Changes Ahead for Cervical Cancer Screening Recommendations

Now open for public comment, the US Preventive Task Force (USPTF) has drafted a recommendation statement that updates their 2003 recommendations for screening for cervical cancer. Based on research examining benefits and risks associated with screening across various groups of women, the new draft recommendations note which women most benefit from cervical cancer screening and can be found online at http://www.uspreventiveservicestaskforce.org/draftrec4.htm.

Specifically, the USPTF recommends that women between the ages of 21 and 65 who have a cervix and engage in sexual intercourse receive screening for cervical cancer with cytology (Papanicolaou [Pap] smear) every 3 years. The statement authors emphasize that this recommendation is applicable only for women who do not have increased risk for cervical cancer; in other words, women who have been diagnosed with a high-grade precancerous cervical lesion or cervical cancer, women with in utero diethylstilbestrol exposure, or those who are immunocompromised (eg, HIV positive) should be screened more regularly.

Regardless of sexual history, the USPTF does not recommend cervical cancer screening in women younger than 21 years of age. (This is in direct contraction with the 2003 recommendations, which stated that screening should begin at age 21 or onset of sexual activity, whichever comes first.) Similarly, the USPTF now does not recommend screening for women who are older than 65 years of age if they have received adequate screening in the past and are not otherwise at high risk for the disease. For women younger than 30 years old, the USPTF added that they recommend against screening for cervical cancer using human papillomavirus (HPV) testing, alone or in combination with cytology.

Based on research, the USPTF determined that screening for women under the age of 21 failed to provide a reduction in cervical cancer incidence and mortality in comparison to initiation of screening compared with beginning screening at age 21 years. Little benefits from screening were seen for women older than 65; the USPTF also noted no benefits for screening among women who had hysterectomies for benign disease. Furthermore, the USPTF found that HPV testing conferred little to no incremental reduction in cervical cancer incidence and mortality compared with cytology alone, with moderate certainty that the harms outweigh the benefits in women under the age of 30 and insufficient evidence to completely determine the harms versus benefits for women over the age of 30.

The USPTF also acknowledged the overall harms and risks associated with cervical cancer screening, including more frequent testing and invasive diagnostic procedures, pain, increased bleeding, and increased mild psychological harms (ie, short-term increases in anxiety and distress). The USPTF found moderate harms associated with screening in women under 21 years of age and women between ages 21 and 65 years of age. They found adequate evidence pointing to small harms associated with screening women over the age of 65 and some harm associated with screening women after total hysterectomy for benign disease.

In addition, the USPTF now recognize that many precancerous cervical lesions will regress and others are indolent and slow-growing so as not to become clinically important over a woman’s lifetime. They added, “Identification and treatment of these lesions constitutes overdiagnosis, with unnecessary potential for treatment-related harms.” The USPTF took these concerns into consideration while drafting their new recommendations.

The new guidelines also discuss cytology methods, noting that research has failed to detect any important clinical differences between liquid-based cytology and conventional cytology. They draft guidelines state, “The USPSTF realizes that the choice of cytology method may not be under the direct control of the clinician and considers cytology screening in appropriate age groups at appropriate intervals to be of substantial net benefit, regardless of method.”

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