Cervical-Cancer Screening Guidelines

The incidence of cervical cancer, as well as mortality rates from the disease, has decreased over the past 30 years because of widespread screening with cervical cytology. The American College of Obstetricians and Gynecologists (ACOG) recently published a clinical management guideline on cervical cytology screening.

Cervical-Cancer Screening Guidelines *

Age group	Screening Recommendation
<21 yr	Do not screen.
21–29 yr	Perform cytologic testing alone every 3 years.
30–65 yr	Perform cytologic and HPV cotesting every 5 years (preferred), or perform cytologic testing alone every 3 years (acceptable).**
>65 yr	Discontinue screening if there has been an adequate number of negative screening results previously (3 consecutive negative cytologic tests or 2 consecutivenegative cotests in the past 10 years, with the most recent test in the past 5 years) and if there is no history of HSIL,*** adenocarcinoma in situ, or cancer.
Women who have undergonehysterectomy	Discontinue screening if the patient has undergone a totalhysterectomy with removal of cervix and if there is no history of HSIL, adenocarcinoma in situ, or cancer.

* The three major sets of screening guidelines were issued by the American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology Multisociety Guidelines Group; the American College of Obstetricians and Gynecologists; and the U.S. Preventive Services Task Force (USPSTF). The guidelines agree on most recommendations, including the recommended age at the start of screening (21 years), the age at which screening can be discontinued if the history of negative screening is adequate (>65 years), and the recommended interval between tests. Specifically, cotesting at a 5-year interval is either preferred or acceptable for women 30 to 65 years of age, whereas cytologic testing alone every 3 years is acceptable for women 21 to 65 years of age. HSIL denotes high-grade squamous intraepithelial lesions.

** The terms “preferred” and “acceptable” are not included in the USPSTF Recommendation Statement.
*** HSIL includes cervical intraepithelial neoplasia grade 3 and cases of grade 2 that stain positive for p16.

References:

1. Schiffman M, Solomon D. Clinical practice. Cervical-cancer screening with human papillomavirus and cytologic cotesting. N Engl J Med. 2013 Dec 12;369(24):2324-31.[Medline]
2. Tatsas AD, Phelan DF, Gravitt PE, Boitnott JK, Clark DP. Practice patterns in cervical cancer screening and human papillomavirus testing. Am J Clin Pathol. 2012 Aug;138(2):223-9. [Medline]
3. Saslow D, Solomon D, Lawson HW, 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;62:147-72. [Medline]
4. Moyer VA. Screening for cervical cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2012;156:880-91. [Medline]
5. ACOG Practice Bulletin number 131: screening for cervical cancer. Obstet Gynecol 2012;120:1222-38. [Medlione]

Management of women with cervical intraepithelial neoplasia or adenocarcinoma in situ

Recommendations

Major Recommendations

The ratings of the strength of recommendation (A-E), the quality of the evidence (I-III), and terminology used by the consensus conference (recommended, preferred, acceptable, unacceptable) are defined at the end of the Major Recommendations.
Note from the American Society for Colposcopy and Cervical Pathology (ASCCP): The management of low-grade cervical intraepithelial neoplasia (CIN) grade 1 has been modified significantly since 2001. Previously, management depended on whether colposcopy was satisfactory and treatment using ablative or excisional was acceptable for all women with CIN 1. In the new guidelines, cytological follow-up is the only recommended management option for women with CIN 1 who have low-grade referral cervical cytology, regardless of whether the colposcopic examination is satisfactory. Treatment is particularly discouraged in adolescents. The basic management of women in the general population with CIN 2,3 underwent only minor modifications, but options for the conservative management of adolescents with CIN 2,3 have been expanded. Moreover, management recommendations for women with biopsy-confirmed adenocarcinoma in situ are now included.

Consensus guidelines for the management of women with abnormal cervical cancer screening tests

Recommended Management of Women with Atypical Squamous Cells of Undetermined Significance (ASC-US)
General Management Approaches
A program of DNA testing for high-risk (oncogenic) types of HPV, repeat cervical cytologic testing, or colposcopy are all acceptable methods for managing women over the age of 20 years with ASC-US. (AI) When liquid-based cytology is used or when cocollection for HPV DNA testing can be done, "reflex" HPV DNA testing is the preferred approach. (AI)
Women with ASC-US who are HPV DNA negative can be followed up with repeat cytologic testing at 12 months. (BII) Women who are HPV DNA positive should be managed in the same fashion as women with LSIL and be referred for colposcopic evaluation. (AII) Endocervical sampling is preferred for women in whom no lesions are identified (BII) and those with an unsatisfactory colposcopy (AII) but is acceptable for women with a satisfactory colposcopy and a lesion identified in the transformation zone. (CII) Acceptable postcolposcopy management options of women with ASC-US who are HPV positive, but in whom cervical intraepithelial neoplasia (CIN) is not identified, are HPV DNA testing at 12 months or repeat cytological testing at 6 and 12 months. (BII) It is recommended that HPV DNA testing not be performed at intervals less than 12 months. (EIII)