Cervical Cancer Screening

Cervical cancer incidence and mortality have decreased significantly since the 1960s due to widespread screening. Today, most cases of cervical cancer occur in women who have not been adequately screened. The United States Preventive Services Task Force (USPSTF) recently published an updated draft recommendation that found convincing evidence that screening with cervical cytology or testing for high-risk human papillomavirus types can detect high-grade precancerous cervical lesions and cervical cancer.

USPSTF found convincing evidence that screening women ages 21 to 65 years substantially reduces cervical cancer incidence and mortality and recommends screening for cervical cancer every 3 years with cervical cytology alone in women ages 21 to 29 years. USPSTF recommends either screening every 3 years with cervical cytology alone or every 5 years with high-risk human papillomavirus (hrHPV) testing alone in women ages 30 to 65 years.

Both screening with cytology alone and hrHPV testing alone offer a reasonable balance between benefits and harms for women ages 30 to 65 years. Randomized control trials suggest that screening with cytology alone is slightly less sensitive for detecting CIN2 and CIN3 than screening with hrHPV testing alone, whereas screening with hrHPV testing alone detects more cases of CIN2 and CIN3 but results in more diagnostic colposcopies for each case detected. Screening every 5 years with hrHPV testing alone in women ages 30 to 65 years results in a slightly lower mortality rate than screening every 3 years with cytology alone but much higher rates of follow-up testing and colposcopy.

Screening more frequently than every 3 years with cytology alone confers little additional benefit, with large increases in harms. Treatment of lesions that would otherwise resolve on their own is harmful because it can lead to procedures with unwanted adverse effects, including the potential for cervical incompetence and preterm labor during pregnancy. Current evidence suggests that a 5 year screening interval offers the best balance of benefits and harms. Screening more frequently than every 5 years with hrHPV testing alone does not substantially improve benefit but significantly increases the number of screening tests and colposcopies.

USPSTF found adequate evidence that screening women older than age 65 years who have had adequate prior screening and are not otherwise at high risk for cervical cancer provides little benefit. Joint guidelines from the American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology define adequate prior screening as three consecutive negative cytology results or two consecutive negative co-testing results within 10 years before stopping screening, with the most recent test occurring within 5 years. USPSTF recommends against screening for cervical cancer in women older than age 65 years who meet these criteria and are not otherwise at high risk for cervical cancer.

Screening may be clinically indicated in older women with an inadequate or unknown screening history. Recent data suggest that one quarter of women ages 45 to 64 years have not been screened for cervical cancer in the preceding 3 years.  Screening should also be considered for women with a history of high-grade precancerous lesions or cervical cancer, in utero exposure to diethylstilbestrol, or a compromised immune system.

Cervical cancer is extremely rare before age 21 years.Because of the slow progression of cervical carcinogenesis and the high likelihood of disease regression in this age group, evidence suggests that screening earlier than age 21 years, regardless of sexual history, would lead to more harm than benefit. USPSTF recommends against screening for cervical cancer in women younger than age 21 years.

USPSTF found convincing evidence that screening women who have had a hysterectomy with removal of the cervix for indications other than a high-grade precancerous lesion or cervical cancer provides no benefit. USPSTF recommends against screening for cervical cancer in this population of women.

https://www.uspreventiveservicestaskforce.org/Page/Document/draft-recommendation-statement/cervical-cancer-screening2

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