abnormalities while avoiding overscreening, which can lead to unnecessary procedures, anxiety, and increased healthcare costs 1. By following these guidelines, healthcare providers can help ensure that individuals with a cervix receive appropriate screening for HPV and cervical cancer, while minimizing the risks associated with overscreening.

From the Research

Pap Screening Guidelines for HPV

• The guidelines for Pap screening for HPV vary based on age and other factors 2, 3.
• For women aged 21-29 years, HPV testing should not be used as a stand-alone test or as a co-test with cytology, except in the diagnosis of ASCUS 2.
• Women aged 30-65 years should be screened with cytology and HPV testing every 5 years or cytology alone every 3 years 2, 3.
• For women with a DNA HPV HR positive result and a negative Pap test, two options are recommended:
  • 12-month follow-up with co-testing (Pap and DNA HPV HR tests)
  • Test for HPV16 or HPV16/18 genotypes, and refer to colposcopy if positive 2.
• Women aged >65 years should not be screened following adequate negative prior screening, unless they have a history of CIN2 or a more severe diagnosis 2, 3.
• Women who have been vaccinated against HPV should follow age-specific recommendations, the same as unvaccinated women 2.

Screening Intervals and Methods

• Screening with cervical cytology alone, primary hrHPV testing alone, or co-testing can detect high-grade precancerous cervical lesions and cervical cancer 3.
• The USPSTF recommends screening for cervical cancer every 3 years with cervical cytology alone in women aged 21-29 years, and every 3 years with cytology alone, every 5 years with hrHPV testing alone, or every 5 years with co-testing in women aged 30-65 years 3.
• The USPSTF also recommends against screening for cervical cancer in women younger than 21 years, women older than 65 years who have had adequate prior screening, and women who have had a hysterectomy with removal of the cervix for indications other than a high-grade precancerous lesion or cervical cancer 3.

Risk of CIN 3+ and Management

• Women aged 21-24 years have a low risk of CIN 3+, and positive Pap test results predict low CIN 3+ risk except for high-grade Pap results 4.
• The 5-year risk of CIN 3+ after HPV-negative/ASC-US is similar across all age groups, while the risk after HPV-positive/ASC-US is lower among women aged 21-24 years than among women aged 25-29 years or 30-64 years 4.
• Conservative management of women aged 21-24 years is supported by the low risk of CIN 3+ 4.

Clinical Correlation of Cervical Cancer Screening

• The Pap smear test is a highly useful, easy, technically safe, and cost-effective tool for detecting cervical epithelial precancerous lesions 5.
• The power of detection of these lesions can be potentiated when using the Pap test and HPV-PCR test together 5.
• Clinical presentation and Pap smear results can vary, with most women being asymptomatic, and a history of sexually transmitted diseases seen in a small percentage of cases 5.