CERVICAL CANCER SCREENING





Acronyms


TERMINOLOGY


SCREENING RECOMMENDATIONS

  • Women who have had the HPV vaccine should follow the same recommendations
  • Reference: USPSTF website
USPSTF 2024 Cervical Cancer Screening Recommendations
Women younger than 21 years
  • Do not screen
Women 21 - 29 years
  • Screen every 3 years with cervical cytology alone
  • HPV testing should not be done on normal cytology
  • Reflex HPV testing on ASCUS is preferred
Women 30 - 65 years
  • Screen with one of the following options:
    • Screen every 5 years with clinician- or patient-collected high-risk human papillomavirus (HPV) primary screening
    • Continue screening every 3 years with cervical cytology alone
    • Screen every 5 years with high-risk HPV testing in combination with cytology (cotesting)
Women > 65 years
  • Do not screen if has had adequate negative prior screening and are not otherwise at high risk for cervical cancer
  • Adequate prior negative screening is defined as:
    • Three consecutive negative cytology results or two consecutive negative cotesting results within 10 years before stopping screening, with the most recent test occurring within 3 to 5 years
    • Routine screening should continue for at least 25 years after spontaneous regression or appropriate management of a precancerous lesion, even if this extends screening past the age of 65 years
Women who have had a hysterectomy
  • Do not screen women who have had a hysterectomy with removal of the cervix and do not have a history of a high-grade precancerous lesion (i.e., cervical intraepithelial neoplasia [CIN] grade 2 or 3) or cervical cancer

  • Reference [4]
ACS 2020 Cervical Cancer Screening Recommendations
Women < 25 years
  • Do not screen
Women 25 - 65 years
  • Primary HPV test alone every 5 years
Women > 65 years
  • Discontinue screening if adequate negative prior screening
  • Adequate negative prior screening defined as 2 consecutive, negative primary HPV tests, or 2 negative cotests, or 3 negative cytology tests within the past 10 years, with the most recent test occurring within the past 3 - 5 years, depending on the test used
  • Individuals aged > 65 years without documentation of prior screening should continue screening until criteria for cessation are met
After hysterectomy
  • Individuals without a cervix and without a history of CIN2 or a more severe diagnosis in the past 25 years or cervical cancer ever should not be screened
Managing HPV results

MANAGEMENT OF ABNORMAL RESULTS


STUDIES

RCT
HPV FOCAL trial - Cervical HPV testing vs Cytology for Detecting CIN 3 or Worse at 48 months, JAMA (2018) [PubMed abstract]
  • The HPV FOCAL trial enrolled 19,009 women 25 - 65 years old with no history of CIN2+ in the past 5 years
Main inclusion criteria
  • Age 25 - 65 years
  • No PAP smear in last 12 months
  • No history of CIN2+ in past 5 years
Main exclusion criteria
  • HIV positive
  • Receiving immunosuppressive therapy
  • Total hysterectomy
Baseline characteristics
  • Average age - 45 years
  • Received HPV vaccine - 0.6%
Randomized screening groups
  • Group 1 (9552 patients): Cervical HPV testing
  • Group 2 (9457 patients): Cytology
  • At baseline, all patients underwent screening with the method from their assigned group
  • Patients in Group 1 with a negative test returned for follow-up at 48 months
  • Patients in Group 2 with a negative test returned for follow-up in 24 months
  • In both groups, positive tests were treated and followed-up per standard recommendations
  • All patients had HPV and cytology done at 48 months with appropriate workup for their final study diagnosis
Primary outcome: Rate of CIN 3 or worse at 48 months
Results

Duration: 48 months
Outcome HPV testing
(rate per 1000)		 Cytology
(rate per 1000)		 Comparisons
CIN3+ at 48 months 2.3 5.5 RR 0.42, 95%CI[0.25 - 0.69] p<0.001
CIN2+ at 48 months 5.0 10.6 RR 0.47, 95%CI[0.34 - 0.67] p<0.001
CIN2+ at baseline screening 15.4 9.6 RR 1.61, 95%CI[1.24 - 2.09] p<0.001

Findings: Among women undergoing cervical cancer screening, the use of primary HPV testing compared with cytology testing resulted in a significantly lower likelihood of CIN3+ at 48 months. Further research is needed to understand long-term clinical outcomes as well as cost-effectiveness.

BIBLIOGRAPHY