Is the current recommendation for cervical cancer screening using HPV testing (primary testing or co‑testing) in women aged 25–65 in a primary‑care setting correct?

HPV Testing for Cervical Cancer Screening: Current Recommendations

Yes, HPV testing for cervical cancer screening in women aged 25–65 is correct and represents the current standard of care, with primary HPV testing every 5 years now the preferred strategy according to the most recent American Cancer Society 2020 guidelines. 1

Preferred Screening Strategy

Primary HPV testing alone every 5 years is the preferred approach for individuals aged 25–65 years. 1 This represents a significant shift from previous guidelines and reflects accumulated evidence showing superior performance of HPV testing compared to cytology alone. 1

Key Points About Primary HPV Testing:

• Only 2 FDA-approved primary HPV tests are currently available for cervical cancer screening, both approved for use starting at age 25 years. 1
• Primary HPV testing detects more advanced precancers (including adenocarcinoma and its precursors) and confers lower risk with a negative result compared to cytology. 1
• The U.S. Preventive Services Task Force included stand-alone HPV testing among recommended tests in 2018. 1

Acceptable Alternative Strategies (Transitional)

If primary HPV testing is not available in your practice setting, two acceptable alternatives exist: 1

• Cotesting (HPV + cytology) every 5 years 1, 2
• Cytology alone every 3 years 1, 2

Important caveat: The American Cancer Society explicitly states that cotesting and cytology-alone options will be phased out as the United States completes the transition to primary HPV testing. 2, 3 These are considered transitional options only. 1

Age-Specific Screening Protocols

Ages 25–29 Years

• Primary HPV testing every 5 years (preferred) 1, 2
• Cotesting every 5 years or cytology alone every 3 years (acceptable alternatives) 1, 2

Ages 30–65 Years

• Primary HPV testing every 5 years (preferred) 1, 2
• Cotesting every 5 years or cytology alone every 3 years (acceptable alternatives) 1, 2, 4, 5

Note: There is some variation between guidelines. The USPSTF 2018 guidelines recommend starting screening at age 21 with cytology alone every 3 years until age 29, then transitioning to HPV-based strategies at age 30. 2, 4, 5 However, the more recent ACS 2020 guideline recommends starting at age 25 with HPV testing. 1

Critical Screening Cessation Criteria (Age >65)

Discontinue all cervical cancer screening when ALL of the following criteria are met: 1, 2

1. Adequate prior negative screening:

   • Either 2 consecutive negative primary HPV tests within the past 10 years 1, 2
   • OR 2 consecutive negative cotests within the past 10 years 1, 2
   • OR 3 consecutive negative cytology tests within the past 10 years 1, 2

2. Most recent test within the recommended interval (within past 3–5 years depending on test used) 1, 2

3. No history of CIN 2 or more severe disease within the past 25 years 1, 2

Once screening is stopped after age 65, do not resume for any reason, including new sexual partners. 3

High-Risk Populations Requiring Modified Protocols

The standard HPV testing recommendations do not apply to the following groups who require more intensive surveillance: 2, 3

• HIV-positive individuals: Annual screening regardless of age 2, 3, 6
• Immunocompromised patients (organ transplant recipients, chronic corticosteroid therapy, ongoing chemotherapy): Annual screening 3
• History of CIN 2/3 or adenocarcinoma in situ: Continue screening for 20–25 years after treatment, even beyond age 65 2, 3, 6
• In utero DES exposure: Continued surveillance per standard guidelines 2, 3

Common Pitfalls to Avoid

Do NOT Screen:

• Individuals under age 25 (or 21 per USPSTF): Screening causes more harm than benefit due to high prevalence of transient HPV infections that spontaneously regress. 1, 2, 3
• After total hysterectomy with cervix removal (if no history of CIN 2+ or cancer in past 25 years) 1, 2, 3
• More frequently than recommended intervals: Annual screening provides minimal additional benefit but substantially increases harms including false positives, unnecessary colposcopies, overtreatment, and adverse obstetric outcomes. 3

Critical Documentation Requirements:

• Never discontinue screening without verifying adequate prior negative screening through medical records review—verbal patient report is insufficient. 6
• Provide written documentation of whether screening was performed at each visit, as self-reports are often inaccurate. 6

HPV Vaccination Status

Screening recommendations are identical for vaccinated and unvaccinated individuals. 1, 2, 6 HPV vaccines do not cover all oncogenic HPV types, so vaccination does not eliminate the need for screening. 1, 2, 6

Management of Positive Results

All abnormal HPV or cytology results should be managed according to the 2019–2020 ASCCP Risk-Based Management Consensus Guidelines. 1, 3, 6 Immediate colposcopy is indicated for high-grade squamous intraepithelial lesion (HSIL). 2, 3