An updated cervical cancer screening guideline from the American Cancer Society has called for less—and more simplified—screening. The guideline was published by Elizabeth T.H. Fontham, MPH, DrPH, of Louisiana State University School of Public Health, New Orleans, and colleagues in CA: A Cancer Journal for Clinicians.1
The updated guideline recommends that individuals with a cervix initiate cervical cancer screening at age 25 and that primary human papillomavirus (HPV) testing (HPV testing without the Papanicolaou [Pap] test) every 5 years be the preferred method of testing through age 65. The guideline also states using HPV testing in combination with a Pap test (called cotesting) every 5 years or Pap tests alone every 3 years are acceptable options for now, as not all laboratories have transitioned to primary HPV testing.
Elizabeth T.H. Fontham, MPH, DrPH
Debbie Saslow, PhD
“These streamlined recommendations can improve compliance and reduce potential harms,” said Debbie Saslow, PhD, Director of Cancer Control Intervention for HPV Vaccination and Women’s Cancers for the American Cancer Society. “They are made possible by some important developments that have allowed us to transform our approach to cervical cancer screening—primarily, a new understanding of the role of HPV and the development of tools to address it.”
Role of HPV in Cervical Cancer
HPV is the cause of nearly all cervical cancers. Evidence shows the HPV test is more accurate than the Pap test and can be done less often; one HPV test every 5 years is more effective than a Pap test every 3 years—and even every year, as was recommended in the 1980s and 1990s—in reducing the risk of cervical cancer.
A negative HPV test is linked to a low cervical cancer risk. In addition, a vaccine for HPV has been in use for nearly 15 years, and more women of screening age are now vaccinated and protected from the majority of cervical cancers.
Which Age to Begin Screening?
The previous American Cancer Society guideline, released in 2012, called for screening starting at age 21. Since then, HPV vaccination rates have improved in the United States. Data suggest vaccination has led to lower rates of precancerous cervical changes. In addition, the incidence of cervical cancer is low in this age group—cancer registry data from 2011 to 2015 indicate an estimated 108 cases of invasive cervical cancer in women between the ages of 20 and 24 in the United States each year.
There are also potential harms related to the treatment of precancerous cells identified by screening including preterm birth, and screening has not been shown to lower the rate of cancer in women in this age group. Also, most HPV infections in women in this age group become undetectable in 1 to 2 years. Those factors led the American Cancer Society to move the recommended age to initiate cervical cancer screening to 25.
“We estimate that compared with the currently recommended strategy of cytology (Pap testing) alone beginning at age 21 and switching to cotesting at age 30, starting with primary HPV testing at age 25, prevented 13% more cervical cancers and 7% more cervical cancer deaths,” said Dr. Saslow. “Our model showed we could do that with a 9% increase in follow-up procedures, but with 45% fewer tests required overall.”
Guideline Recommendations
The American Cancer Society recommends that individuals with a cervix initiate cervical cancer screening at age 25 and undergo primary HPV testing every 5 years through age 65 (preferred). If primary HPV testing is not available, individuals between the ages of 25 and 65 should be screened with cotesting (HPV testing in combination with cytology) every 5 years or cytology alone every 3 years (acceptable). The American Cancer Society classifies this as a strong recommendation.
Cotesting or cytology testing alone is included as an acceptable option for cervical cancer screening because access to an HPV test that has been approved by the U.S. Food and Drug Administration for primary screening may be limited in some settings. As the United States makes the transition to primary HPV testing, the use of cotesting or cytology alone for cervical cancer screening will not be included in future guidelines.
The American Cancer Society recommends that individuals with a cervix who are older than age 65, who have no history of cervical intraepithelial neoplasia grade 2+ within the past 25 years, and who have documented adequate negative prior screening in the 10-year period prior to age 65 discontinue cervical cancer screening with any modality. The American Cancer Society classifies this as a qualified recommendation.
Adequate negative prior screening is currently defined as two consecutive negative primary HPV tests, two negative cotests, or three negative cytology tests within the past 10 years, with the most recent test occurring within the past 5 years. These criteria do not apply to persons who are currently under surveillance for abnormal screening results.
If sufficient documentation of prior screening criteria for screening cessation is not available, individuals with a cervix who are older than age 65 without conditions limiting life expectancy should be screened until criteria are met.
Cervical cancer screening may be discontinued in individuals of any age with a limited life expectancy.
American Cancer Society screening guidelines are created by the Guideline Development Group—11 clinicians and population health-care professionals and 1 patient advocate appointed by the American Cancer Society Board of Directors to create all of its cancer screening guidelines. To avoid professional conflicts of interest, the Guideline Development Group considers content-specific input and the opinions of expert clinical specialists but is responsible for supervising review of the evidence and transforming the evidence into writing the guidelines.
Disclosure: For full disclosures of the study authors, visit acsjournals.onlinelibrary.wiley.com.
REFERENCE
1. Fontham ETH, Wolf AMD, Church TR, et al: Cervical cancer screening for individuals at average risk: 2020 guideline update from the American Cancer Society. CA Cancer J Clin. July 30, 2020 (early release online).
