Cervical Cancer Screening and Prevention Update

Women's Health

Cervical cancer incidence and mortality have decreased substantially over the past 40 years, largely due to screening. Simply stated, screening saves lives.

The New HPV test ‘is simply better’ than the PAP Smear

The Pap test had long been the standard for cervical cancer screening. However, studies have suggested cytology-based screening is less efficient for those who have undergone HPV vaccination, resulting in a high rate of false-positive results.

The HPV test emerged as an alternative — given that most cervical cancers are caused by HPV — after the FDA approved the test in 2014. The rationale for recommending the HPV test as a primary screening tool is that it is superior to the Pap test, Research suggests that women screened for cervical cancer via primary HPV testing had a lower likelihood of developing cancerous lesions than women who underwent standard cytology testing.

For more than 50 years, routine use of the Pap test to screen for cervical cancer reduced deaths from the disease by more than 70 percent. A Pap test is a standard way that healthcare providers can check to see if there are any changes in the cervix that might cause concern. The Pap test involves looking at a sample of cells from the cervix under a microscope to see if there are any that are abnormal. It is a good test for finding not only cancer but also cells that might become cancerous in the future.

Recently The American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology released new guidelines for the prevention and early detection of cervical cancer. The guidelines generally advise a reduction in the number of tests women get over their lifetime, to better ensure that they receive the benefits of testing while minimizing the harms; they include a preference for co-testing using the Pap test and a highly sensitive HPV test for women ages 25 to 65.(1)

An updated guideline issued by the American Cancer Society in July 2020 recomends that cervical cancer screening with the HPV test be performed every 5 years beginning at age 25 instead of 21 years and continuing to 65 years. The recommendation relies solely on the HPV test as the preferred test, and phases out the Pap test and cotesting with the Pap test and HPV testing. The ACS says the update is based on “decades of studies comparing the effectiveness of HPV testing compared with cytology, and bolstered by evidence of the impact of HPV vaccination, including a dramatic decline in cervical pre cancers and, more recently, cervical cancers among young women”. Not all physicians are in agreement with the recommendation citing research that HPV testing alone misses twice as much cervical cancer as cotesting. Women should discuss the role of contesting with their doctor. (2)

  • Those aged 25 to 65 should have a primary HPV test* every 5 years. If primary HPV testing is not available, screening may be done with either a co-test that combines an HPV test with a Papanicolaou (Pap) test every 5 years or a Pap test alone every 3 years.
  • Screening is not recommended for women over 65 who have had at least three consecutive negative Pap tests or at least two negative HPV tests in the past 10 years, with the most recent test in the past 5 years. Women in this age group who have a history of cervical pre-cancer (CIN2 or a more severe diagnosis) should continue routine screening for at least 20 years, even if this extends beyond age 65.
  • Women who have undergone a hysterectomy (with removal of the cervix) for reasons not related to cervical cancer or pre-cancer should no longer be screened.
  • Women who have been vaccinated against HPV should follow the age-specific recommendations in these guidelines (for unvaccinated women). Currently, there are no alternative screening recommendations for women vaccinated against HPV.

The new guidelines are not intended for women with a history of cervical cancer, women who were exposed to DES (diethylstilbestrol) during a pregnancy, and women who are immunosuppressed (e.g., HIV positive).

It is important for women to know if a Pap test was performed because it is possible to have a pelvic exam without a Pap test. It is also important that women know and understand their Pap test results and follow through with any recommendations made by their healthcare provider. Some abnormal Pap tests will be followed by colposcopy (examination of the cervix using a magnifying device to see it more clearly) and biopsy of any areas on the cervix that appear abnormal. Any pre-cancerous areas can then be seen and, if needed, treated by a woman’s healthcare provider.

Current cervical cancer screening guidelines state that women with a slightly abnormal Pap test result (called ASC-US) and a negative HPV test can be screened again in three years with co-testing or with the Pap test alone. Women with a negative Pap result but a positive HPV test can either be rescreened with co-testing in one year or tested to determine specific types of HPV (HPV types 16 and 18).

Major educational efforts are being directed toward the appropriate approach to cervical cancer screening in adolescent girls (less than 21 years of age). Sexually active girls and young women frequently have HPV infections and will even have abnormal Pap tests. Many of these young women will have spontaneous resolution of their infections and abnormal Pap test without the need for gynecological intervention, and cancer in this age group is exceedingly rare.

References:

  1. [The American Cancer Society Guidelines for the Prevention and Early Detection of Cervical Cancer.](https://www.cancer.org/cancer/cervical-cancer/detection-diagnosis-staging/cervical-cancer-screening-guidelines.html#:~:text=Cervical%20cancer%20testing%20(screening%29%20should,test%20alone%20every%203%20years)
  2. Kaufman HW, et al. Am J Clin Pathol. 2020.doi:10.1093/ajcp/aqaa074.
  3. ACOG statement on cervical cancer screening guidelines. Available at: www.acog.org/news/news-releases/2020/07/acog-statement-on-cervical-cancer-screening-guidelines. Accessed Oct. 5, 2020.
  4. Fontham ETH, et al. CA Cancer J Clin. 2020;doi:10.3322/caac.21628.
  5. Huh WK, et al. Gynecol Oncol. 2015;doi:10.1016/j.ygyno.2014.12.022.
  6. Lei J, et al. N Engl J Med. 2020;doi:10.1056/NEJMoa1917338.
  7. Massad LS. JAMA. 2018;doi:10.1001/jama.2018.7911.
  8. Ogilvie GS, et al. JAMA. 2018;doi:10.1001/jama.2018.7464.
  9. Saslow D, et al. CA Cancer J Clin. 2020;doi:10.3322/caac.21616.
  10. Schiffman M, et al. J Natl Cancer Inst. 2017;doi:10.1093/jnci/djx225.
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