Updated guidance on cervical cancer screening for average-risk women
US Preventive Services Task Force; Curry SJ, Frist AH, Owens DK, et al. Screening for cervical cancer: US Preventive Services Task Force recommendation statement. JAMA. 2018;320:674-686.
Fontham ET, Wolf AM, Church TR, et al. Cervical cancer screening for individuals at average risk: 2020 guideline update from the American Cancer Society. CA Cancer J Clin. 2020;70:321-346.
As more is understood about the natural history of HPV and its role in the development of cervical cancer and its precursors, refinements and updates have been made to our approaches for screening people at risk. There is much evidence and experience available on recommending Pap testing and HPV cotesting (testing for HPV along with cytology even if the cytology result is normal) among women aged 30 to 65 years, as that has been an option since the 2012 guidelines were published.15
We know also that HPV testing is more sensitive for detecting cervical intraepithelial neoplasia grade 3 (CIN 3) or greater at 5 years and that a negative HPV test is more reassuring than a negative Pap test.16
Primary HPV tests
HPV tests can be used in conjunction with cytology (that is, cotesting) or as a primary screening that if positive, can reflex either to cytology or to testing for the most oncogenic subtypes. Currently, only 2 FDA-approved primary screening tests are available, the cobas 4800 HPV test system (Roche Diagnostics) and the BD Onclarity HPV assay (Becton, Dickinson and Company).17 Most laboratories in the United States do not yet have the technology for primary testing, and so instead they offer one of the remaining tests (Hybrid Capture 2 [Qiagen] and Cervista and Aptima [Hologic]), which do not necessarily have the same positive and negative predictive value as the tests specifically approved for primary testing. Thus, many clinicians and patients do not yet have access to primary HPV testing.
In addition, due to slow uptake of the HPV vaccine in many parts of the United States,13 there is concern that adding HPV testing in nonvaccinated women under age 30 would result in a surge of unnecessary colposcopy procedures for women with transient infections. Thus, several large expert organizations differ in opinion regarding screening among certain populations and by which test.
Screening guidance from national organizations
The US Preventive Services Task Force (USPSTF) and the American Cancer Society (ACS) differ in their recommendations for screening women in their 20s for cervical cancer.18,19 The USPSTF guidelines, which were published first, focus not only on the best test but also on what is feasible and likely to benefit public health, given our current testing capacity and vaccine coverage. The USPSTF recommends starting screening at age 21 with cytology and, if all results are normal, continuing every 3 years until age 30, at which point they recommend cytology every 3 years or cotesting every 5 years or primary HPV testing alone every 5 years (if all results are normal in each case).
In contrast, the ACS published "aspirational” guidelines, with the best evidence-based recommendations, but they acknowledge that due to availability of different testing options, some patients still need to be screened with existing modalities. The ACS recommends the onset of screening at age 25 with either primary HPV testing every 5 years (preferred) or cotesting every 5 years or cytology every 3 years.
Both the USPSTF and ACS guidelines state that if using cytology alone, the screening frequency should be every 3 years, and if using an HPV-based test, the screening interval (if all results are normal) can be extended to every 5 years.
WHAT THIS EVIDENCE MEANS FOR PRACTICE
Notably, the newest guidelines for cervical cancer screening essentially limit “screening” to low-risk women who are immunocompetent and who have never had an abnormal result, specifically high-grade dysplasia (that is, CIN 2 or CIN 3). Guidelines for higher-risk groups, including the immunosuppressed, and surveillance among women with prior abnormal results can be accessed (as can all the US guidelines) at the American Society for Colposcopy and Cervical Pathology (ASCCP) website (http://www.asccp.org/).
Notably, the newest guidelines for cervical cancer screening essentially limit “screening” to low-risk women who are immunocompetent and who have never had an abnormal result, specifically high-grade dysplasia (that is, CIN 2 or CIN 3). Guidelines for higher-risk groups, including the immunosuppressed, and surveillance among women with prior abnormal results can be accessed (as can all the US guidelines) at the American Society for Colposcopy and Cervical Pathology (ASCCP) website (http://www.asccp.org/).
Continue to: New ASCCP management guidelines focus on individualized risk assessment...