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Updated Cervical Cancer Screening Guidelines

  • Practice Advisory PA
  • April 2021

(Replaces Practice Bulletin No. 168, October 2016)

ASCCP and the Society of Gynecologic Oncology endorse this Practice Advisory.


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 .

Updated Cervical Cancer Screening Guidelines

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 clinical@acog.org with any questions.


References

  1. Curry SJ, Krist AH, Owens DK, Barry MJ, Caughey AB, Davidson KW, et al. Screening for cervical cancer: U.S. Preventive Services Task Force recommendation statement. U.S. Preventive Services Task Force. JAMA 2018;320:674–86. Available at: href="https://jamanetwork.com/journals/jama/fullarticle/2697704. Retrieved April 12, 2021.
    Article Locations:
    Article LocationArticle LocationArticle Location
  2. Saslow D, Solomon D, Lawson HW, Killackey M, Kulasingam SL, Cain J, 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. Am J Clin Pathol 2012;137:516–42. Available at: https://academic.oup.com/ajcp/article/137/4/516/1760450. Retrieved April 12, 2021.
    Article Locations:
    Article Location
  3. American College of Obstetricians and Gynecologists. Updated guidelines for management of cervical cancer screening abnormalities. Practice Advisory. Washington, DC: American College of Obstetricians and Gynecologists; 2020. Available at: https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/2020/10/updated-guidelines-for-management-of-cervical-cancer-screening-abnormalities. Retrieved April 12, 2021.
    Article Locations:
    Article Location
  4. Perkins RB, Guido RS, Castle PE, Chelmow D, Einstein MH, Garcia F, et al. 2019 ASCCP risk-based management consensus guidelines for abnormal cervical cancer screening tests and cancer precursors. 2019 ASCCP Risk-Based Management Consensus Guidelines Committee [published erratum appears in J Low Genit Tract Dis 2020;24:427]. J Low Genit Tract Dis 2020;24:102–31. Available at: https://journals.lww.com/jlgtd/Fulltext/2020/04000/2019_ASCCP_Risk_Based_Management_Consensus.3.aspx. Retrieved April 12, 2021.
    Article Locations:
    Article Location
  5. Fontham ET, Wolf AM, Church TR, Etzioni R, Flowers CR, Herzig A, et al. Cervical cancer screening for individuals at average risk: 2020 guideline update from the American Cancer Society. CA Cancer J Clin 2020;70:321–46. Available at: https://acsjournals.onlinelibrary.wiley.com/doi/10.3322/caac.21628. Retrieved April 12, 2021.
    Article Locations:>
    Article LocationArticle LocationArticle LocationArticle Location
  6. Kim JJ, Burger EA, Regan C, Sy S. Screening for cervical cancer in primary care: a decision analysis for the US Preventive Services Task Force. JAMA 2018;320:706–14. Available at: : https://jamanetwork.com/journals/jama/fullarticle/2697702. Retrieved April 12, 2021.
    Article Locations:
    Article Location
  7. Melnikow J, Henderson JT, Burda BU, Senger CA, Durbin S, Weyrich MS. Screening for cervical cancer with high-risk human papillomavirus testing: updated evidence report and systematic review for the US Preventive Services Task Force. JAMA 2018;320:687–705. Available at: https://jamanetwork.com/journals/jama/fullarticle/2697703. Retrieved April 12, 2021.
    Article Locations:
    Article Location
  8. Centers for Disease Control and Prevention. HPV-associated cervical cancer rates by race and ethnicity. Available at: https://www.cdc.gov/cancer/hpv/statistics/cervical.htm. Retrieved April 12, 2021.
    Article Locations:
    Article Location
  9. Beavis AL, Gravitt PE, Rositch AF. Hysterectomy-corrected cervical cancer mortality rates reveal a larger racial disparity in the United States. Cancer 2017;123:1044–50. Available at: https://acsjournals.onlinelibrary.wiley.com/doi/10.1002/cncr.30507. Retrieved April 12, 2021.
    Article Locations:
    Article Location
  10. Buskwofie A, David-West G, Clare CA. A review of cervical cancer: incidence and disparities. J Natl Med Assoc 2020;112:229–32. Available at: https://www.sciencedirect.com/science/article/abs/pii/S0027968420300432. Retrieved April 12, 2021.
    Article Locations:
    Article LocationArticle LocationArticle Location
