The American College of Obstetricians and Gynecologists (ACOG) joins ASCCP and the Society of  Gynecologic Oncology (SGO) in endorsing the U.S. Preventive Services Task Force (USPSTF) cervical cancer screening recommendations 1 , which replace ACOG Practice Bulletin No. 168, Cervical Cancer Screening and Prevention, as well as the 2012 ASCCP cervical cancer screening guidelines 2 .

The adoption of the USPSTF guidelines expands the recommended options for cervical cancer screening in average-risk individuals aged 30 years and older to include screening every 5 years with primary high-risk human papillomavirus (hrHPV) testing. Primary hrHPV testing uses high-risk HPV testing alone (no cytology) with a test that is approved by the U.S. Food and Drug Administration (FDA) for stand-alone screening. Consistent with prior guidance, screening should begin at age 21 years, and screening recommendations remain unchanged for average-risk individuals aged 21–29 years and those who are older than 65 years Table 1. Management of abnormal cervical cancer screening results should follow current ASCCP guidelines 3 4 .

Screening Options

There are now three recommended options for cervical cancer screening in individuals aged 30–65 years: primary hrHPV testing every 5 years, cervical cytology alone every 3 years, or co-testing with a combination of cytology and hrHPV testing every 5 years Table 1. All three screening strategies are effective, and each provides a reasonable balance of benefits (disease detection) and potential harms (more frequent follow-up testing, invasive diagnostic procedures, and unnecessary treatment in patients with false-positive results) 1 . Data from clinical trial, cohort, and modeling studies demonstrate that among average-risk patients aged 25–65 years, primary hrHPV testing and co-testing detect more cases of high-grade cervical intraepithelial neoplasia than cytology alone, but hrHPV-based tests are associated with an increased risk of colposcopies and false-positive results 1 6 7 .

Currently, there are two hrHPV tests approved by the FDA for primary screening in individuals aged 25 years and older. Although cytology alone is the recommended screening method for individuals aged 21–29 years, ACOG, ASCCP, and SGO advise that primary hrHPV testing every 5 years can be considered for average-risk patients aged 25–29 years based on its FDA-approved age for use and primary hrHPV testing’s demonstrated efficacy in individuals aged 25 years and older.

Future Directions

Primary Human Papillomavirus Testing

In 2020, the American Cancer Society (ACS) updated its cervical cancer screening guidelines to recommend primary hrHPV testing as the preferred screening option for average-risk individuals aged 25–65 years 5 . Despite the demonstrated efficacy and efficiency of primary hrHPV testing, uptake of this screening method has been slow because of the limited availability of FDA-approved tests and the significant laboratory infrastructure changes required to switch to this screening platform. Limited access to primary hrHPV testing is of particular concern in rural and under-resourced communities and among communities of color, which have disproportionately high rates of cervical cancer incidence, morbidity, and mortality 8 9 10 . Although cytology-based screening options are still included in the ACS guidelines in acknowledgement of these barriers to widespread access and implementation, ACS strongly advocates phasing out cytology-based screening options in the near future 5 . Until primary hrHPV testing is widely available and accessible, cytology-based screening methods should remain options in cervical cancer screening guidelines. Although HPV self-sampling has the potential to greatly improve access to cervical cancer screening, and there is an increasing body of evidence to support its efficacy and utility, it is still investigational in the United States 5 11 .

Age to Initiate Screening

The introduction of vaccines targeting the most common cancer-causing HPV genotypes has advanced the primary prevention of cervical cancer. As vaccination coverage increases and more vaccinated individuals reach the age to initiate cervical cancer screening, HPV prevalence is expected to continue to decline 12 13 . This could prompt future changes to screening guidelines, such as raising the screening initiation age to 25 years, as is recommended in the recently updated ACS guidelines 5 . Although HPV vaccination rates continue to improve, nationwide HPV vaccination coverage remains below target levels, and there are racial, ethnic, socioeconomic, and geographic disparities in vaccination rates 13 14 15 16 . Cervical cancer screening rates also are below expectations, with the lowest levels reported among individuals younger than 30 years 17 18 . Raising the screening start age to 25 years could increase the already high rate of underscreening among individuals aged 25–29 years and exacerbate existing health inequities in cervical cancer screening, incidence, morbidity, and mortality 10 17 18 19 . Given these significant health equity concerns and the current suboptimal rates of cervical cancer screening and HPV vaccination, ACOG, ASCCP, and SGO continue to recommend initiation of cervical cancer screening at age 21 years.

Conclusion

Although cervical cancer screening options have expanded, cervical cytology, primary hrHPV testing, and co-testing are all effective in detecting cervical precancerous lesions and cancer. The specific strategy selected is less important than consistent adherence to routine screening guidelines. Inadequate cervical cancer screening remains a significant problem in the United States, with persistent health inequities across the entire spectrum of cervical cancer care 10 17 19 . Given these concerns, ACOG, ASCCP, and SGO continue to recommend cervical cancer screening initiation at age 21 years. Human papillomavirus vaccination is another important prevention strategy against cervical cancer, and obstetrician–gynecologists and other health care professionals should continue to strongly recommend HPV vaccination to eligible patients and stress the benefits and safety of the HPV vaccine 20 . Cervical cancer prevention, screening, and treatment are critical components of comprehensive reproductive health care.

Please contact [email protected] with any questions.