Cervical Cancer Screening Guidelines

Introduction to Cervical Cancer Screening

• Cervical cancer screening has decreased cervical cancer incidence and mortality by over 70% in the United States, highlighting the effectiveness of screening 1
• The average time for a high-grade precancerous lesion to progress to cervical cancer is approximately 10 years, allowing ample time for detection, as reported by the American College of Physicians 2

Screening Recommendations

• The American Cancer Society recommends starting screening at age 25 instead of 21, with primary HPV testing every 5 years as the preferred screening method 3
• Cytology alone every 3 years is an acceptable alternative screening method, as recommended by the American College of Physicians and the American Cancer Society 4, 2
• Co-testing (HPV + cytology) every 5 years is an acceptable alternative screening method, with a strength of evidence rated as moderate, as recommended by the National Comprehensive Cancer Network 5
• The following table summarizes the screening recommendations by age group:

6, 7, 5, 3

• HPV testing is NOT recommended in women under 30 due to high prevalence of transient HPV infections in younger women, according to the American College of Physicians and the American Cancer Society 2, 3
• Annual screening is NOT recommended due to increased false positives with minimal benefit, as reported by the American College of Physicians and the American Cancer Society 2, 8

Discontinuing Screening

• Discontinue screening if there is no history of cervical intraepithelial neoplasia grade 2 (CIN2) or more severe diagnosis in the past 25 years, as recommended by the American Cancer Society 3
• Discontinue screening if there is documented adequate negative prior screening in the past 10 years, defined as 2 consecutive negative HPV tests, 2 negative cotests, or 3 negative cytology tests within the past 10 years, with the most recent test occurring within the recommended interval, as recommended by the American Cancer Society 3
• Women over 65 without adequate prior screening should continue screening until criteria for cessation are met, as recommended by the American Cancer Society 3
• Women who have had a total hysterectomy with removal of the cervix and no history of CIN2+ in the past 25 years or cervical cancer ever do not need screening, as recommended by the American Cancer Society 3
• Women who have had a subtotal (supracervical) hysterectomy should continue routine screening, according to the American Cancer Society 9

Special Populations

• Women with HIV infection, compromised immune system, in utero exposure to diethylstilbestrol, or previous treatment of high-grade precancerous lesion or cervical cancer should receive individualized follow-up, as recommended by the American Academy of Family Physicians 10
• Pregnant women with LSIL should undergo colposcopy, but deferring until 6 weeks after childbirth is also an option, as recommended by the National Comprehensive Cancer Network 5
• Women attending STD clinics have precursor lesions for cervical cancer about five times more frequently than women attending family planning clinics, according to the Centers for Disease Control and Prevention (CDC) 11, 12
• Ethnic minorities, particularly Hispanic women and Vietnamese women, are at higher risk, as noted by the American Geriatrics Society 13
• Women with low socioeconomic status, less education, and limited financial resources are at higher risk, as reported by the American Geriatrics Society 13
• Women with risk factors such as multiple sexual partners, history of HPV or HIV infection, history of cervical dysplasia, smoking, and immunosuppression are at higher risk, according to the American Geriatrics Society 13

Barriers to Screening

• Personal factors such as fear, embarrassment, anxiety, inadequate knowledge, lack of time, and misperception of risk can prevent women from getting screened, according to the American Cancer Society 14
• Cultural factors such as provider gender concerns, lack of acculturation, and religious beliefs can prevent women from getting screened, as noted by the American Cancer Society 14
• Systemic factors such as lack of insurance, poverty, legal migratory status, geographic isolation, and lack of providers can prevent women from getting screened, according to the American Cancer Society 14

Benefits and Harms of Screening

• Benefits of screening include a substantial reduction in cervical cancer incidence and mortality, while harms include unnecessary procedures and treatments due to detection of transient HPV infections and lesions that would likely regress spontaneously, according to the American Cancer Society 8
• Screening every 3 years is associated with approximately 760 colposcopies per 1000 women over a lifetime, while annual screening nearly triples this number to about 2000 colposcopies per 1000 women, as reported by the American Cancer Society 8
• HPV vaccination status does NOT change screening recommendations, as recommended by the American Cancer Society 8, 9, 3, 5