Current Pap Smear Screening Guidelines

Age to Start Screening

• The American College of Obstetricians and Gynecologists recommends that cervical cancer screening should begin at age 21, regardless of sexual activity history, due to the very low incidence of cervical cancer in younger women (only 0.1% of all cervical cancer cases occur in women under 21) 1, 2, 3
• Previous guidelines that recommended screening within 3 years of onset of sexual activity have been replaced with this fixed age recommendation, as the risk of cervical cancer is low in women under 21 4, 3

Screening Intervals

Women Aged 21-29

• The American College of Obstetricians and Gynecologists recommends screening every 3 years with conventional or liquid-based Pap tests for women aged 21-29 1, 5, 6

Women Aged 30-65

• The American College of Obstetricians and Gynecologists recommends a preferred approach of screening every 5 years with both HPV test and Pap test (co-testing) for women aged 30-65, as HPV co-testing allows for the longer 5-year interval due to its increased sensitivity 1, 5, 6
• An acceptable alternative is to screen every 3 years with Pap test alone for women aged 30-65 1, 5, 6

When to Stop Screening

• The American College of Obstetricians and Gynecologists recommends that women older than 65 years who have had ≥3 consecutive negative Pap tests or ≥2 consecutive negative HPV and Pap tests within the last 10 years, with the most recent test occurring within the last 5 years, should stop cervical cancer screening 1, 5, 6
• Women who have had a total hysterectomy (with removal of the cervix) for benign reasons and have no history of high-grade precancerous lesions should discontinue screening, according to the American College of Obstetricians and Gynecologists 1, 2, 6

Special Considerations

• Women with a history of cervical cancer or high-grade precancerous lesions require different follow-up protocols, as recommended by the American College of Obstetricians and Gynecologists 6
• Women who have had a hysterectomy but still have a cervical cuff present may still need screening, according to the American Academy of Family Physicians 7
• Women with HIV infection or who are otherwise immunocompromised may require more frequent screening, as recommended by the American College of Obstetricians and Gynecologists 2

Rationale for Current Guidelines

• Extended screening intervals (every 3 years vs. annually) reduce the potential harms of overtreatment while maintaining nearly the same level of cancer prevention, with screening effectiveness improving by less than 5% when comparing annual screening to every 3 years 7
• The risk of false positives and unnecessary procedures is reduced with less frequent screening, as recommended by the American College of Obstetricians and Gynecologists 6
• HPV co-testing allows for the longer 5-year interval in women 30-65 due to its increased sensitivity, according to the American College of Obstetricians and Gynecologists 5, 6

Cervical Cancer Screening Guidelines

Screening Intervals and Methods

• The National Comprehensive Cancer Network recommends screening every 3 years using conventional or liquid-based Pap cytology alone for women aged 21-29 years 8
• The National Comprehensive Cancer Network suggests that HPV co-testing is not recommended for women under 30 because HPV infections are extremely common and usually transient in younger women 8, 9
• The National Comprehensive Cancer Network recommends a preferred strategy of co-testing with both HPV DNA test and Pap cytology every 5 years for women aged 30-65 years 8
• The National Comprehensive Cancer Network states that HPV testing should never be used as a stand-alone screening test 8
• The Centers for Disease Control and Prevention recommends following CDC-specific guidelines for HIV-infected women rather than standard screening intervals 10
• The National Comprehensive Cancer Network recommends screening annually for women with DES exposure in utero due to increased risk of cervical and vaginal cancers 10
• The National Comprehensive Cancer Network suggests that pregnant women should follow the same screening intervals as non-pregnant women 8
• The National Comprehensive Cancer Network recommends conservative management for abnormal results in pregnant women, with treatment deferred until after delivery unless invasive cancer is detected 8
• The National Comprehensive Cancer Network states that HPV-vaccinated women should be screened using identical recommendations as unvaccinated women, as vaccination does not change screening protocols 8

Management of Abnormal Results

• The National Comprehensive Cancer Network recommends managing ASC-US with HPV triage testing, performing colposcopy only if HPV-positive 9
• The National Comprehensive Cancer Network suggests that if HPV testing is unavailable, repeating the Pap test in 1 year is acceptable for ASC-US management 9
• The National Comprehensive Cancer Network recommends that if HPV 16 or 18 is detected in HPV-positive women with normal cytology, proceeding directly to colposcopy is due to higher CIN3+ risk 9
• The National Comprehensive Cancer Network suggests that for other high-risk HPV types (non-16/18) in HPV-positive women with normal cytology, repeating co-testing in 1 year is recommended 11

Rationale for Current Guidelines

• The Ca-A Cancer Journal for Clinicians states that the Pap test has 70-80% sensitivity for high-grade CIN, and false negatives cannot be entirely eliminated even in optimized programs 12
• The Ca-A Cancer Journal for Clinicians reports that approximately 50% of cervical cancers in the US occur in women who have never been screened, making access to screening more important than screening frequency 12
• The National Comprehensive Cancer Network recommends that co-testing with HPV allows safe extension to 5-year intervals in women 30-65 due to the high negative predictive value of dual-negative results 8