“Today, there is little evidence to support the annual screening of women at any age by any screening test, method, or modality,” say joint recommendations from the American Cancer Society, the American Society for Colposcopy and Cervical Pathology, and the American Society for Clinical Pathology (ACS/ASCCP/ASCP).
The guideline emphasizes that point, going on to state: “Women at any age should not be screened annually by any screening method; rather, recommended screening intervals for women are based on age and clinical history.”2
Overview of the guidelines
In March 2012, the ACS/ASCCP/ASCP and the US Preventive Services Task Force (USPSTF) updated existing recommendations on the fine points of cervical cancer screening. Both sets of guidelines note that financial cost was not considered in formulating the recommendations. They also point out that the guidelines apply only to women who have a cervix. In addition, both sets of guidelines exclude women who have been identified as having a high-grade precancerous lesion or cervical cancer, women who were exposed in utero to diethylstilbestrol, and women who are immunocompromised (e.g., HIV-positive).
The recommendations are categorized according to the age of the patient and her clinical history (or lack thereof):
- Adolescents: No screening. “Adolescent cervical cancer prevention programs should focus on universal HPV vaccination, which is safe, highly efficacious, and, when used in adolescents before they become sexually active, highly effective and cost-effective,” notes ACS/ASCCP/ASCP.2
- Women 21 to 29 years old: Begin screening at age 21 and continue every 3 years until the age of 29 years. Routine testing for oncogenic human papillomavirus (HPV) strains is not recommended in this population.
- Women 30 to 65 years old: Cytology screening every 3 years or co-testing (cytology plus HPV testing) every 5 years. The 5-year co-testing interval is recommended by ACS/ASCCP/ASCP, whereas the USPSTF simply states: “Screening women ages 21 to 65 years every 3 years with cytology provides a reasonable balance between benefits and harms.” The USPSTF also notes that “HPV testing combined with cytology (co-testing) every 5 years in women ages 30 to 65 years offers a comparable balance of benefits and harms, and is therefore a reasonable alternative for women in this age group who would prefer to extend the screening interval.”
- Women over 65 years: Discontinue screening, provided the woman has undergone adequate screening in preceding years with negative results (TABLE).
Recommended cervical cancer screening under updated guidelines
|<21 years||Do not screen, regardless of the age of sexual initiation and other risk factors|
|21–29 years||Screen with cytology every 3 years|
|30–65 years||Screen with cytology every 3 years (preferred) or with a combination of cytology and HPV testing every 5 years||Screen with a combination of cytology and HPV testing every 5 years (preferred) or cytology alone every 3 years|
|>65 years||Do not screen women who have had adequate prior screening and who are not otherwise at high risk of cervical cancer||Do not screen women who have evidence of adequate prior screening and no history of CIN 2+ within the past 20 years. Do not resume screening for any reason, even if a woman reports having a new sexual partner.|
|After hysterectomy||Do not screen women who have undergone removal of the cervix and who have no history of CIN 2+ or cervical cancer||Do not screen for vaginal cancer in women who have undergone removal of the cervix and who have no history of CIN 2+. Evidence of adequate negative prior screening is not required. Do not resume screening for any reason, even if a woman reports having a new sexual partner.|
|HPV-vaccinated||Continue screening, according to age and clinical history|
|USPSTF = US Preventive Services Task Force; ACS/ASCCP/ASCP = American Cancer Society/American Society for Colposcopy and Cervical Pathology/American Society of Clinical Pathology|
What to do about discordant co-test results
When a woman has atypical cells of undetermined significance (ASC-US) on cytology in combination with a negative HPV test, she should be managed the same way as women with normal screening results, says Andrew M. Kaunitz, MD, professor and associate chairman of obstetrics and gynecology at the University of Florida–Jacksonville. Dr. Kaunitz serves on the OBG Management Board of Editors.
“I anticipate that the greatest confusion over the new guidelines will center on the management of women who are found to be negative by cytology but positive on an HPV test,” he says. The ACS/ASCCP/ASCP guidelines offer two options for this population:
- Option 1: Repeat co-testing in 1 year. Women who are still HPV positive at the time of repeat co-testing, or who have low-grade squamous intraepithelial lesions (LSIL) or more severe findings on cytology, should undergo colposcopy and be managed according to ASCCP guidelines.3 Women who test HPV-negative and who have normal cytology or atypical squamous cells of undetermined significance (ASC-US) at the time of repeat co-testing should be returned to regular screening.
- Option 2: Immediate testing for HPV 16 and 18. Women who test positive for either of these viral types should undergo colposcopy. Women who test negative for both of these viral types should be co-tested in 12 months and managed according to Option 1.