Almost all cervical cancers are caused by the human papillomavirus, genotypes 16 and 18 being the most high risk types.
The 2018 USPSTF cervical screening recommendations advise screening average risk women ages 30-65 years of age every 3 years with cervical cytology alone, every 5 years with high risk human papillomavirus (hrHPV) testing alone, or every 5 years with co-testing (cytology and hrHPV testing).
The American Cancer Society (ACS) recommends cervical cancer screenings from 25 to 65 years of age with primary HPV testing, repeated every 5 years. If primary HPV testing is not available, co-testing every 5 years or cytology alone every 3 year is recommended as an alternative.
Clinicians are responsible for increasing adherence to screenings through appointment reminders, performing testing during other appointments, and educating patients on screening intervals.
Adherence to HPV immunization schedules are important in the prevention of cervical cancer, although the role has not been fully established.
Widespread cervical cancer screening practices began in earnest in the United States in the 1950’s. Since then, mortality has markedly decreased. In 1975, 5.55 per 100,000 women died from cervical cancer; while in 2000, that rate dropped to 2.8 deaths per 100,000 women (American College of Obstetricians and Gynecologists [ACOG], 2016; Curry et al., 2018). New research, advancement in treatments, vaccine prevention strategies, and health promotion guidelines continue to evolve, coupled with cervical cancer screening process improvements, have continued the steady decline in mortality to only 2.3 deaths per 100,000 women in 2015 (Curry et al., 2018).
Currently, cervical cancer screening tests include Papanicolaou test (cytology) or the HPV testing, either alone or in combination. The goals of screening are to detect treatable abnormalities and precancers as well as detect early stages of invasive cervical cancer, thereby initiating early intervention and improving outcomes (Fontham et al., 2020).
Who Is At Risk?
There are different screening and surveillance guidelines based on a risk stratification. Average risk individuals are women without symptoms, immunocompetent, and with a negative prior screening history (Feldman et al., 2020). Even though sexual intercourse increases the risk of potential exposure to high risk human papillomavirus (hrHPV), the screening recommendations consider all average risk individuals independent of sexual history (Curry et al., 2018).
Women with HIV infection, are immunocompromised, have exposure to diethylstilbestrol, or a medical history of cervical cancer or high-grade precancerous lesions are at a higher risk and require individualized follow up (Curry et al., 2018).
Updates to Recommendations by Expert Groups
Multiple expert groups produce recommendations regarding cervical cancer screenings. Each set of screening guidelines similarly juggle benefits of early detection of disease and reduction in incidence and mortality from cervical cancer, with consideration for potential false positives, unnecessary procedures, and harms from invasive, intimate procedures (Feldman et al., 2020). Likewise, cost, ease of testing, and adherence are considerations.
The 2018 United States Preventive Screening Task Force (USPSTF) recommendations included a major update to screening guidelines for women 30 to 65 years of age. The panel concluded that screening every 3 years with cervical cytology alone, every 5 years with high risk human papillomavirus (hrHPV) testing alone, or every 5 years with co-testing (cytology and hrHPV) showed similar effectiveness in detection of cervical cancer (Curry et al., 2018). Research did not support screening intervals less than 5 years for primary HPV testing and co-testing due to the potential for unnecessary procedures (Sawaya et al., 2015). The USPSTF recommendations advise cervical cancer screening for women ages 21 to 29 every 3 years with cytology alone; against screening women under age 21; and against screening women older than 65 with adequate prior screening and who are not at high risk for cervical cancer, and women who have undergone a complete hysterectomy (including the removal of the cervix) with no past medical history of high-grade precancerous lesions or cervical cancer (Curry et al., 2018).
The American College of Physicians’ recommendations were last updated in 2016 and recommend screening women starting at age 21 with cytology alone, repeated every 3 years. At age 30 years testing should move to every 5 years and include HPV testing and cytology testing (also called co-testing). At age 65, screenings should stop after 3 consecutive negative cytology results or 2 consecutive negative cytology and HPV testing within the last 10 years (Sawaya et al., 2015).
The American Cancer Society (ACS) recommends initiation of screening at age 25 with primary HPV testing every 5 years. This is continued through age 65. However, if HPV testing is not available, individuals of ages 25 to 65 can be screened with co-testing every 5 years or cytology alone every 3 years. Screenings should stop at age 65 if the patient does not have a history of cervical malignancy within the past 25 years and has adequate negative screening for the past 10 years. The change to initiate screenings at 25 years of age, as opposed to 21, was likely due to low rates of cervical cancer in those ages 20 to 24 as well as multiple observational studies demonstrating spontaneous resolution of HPV infection in this age group (Feldman et al., 2020).
