Cervical Cancer Screening and Prevention Update
For more than 50 years, routine use of the Pap test to screen for cervical cancer has 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.
Usually, healthcare providers perform the Pap test as part of a routine pelvic exam at recommended intervals, but a Pap is not always done at the time of a routine pelvic exam, so it is important to ask your healthcare provider if a Pap was done.
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 30 to 65.
The updated guidelines recommend the following.
- Women should not be screened before age 21.
- Women 21 to 29 should be screened with the Pap test alone (conventional or liquid-based) every three years. HPV testing should not be used for screening in this age group.
- For women 30 and older, the preferred approach is the Pap test plus HPV testing (“co-testing”) every five years. Continued screening with the Pap test alone (without HPV testing) every three years is an acceptable alternative. Although screening with HPV testing alone is promising, at this time it is not recommended for most clinical settings.
- 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.