Good-bye Annual Exams: New Cervical Cancer Screening Guidelines Focus on Patient's Age

The days of annual screening for cervical cancer are over. The new screening guidelines for the prevention and early detection of cervical cancer are now largely based on the patient’s age and, for the first time, testing for human papillomavirus (HPV) DNA has been incorporated into the screening process. Two new guidelines were released by separate groups, but the recommendations essentially are consistent. One set of guidelines was cosponsored by the American Cancer Society, the American Society for Colposcopy and Cervical Pathology, and the American Society for Clinical Pathology,1 and the other set was released by the U.S. Preventive Services Task Force.2
 
The age-based guidelines recommend that cervical cancer screening should begin at age 21 years. Women younger than 21 years should not be screened for any reason. Women aged 21 to 29 years should receive high-quality screening with cytology alone (Papanicolaou testing) every 3 years. HPV testing should not be used for cervical cancer screening in women in this age group.
 
The preferred method of cervical cancer screening in women aged 30 to 65 years is cytology and HPV testing every 5 years. Screening with cytology alone every 3 years is also acceptable. Evidence-based data show that nearly 100% of cases of cervical cancer also test positive for HPV.3 The benefit of adding HPV testing is that it augments the detection of adenocarcinoma of the cervix and its precursors.1 If the results of the Pap test are positive but the results of the HPV test are negative, no additional action is required, and routine screening per the age-specific guidelines should continue. However, if the Pap test results are negative but the HPV test results are positive, there are 2 options for follow-up testing.
 
The first option is to repeat cotesting in 12 months. If the result of either the Pap test or the HPV test is positive, a colposcopy should be performed. If the results of both tests are negative, age-appropriate routine screening should be resumed.
 
The second option is immediate HPV genotype-specific testing for HPV16 alone or HPV16/18. If women test positive for either genotype, a colposcopy is recommended. If women test negative for HPV16 or HPV 16/18, they should receive cotesting in 12 months, and management of the results should be based on those described in option 1.
 
Cervical cancer screening with any modality is not required in women older than 65 years who have had adequate negative prior screening and no history of cervical intraepitheal neoplasia grade 2 (CIN2) or higher within the past 20 years. Once screening is stopped, it should not be resumed for any reason. (Adequate negative prior screening is 3 consecutive negative cytology results or 2 consecutive negative cotest results within 10 years of discontinuing screening, with the most recent test occurring within 5 years.1)
 
Routine screening should continue for at least 20 years as follow-up after an episode of CIN2, CIN3, or adenocarcinoma in situ even if the 20-year follow-up extends screening past age 65 years. If a woman at any age with no history of CIN2+ has a hysterectomy with removal of the cervix, screening is no longer required and should not be resumed for any reason.
 
These new requirements are probably welcome news to most women. The benefit for women’s health clinicians is that more time can be spent during the examination on discussions about the importance of breast self-examinations, healthy diet and exercise, risky behaviors, family planning, menopausal transition, osteoporosis prevention, referral for mammography, colorectal cancer screening, and evaluation of continence and pelvic floor functioning.4

References:

1. Saslow D, Solomon D, Lawson HW, et al. American Cancer Society, American Society for Colposcopy and Cervical Pathology and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer. Available at: http://onlinelibrary.wiley.com/doi/10.3322/caac.21139/pdf. Accessed March 15, 2011.2. U.S. Preventive Services Task Force. Screening for cervical cancer. Available at: http://www.uspreventiveservicestaskforce.org/uspstf/uspscerv.htm. Accessed March 15, 2012.3. Walboomers JM, Jacobs MV, Manos MM, et al. Human papillomavirus is a necessary cause of invasive cervical cancer worldwide. J Pathol. 1999;189:12-19.4. The American Congress of Obstetricians and Gynecologists Web site. New cervical cancer screening recommendations from the U.S. Preventive Services Task Force and the American Cancer Society/American Society for Colposcopy and Cervical Pathology/American Society for Clinical Pathology. Available at: http://www.acog.org/About_ACOG/Announcements/New_Cervical_Cancer_Screening_Recommendations. Accessed March 15, 2011.