Role of Human Papillomavirus in Cervical Cancer Screening
HPV is responsible for the majority of cases of cervical cancer. Of the over 150 HPV genotypes, 13 genotypes have been shown to cause cervical cancer (American College of Obstetrics & Gynecology [ACOG], 2020). Genotypes 16 and 18, the ‘high risk’ genotypes, are associated with 66% to 70% of cervical cancers and are included in screening tests (Wuerthner & Avila-Wallace, 2016). Approximately 90% of HPV infections clear within a few years, but persistent HPV infections produce a higher risk for cervical intraepithelial neoplasia, making early identification and surveillance through screenings important for good outcomes (Sawaya et al., 2015).
Primary HPV testing alone has recently emerged as a capable and effective screening test to prevent cervical cancer. In fact, primary HPV screening in women >25 years was found to be significantly more sensitive for the detection of CIN3+ than cytology alone (Fontham et al., 2020). As of 2017, primary HPV testing was limited to a few US laboratories and access to testing may be lacking (Feldman et al., 2020). Another concern, the number of false positives is higher in primary hrHPV testing than cytology alone, especially in women in their 20’s, potentially causing an increase in unnecessary procedures, like colposcopies (Feldman et al., 2020).
Improving Prevention Methods
Over 50% of women diagnosed with cervical cancers were not screened appropriately (Feldman et al., 2020). Given the efficacy of screenings, clinicians can improve adherence by actions such as developing a reminder system to actively notify patients of screening intervals as well as reaching out to schedule an appointment. Clinicians can look for opportunities to perform cervical cancer screening when patients are present for other complaints. Urgent care and emergency rooms are potential places to screen patients otherwise unlikely to comply with interval schedules.
On the other hand, practitioners should adhere to the screening schedule as recommended by expert groups. In average risk patients, the “yearly pap” is no more, relieving patients of an unnecessary anxiety-provoking procedure, potentially more invasive subsequent testing and the cost that burdens both individuals and healthcare at large(Sawaya et al., 2015).
One important prevention tool that precedes cervical cancer screening is the HPV vaccine. The series targets boys and girls ages 11 to 12 years (but may be given as early as 9 years of age) and consists of 2 or 3 shots depending on age of initiation. The HPV immunization available in the U.S. covers 9 HPV genotypes, with a greater than 99% efficacy when administered prior to HPV exposure (ACOG), 2020). Increasing vaccine rates to 80% of eligible recipients, an estimated additional 53,000 cases of cervical cancer could be prevented (ACOG), 2020). The effect of vaccination on persons with high-grade precancerous cervical lesions and cervical cancer has not been established, and all women should continue cervical cancer screenings despite vaccination status (Feldman et al., 2020).
Curry, S. J., Krist, A. H., Owens, D. K., Barry, M. J., Caughey, A. B., Davidson, K. W., . . . Wong, J. B. (2018). Screening for Cervical Cancer. Jama,320(7), 674. doi:10.1001/jama.2018.10897
Fontham, E. T., Wolf, A. M., Church, T. R., Etzioni, R., Flowers, C. R., Herzig, A., . . . Smith, R. A. (2020). Cervical cancer screening for individuals at average risk: 2020 guideline update from the American Cancer Society. CA: A Cancer Journal for Clinicians,70(5), 321-346. doi:10.3322/caac.21628
Human Papillomavirus Vaccination. (2020). ACOG Committee Opinion No 809. American College of Obstetrics & Gynecology. Obstetrics & Gynecology,136(2), 435-436. doi:10.1097/aog.0000000000004001
Sawaya, G. F., Kulasingam, S., Denberg, T. D., & Qaseem, A. (2015). Cervical Cancer Screening in Average-Risk Women: Best Practice Advice From the Clinical Guidelines Committee of the American College of Physicians. Annals of Internal Medicine,162(12), 851. doi:10.7326/m14-2426
Wuerthner, B. A., & Avila-Wallace, M. (2016). Cervical cancer. The Nurse Practitioner,41(9), 18-23. doi:10.1097/01.npr.0000490390.43604.5f
Cervical Cancer Screening Updates
Takeaways
Widespread cervical cancer screening practices began in earnest in the United States in the 1950’s. Since then, mortality has markedly decreased. In 1975, 5.55 per 100,000 women died from cervical cancer; while in 2000, that rate dropped to 2.8 deaths per 100,000 women (American College of Obstetricians and Gynecologists [ACOG], 2016; Curry et al., 2018). New research, advancement in treatments, vaccine prevention strategies, and health promotion guidelines continue to evolve, coupled with cervical cancer screening process improvements, have continued the steady decline in mortality to only 2.3 deaths per 100,000 women in 2015 (Curry et al., 2018).
