What are the updated cervical cancer screening recommendations from the US Preventive Services Task Force (USPSTF)?

Updated USPSTF Cervical Cancer Screening Recommendations (2018)

The most significant update in the 2018 USPSTF guidelines is the explicit endorsement of primary high-risk HPV (hrHPV) testing alone every 5 years as an equally acceptable screening option for women aged 30-65 years, alongside cytology alone every 3 years and cotesting every 5 years. 1, 2

Key Changes from 2012 Guidelines

The 2018 update represents an evolution rather than revolution, with one critical addition:

• Primary hrHPV testing alone every 5 years is now explicitly recommended as a standalone screening option for women aged 30-65 years, whereas the 2012 guidelines only endorsed cytology alone or cotesting 1, 2

• The 2012 guidelines specifically recommended against HPV testing alone in women under 30 years, and this prohibition remains unchanged in 2018 1

Complete 2018 Screening Algorithm

Women Aged 21-29 Years

• Screen with cervical cytology alone every 3 years (Grade A recommendation) 1, 2
• HPV testing (alone or with cotesting) is explicitly not recommended in this age group 3
• This applies regardless of sexual history or HPV vaccination status 1

Women Aged 30-65 Years

Three equally acceptable options (Grade A recommendation) 1, 2:

1. Cervical cytology alone every 3 years
2. Primary hrHPV testing alone every 5 years (new in 2018)
3. Cotesting (cytology + hrHPV) every 5 years

• All three strategies provide similar mortality reduction with different harm profiles 2, 4
• Cotesting increases follow-up procedures without substantially increasing detection of high-grade lesions compared to hrHPV alone 1

Women Under Age 21

• Do not screen, regardless of sexual history (Grade D recommendation) 1, 2
• Screening before age 21 causes more harm than benefit due to unnecessary treatment of lesions that naturally regress 3

Women Over Age 65

• Discontinue screening if adequate prior screening documented and not otherwise high-risk (Grade D recommendation) 1, 2
• Adequate prior screening = 3 consecutive negative cytology tests OR 2 consecutive negative cotests within past 10 years, with most recent test within 5 years 3, 5

Post-Hysterectomy

• Do not screen if cervix removed and no history of high-grade precancerous lesion (CIN 2/3) or cervical cancer (Grade D recommendation) 1, 2

Important Caveats and Implementation Challenges

FDA Approval Concerns

• The USPSTF initially hesitated to endorse primary hrHPV testing in their 2017 draft due to limited FDA-approved tests for primary screening 1
• The final 2018 statement included this option after public comment, acknowledging that hrHPV testing will eventually dominate screening but implementation readiness varies 1

Populations Excluded from Standard Guidelines

These recommendations do not apply to 1:

• Women with diagnosed high-grade precancerous lesions or cervical cancer
• Women with in utero diethylstilbestrol exposure
• Immunocompromised women (including HIV-positive individuals)
• These populations require individualized, more intensive surveillance 3, 6

Special Screening Scenarios

History of CIN 2/3 or cervical cancer:

• Continue screening for at least 20-25 years after treatment, even if this extends past age 65 5

Never-screened women over 65:

• Offer screening despite age, as 42% of cervical cancers in women ≥65 occur in never-screened individuals 5
• Modeling shows 74% mortality reduction with screening versus remaining unscreened 5

HPV vaccination status:

• Vaccinated women follow identical screening recommendations as unvaccinated women 3
• Vaccination does not eliminate screening need because vaccines don't cover all oncogenic HPV types 3

Common Pitfalls to Avoid

• Do not use HPV testing (alone or cotesting) in women under 30 years - this leads to unnecessary procedures for transient infections that clear spontaneously 3

• Do not stop screening at age 65 without verifying adequate prior screening through medical records - verbal patient report is insufficient 5

• Do not discontinue screening in women with prior CIN 2/3 until 20-25 years post-treatment, regardless of current age 5

• Do not screen women post-hysterectomy for benign indications - this provides no benefit and represents unnecessary healthcare utilization 5

Evidence Quality and Certainty

The USPSTF assigned high certainty that benefits outweigh harms for all three screening strategies in women aged 30-65 years 1, 2. The decision analysis modeling demonstrated that while strategies differ in their balance of colposcopies, false-positives, and cancer detection, all substantially reduce cervical cancer mortality compared to no screening 4.