Resident Editors: Anne Montgomery, MD

Faculty Editors: Meg Autry, MD and Molly Heublein, MD

Background

• The incidence of cervical cancer has decreased dramatically in the US, largely due to increased screening and early detection.
• Persistent HPV infection required for the development of cervical cancer.
  • Infection common but usually transient.
  • Disease progression usually indolent.

Routine Screening Guidelines

• START screening with cytology at age 21, regardless of age of onset of sexual activity or other behavior-related risk factors.
• CONTINUE screening at the following intervals:
  • 21-29yo: cytology every 3 years
  • 30-65yo: cytology + HPV co-testing every 5 years OR cytology every 3 years
• STOP screening at 65yo if the following criteria are met:
  • 3 consecutive negative cytology results or 2 consecutive negative co-tests within the past 10 years;
  • Most recent test within 5 years;
  • No history of treated CIN 2, CIN 3, or cervical cancer within 20 years;
  • After total hysterectomy if not done for cervical dysplasia.

Special Populations

• HIV-positive
  • Start screening at onset of sexual activity or at 21yo, whichever comes first.
  • Screen every 12 months x3; if normal, can space to cytology every 3 years if <30yo or cytology + HPV co-testing every 3 years if >30yo.
  • Continue screening for life.
• Immunocompromised (eg. transplant or autoimmune disease on immunosuppression)
  • No specific guidelines but typically screened with cytology every 12 months.
  • Could likely space screening intervals as with HIV above.
• Prior hysterectomy
  • If total hysterectomy (removal of cervix) and no history of CIN 2 or higher, stop screening.
  • If total hysterectomy with history of CIN2 or higher, screen with vaginal Pap every 3 years for 20 years after treatment.
  • If cervix in place, continue screening as recommended.
• History of CIN2 or higher (treated)
  • Continue routing screening as above for 20 years after treatment.
• Previous HPV Vaccination
  • Routine screening, as above.
    • ​30% of oncogenic HPV strains are not covered by the vaccine.
  • Don’t forget to offer HPV vaccination to all women who have not received it up to 26yo!
• DES Exposure
  • Screen annually
  • DES exposure stopped in 1971, therefore applies to women >40 years.

Screening Tests

• Cervical cytology tests (aka Pap testing)
  • Conventional smear: provider plates cells on slide, fixes, and sends to lab.
    • ​HPV testing must be performed on separate sample.
  • Liquid-based: provider suspends cells in liquid medium.
    • HPV testing can be performed on the same sample.
    • ​At UCSF, available at Mt Zion (ThinPrep) and SFGH (SurePath).
  • ​​Current evidence indicates that there are no clinically important differences between liquid-based cytology and conventional cytology.
• HPV testing for high-risk genotypes (tested strains vary across test kits and sites)
  • Reflex testing: determines need for colpo with ASC-US pap result.
  • Co-testing: used in combination with cytology in women >30yo to decrease screening interval.
  • Primary screening: test approved by FDA in 2014 but no current guidelines.
    • ​Evidence suggests that HPV testing alone is as safe and effective as cytology; screen no more than every 3 years in women >25yo

For information on how to perform a pap, see section on How to Perform a Pap Smear. For information on how to approach an abnormal pap or a woman with a history of an abnormal pap, see section on Approach to Pap Test Results.

References

Committee on Practice Bulletins—Gynecology. ACOG Practice Bulletin Number 168: Cervical cancer screening and prevention. Obstet Gynecol 2016;128:e111-130.

Huh W et al. Use of primary high-risk human papillomavirus testing for cervical cancer screening: interim clinical guidance. J Low Genit Tract Dis. 2015;19(2):91-96.

Moyer VA et al. Screening for Cervical Cancer: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2012.

Saslow D 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. CA Cancer J Clin. 2012;62(3):147.