Currently, cervical cancer screening tests include Papanicolaou test (cytology) or the HPV testing, either alone or in combination. The goals of screening are to detect treatable abnormalities and precancers as well as detect early stages of invasive cervical cancer, thereby initiating early intervention and improving outcomes (Fontham et al., 2020).
Who Is At Risk?
There are different screening and surveillance guidelines based on a risk stratification. Average risk individuals are women without symptoms, immunocompetent, and with a negative prior screening history (Feldman et al., 2020). Even though sexual intercourse increases the risk of potential exposure to high risk human papillomavirus (hrHPV), the screening recommendations consider all average risk individuals independent of sexual history (Curry et al., 2018).
Women with HIV infection, are immunocompromised, have exposure to diethylstilbestrol, or a medical history of cervical cancer or high-grade precancerous lesions are at a higher risk and require individualized follow up (Curry et al., 2018).
Updates to Recommendations by Expert Groups
Multiple expert groups produce recommendations regarding cervical cancer screenings. Each set of screening guidelines similarly juggle benefits of early detection of disease and reduction in incidence and mortality from cervical cancer, with consideration for potential false positives, unnecessary procedures, and harms from invasive, intimate procedures (Feldman et al., 2020). Likewise, cost, ease of testing, and adherence are considerations.
The 2018 United States Preventive Screening Task Force (USPSTF) recommendations included a major update to screening guidelines for women 30 to 65 years of age. The panel concluded that screening every 3 years with cervical cytology alone, every 5 years with high risk human papillomavirus (hrHPV) testing alone, or every 5 years with co-testing (cytology and hrHPV) showed similar effectiveness in detection of cervical cancer (Curry et al., 2018). Research did not support screening intervals less than 5 years for primary HPV testing and co-testing due to the potential for unnecessary procedures (Sawaya et al., 2015). The USPSTF recommendations advise cervical cancer screening for women ages 21 to 29 every 3 years with cytology alone; against screening women under age 21; and against screening women older than 65 with adequate prior screening and who are not at high risk for cervical cancer, and women who have undergone a complete hysterectomy (including the removal of the cervix) with no past medical history of high-grade precancerous lesions or cervical cancer (Curry et al., 2018).
The American College of Physicians’ recommendations were last updated in 2016 and recommend screening women starting at age 21 with cytology alone, repeated every 3 years. At age 30 years testing should move to every 5 years and include HPV testing and cytology testing (also called co-testing). At age 65, screenings should stop after 3 consecutive negative cytology results or 2 consecutive negative cytology and HPV testing within the last 10 years (Sawaya et al., 2015).
The American Cancer Society (ACS) recommends initiation of screening at age 25 with primary HPV testing every 5 years. This is continued through age 65. However, if HPV testing is not available, individuals of ages 25 to 65 can be screened with co-testing every 5 years or cytology alone every 3 years. Screenings should stop at age 65 if the patient does not have a history of cervical malignancy within the past 25 years and has adequate negative screening for the past 10 years. The change to initiate screenings at 25 years of age, as opposed to 21, was likely due to low rates of cervical cancer in those ages 20 to 24 as well as multiple observational studies demonstrating spontaneous resolution of HPV infection in this age group (Feldman et al., 2020).
Role of Human Papillomavirus in Cervical Cancer Screening
HPV is responsible for the majority of cases of cervical cancer. Of the over 150 HPV genotypes, 13 genotypes have been shown to cause cervical cancer (American College of Obstetrics & Gynecology [ACOG], 2020). Genotypes 16 and 18, the ‘high risk’ genotypes, are associated with 66% to 70% of cervical cancers and are included in screening tests (Wuerthner & Avila-Wallace, 2016). Approximately 90% of HPV infections clear within a few years, but persistent HPV infections produce a higher risk for cervical intraepithelial neoplasia, making early identification and surveillance through screenings important for good outcomes (Sawaya et al., 2015).