  11. Yeh PT, Kennedy CE, de Vuyst H, Narasimhan M. Self-sampling for human papillomavirus (HPV) testing: a systematic review and meta-analysis. BMJ Glob Health 2019;4:e001351. Available at: https://gh.bmj.com/content/4/3/e001351.long. Retrieved April 12, 2021.
    Article Locations:
    Article Location
  12. Benard VB, Castle PE, Jenison SA, Hunt WC, Kim JJ, Cuzick J, et al. Population-based incidence rates of cervical intraepithelial neoplasia in the human papillomavirus vaccine era. New Mexico HPV Pap Registry Steering Committee. JAMA Oncol 2017;3:833–7. Available at: https://jamanetwork.com/journals/jamaoncology/fullarticle/2554749. Retrieved April 12, 2021.
    Article Locations:
    Article Location
  13. Rosenblum HG, Lewis RM, Gargano JW, Querec TD, Unger ER, Markowitz LE. Declines in prevalence of human papillomavirus vaccine-type infection among females after introduction of vaccine—United States, 2003-2018. MMWR Morb Mortal Wkly Rep 2021;70:415–20. Available at: https://www.cdc.gov/mmwr/volumes/70/wr/mm7012a2.htm. Retrieved April 12, 2021.
    Article Locations:
    Article LocationArticle Location
  14. Elam-Evans LD, Yankey D, Singleton JA, Sterrett N, Markowitz LE, Williams CL, et al. National, regional, state, and selected local area vaccination coverage among adolescents aged 13-17 years - United States, 2019. MMWR Morb Mortal Wkly Rep 2020;69:1109–16. Available at: https://www.cdc.gov/mmwr/volumes/69/wr/mm6933a1.htm. Retrieved April 12, 2021.
    Article Locations:
    Article Location
  15. U.S. Department of Health and Human Services. Increase the proportion of adolescents who get recommended doses of the HPV vaccine—IID 08. Healthy People 2030. Available at: https://health.gov/healthypeople/objectives-and-data/browse-objectives/vaccination/increase-proportion-adolescents-who-get-recommended-doses-hpv-vaccine-iid-08. Retrieved April 12, 2021.
    Article Locations:
    Article Location
  16. Agénor M, Pérez AE, Peitzmeier SM, Borrero S. Racial/ethnic disparities in human papillomavirus vaccination initiation and completion among U.S. women in the post-Affordable Care Act era. Ethn Health 2020;25:393–407. Available at: https://www.tandfonline.com/doi/abs/10.1080/13557858.2018.1427703. Retrieved April 12, 2021.
    Article Locations:
    Article Location
  17. MacLaughlin KL, Jacobson RM, Radecki Breitkopf C, Wilson PM, Jacobson DJ, Fan C, et al. Trends over time in Pap and Pap-HPV cotesting for cervical cancer screening. J Womens Health (Larchmt) 2019;28:244–9. Available at: https://www.liebertpub.com/doi/10.1089/jwh.2018.7380. Retrieved April 12, 2021.
    Article Locations:
    Article LocationArticle LocationArticle Location
  18. Sabatino SA, Thompson TD, White MC, Shapiro JA, de Moor J, Doria-Rose VP, et al. Cancer screening test receipt—United States, 2018. MMWR Morb Mortal Wkly Rep 2021;70:29–35. Available at: https://www.cdc.gov/mmwr/volumes/70/wr/mm7002a1.htm. Retrieved April 14, 2021.
    Article Locations:
    Article LocationArticle Location
  19. Johnson NL, Head KJ, Scott SF, Zimet GD. Persistent disparities in cervical cancer screening uptake: knowledge and sociodemographic determinants of Papanicolaou and human papillomavirus testing among women in the United States. Public Health Rep 2020;135:483–91. Available at: https://journals.sagepub.com/doi/10.1177/0033354920925094.
    Article Locations:
    Article LocationArticle Location
  20. Human papillomavirus vaccination. ACOG Committee Opinion No. 809. American College of Obstetricians and Gynecologists Obstet Gynecol 2020;136:e15–21. Available at: https://journals.lww.com/greenjournal/Fulltext/2020/08000/Human_Papillomavirus_Vaccination__ACOG_Committee.48.aspx. Retrieved April 12, 2021.
    Article Locations:
    Article Location

A Practice Advisory is a brief, focused statement issued to communicate a change in ACOG guidance or information on an emergent clinical issue (eg, clinical study, scientific report, draft regulation). A Practice Advisory constitutes ACOG clinical guidance and is issued only on-line for Fellows but may also be used by patients and the media. Practice Advisories are reviewed periodically for reaffirmation, revision, withdrawal or incorporation into other ACOG guidelines.

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