Primary HPV testing alone has recently emerged as a capable and effective screening test to prevent cervical cancer. In fact, primary HPV screening in women >25 years was found to be significantly more sensitive for the detection of CIN3+ than cytology alone (Fontham et al., 2020). As of 2017, primary HPV testing was limited to a few US laboratories and access to testing may be lacking (Feldman et al., 2020). Another concern, the number of false positives is higher in primary hrHPV testing than cytology alone, especially in women in their 20’s, potentially causing an increase in unnecessary procedures, like colposcopies (Feldman et al., 2020).
Improving Prevention Methods
Over 50% of women diagnosed with cervical cancers were not screened appropriately (Feldman et al., 2020). Given the efficacy of screenings, clinicians can improve adherence by actions such as developing a reminder system to actively notify patients of screening intervals as well as reaching out to schedule an appointment. Clinicians can look for opportunities to perform cervical cancer screening when patients are present for other complaints. Urgent care and emergency rooms are potential places to screen patients otherwise unlikely to comply with interval schedules.
On the other hand, practitioners should adhere to the screening schedule as recommended by expert groups. In average risk patients, the “yearly pap” is no more, relieving patients of an unnecessary anxiety-provoking procedure, potentially more invasive subsequent testing and the cost that burdens both individuals and healthcare at large (Sawaya et al., 2015).
One important prevention tool that precedes cervical cancer screening is the HPV vaccine. The series targets boys and girls ages 11 to 12 years (but may be given as early as 9 years of age) and consists of 2 or 3 shots depending on age of initiation. The HPV immunization available in the U.S. covers 9 HPV genotypes, with a greater than 99% efficacy when administered prior to HPV exposure (ACOG), 2020). Increasing vaccine rates to 80% of eligible recipients, an estimated additional 53,000 cases of cervical cancer could be prevented (ACOG), 2020). The effect of vaccination on persons with high-grade precancerous cervical lesions and cervical cancer has not been established, and all women should continue cervical cancer screenings despite vaccination status (Feldman et al., 2020).
Want More Information…
Cervical Cancer Screening: More Choices in 2019 | Cancer Screening, Prevention, Control | JAMA
Screening for Cervical Cancer: US Preventive Services Task Force Recommendation Statement | Cancer Screening, Prevention, Control | JAMA
Practice Bulletin #168, Cervical Cancer Screening and Prevention
Cervical Cancer Screening – American Family Physician
Adult Immunization Schedule by Vaccine and Age Group
References
Cervical Cancer Screening and Prevention. (2016, October). American College of Obstetricians and Gynecologists [ACOG]. Retrieved January 11, 2021, from https://www.acog.org/en/Clinical/Clinical%20Guidance/Practice%20Bulletin/Articles/2016/10/Cervical%20Cancer%20Screening%20and%20Prevention
Curry, S. J., Krist, A. H., Owens, D. K., Barry, M. J., Caughey, A. B., Davidson, K. W., . . . Wong, J. B. (2018). Screening for Cervical Cancer. Jama, 320(7), 674. doi:10.1001/jama.2018.10897
Feldman, S., MD, MPH, Goodman, A., MD, MPH, MS, & Peipert, J. F., MD, PhD. (2020, December). Screening for cervical cancer in resource-rich settings. Retrieved January 15, 2021, from https://www.uptodate.com/contents/screening-for-cervical-cancer-in-resource-rich-settings?search=cervical+cancer+screening&source=search_result&selectedTitle=1~124&usage_type=default&display_rank=1
Fontham, E. T., Wolf, A. M., Church, T. R., Etzioni, R., Flowers, C. R., Herzig, A., . . . Smith, R. A. (2020). Cervical cancer screening for individuals at average risk: 2020 guideline update from the American Cancer Society. CA: A Cancer Journal for Clinicians, 70(5), 321-346. doi:10.3322/caac.21628
Human Papillomavirus Vaccination. (2020). ACOG Committee Opinion No 809. American College of Obstetrics & Gynecology. Obstetrics & Gynecology, 136(2), 435-436. doi:10.1097/aog.0000000000004001
Sawaya, G. F., Kulasingam, S., Denberg, T. D., & Qaseem, A. (2015). Cervical Cancer Screening in Average-Risk Women: Best Practice Advice From the Clinical Guidelines Committee of the American College of Physicians. Annals of Internal Medicine, 162(12), 851. doi:10.7326/m14-2426
Wuerthner, B. A., & Avila-Wallace, M. (2016). Cervical cancer. The Nurse Practitioner, 41(9), 18-23. doi:10.1097/01.npr.0000490390.43604.5f
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