By Rebecca Bowers

EXECUTIVE SUMMARY

The US Preventive Services Task Force has issued final recommendations for cervical cancer screening, calling for women ages 21 to 29 to be tested with cervical cytology every three years.
  • For women 30 to 65 years of age, the new guidance calls for screening with the Pap test every three years or with the high-risk human papillomavirus (hrHPV) test alone or with both tests every five years.
  • The new guidance applies to women with a cervix who do not have any signs or symptoms of cervical cancer.

The US Preventive Services Task Force (USPSTF) has issued final recommendations for cervical cancer screening, calling for women ages 21 to 29 to be tested with cervical cytology every three years. For women 30 to 65 years of age, the new guidance calls for screening with the Pap test every three years, or with the high-risk human papillomavirus (hrHPV) test alone or with both tests every five years.1

The new guidance applies to women with a cervix who do not have any signs or symptoms of cervical cancer and does not depend on their sexual history or whether they have received the HPV vaccine. The recommendation does not include women with certain cervical cancer risk factors, such as HIV infection, immunocompromise, exposure to diethylstilbestrol in utero, and prior treatment of a high-grade precancerous lesion. Clinicians should provide individualized follow-up for these women.1

As in its 2012 guidance, the task force does not recommend cervical cancer screening for the following groups: women younger than 21 years of age, women older than 65 years of age who have received adequate screening previously and do not have a high risk for the disease, and women who have undergone uterus and cervix removal and who do not have a history of either cervical cancer or a high-grade precancerous lesion.1

In its recommendations on the subject, the task force guidance recommends that women ages 30 to 65 have the choice of screening using the hrHPV test and Pap test together every five years, which increases the interval between screenings. For the first time, the new guidance includes the choice of receiving hrHPV testing alone every five years.

“The current guidelines preserve the greatest range of choices for practitioners and patients; in the sense that both will benefit,” says obstetrician/gynecologist Lee Learman, MD, PhD, senior associate dean for graduate medical education and academic affairs and professor at Florida Atlantic University’s Schmidt College of Medicine and lead author of an accompanying editorial to the published guidance.2 “More efficient cervical cancer screening every three to five years will liberate time at the annual visit to discuss prevention of other cancers and chronic diseases that disproportionately burden women.”

A joint statement from the American College of Obstetricians and Gynecologists, the American Society for Colposcopy and Cervical Pathology, and the Society of Gynecologic Oncology notes that with several screening options now available, the new recommendations emphasize the patient-provider shared decision-making process for informed choice on the most suitable screening method for the individual. Although the new recommendations are important, there needs to be a continued effort to ensure all women are screened adequately since there is a significant number of U.S. women who remain unscreened, the statement affirms. It also calls for all women to have access to all tests, with appropriate coverage by insurance companies.

“We hope the USPSTF recommendations foster more discussions between patients and providers about cervical cancer screening, promote opportunities for patient education on the benefits and safety of HPV vaccination for cervical cancer prevention and encourage providers to offer HPV vaccines in their offices,” the statement says.3

The new recommendation indicates that more research needs to be done to determine if different strategies for cervical cancer screening could help reduce the number of deaths from the disease. Continued scientific efforts are necessary for better follow-up with the currently available screening methods as well, and to make sure screening access and treatment are available across different populations, it affirms.

“We know that some populations are affected by cervical cancer more than others,” says the task force vice chair Douglas Owens, MD, MS, Henry J. Kaiser, Jr. Professor, and director of the Center for Health Policy in the Freeman Spogli Institute for International Studies and of the Center for Primary Care and Outcomes Research in the Department of Medicine and School of Medicine at Stanford University. “We need more research to determine how we can effectively reduce disparities among these women, and ultimately help save more lives.”

The new guidance creates an “exciting possibility” of self-administered HPV specimen collection, says Anita Nelson, MD, professor and chair of the obstetrics and gynecology department at Western University of Health Sciences in Pomona, CA. Although such a move may make it easier for women with poor access to healthcare to be tested at home, it may have significant economic effects on clinicians.

“Such a change will certainly require extensive education to reassure women we are not abandoning them and track women over time to remind them of a once-every-five-year test,” says Nelson. “With the mobility of women geographically and their need to switch healthcare systems periodically, that may not be possible.”

Evaluate the Evidence

In issuing its current guidance, the task force ordered an examination of the scientific evidence regarding cervical cancer screening to provide updated recommendations.4 The review included results from studies that compared screening with hrHPV testing alone or cotesting to screening with just cervical cytology. The review did not cover information about the accuracy of the tests or the effectiveness of cytology for cervical cancer screening, since these issues were covered in the 2012 review.5 The current review also did not focus on data regarding women < 21 years of age or those with removal of the uterus and cervix. However, the review confirmed that there was no change in the evidence since the 2012 review.

Compared to cytology, testing for high-risk HPV types identified a higher rate of precancerous changes, according to the review. In addition, higher false-positive results and follow-up tests were associated with the hrHPV tests than with cytology.4

The review demonstrates that there is “strong evidence for the effectiveness of high-risk HPV testing used alone as a cervical cancer screening test,” noted Joy Melnikow, MD, MPH, director of the Center for Healthcare Policy and Research and professor of family and community medicine at the University of California, Davis. Melnikow served as lead author for the evidence review.

“We found that regular screening with any method will lead to lower cervical cancer rates,” said Melnikow in a press statement. “In the U.S., where most women are not part of an organized screening program, our biggest challenge is reaching women who have not been screened.”

REFERENCES

  1. US Preventive Services Task Force, Curry SJ, Krist AH, et al. Screening for cervical cancer: US Preventive Services Task Force recommendation statement. JAMA 2018;320:674-686.
  2. Learman LA, Garcia FAR. Screening for cervical cancer: New tools and new opportunities. JAMA 2018;320:647-649.
  3. American College of Obstetricians and Gynecologists, American Society for Colposcopy and Cervical Pathology, Society of Gynecologic Oncology. Leading women’s health care groups issue joint statement on USPSTF final cervical cancer screening recommendations. Aug. 21, 2018. Available at: https://bit.ly/2PI8GJQ. Accessed Sept. 20, 2018.
  4. Melnikow J, Henderson JT, Burda BU, et al. Screening for cervical cancer with high-risk human papillomavirus testing: Updated evidence report and systematic review for the US Preventive Services Task Force. JAMA 2018;320:687-705.
  5. Vesco KK, Whitlock EP, Eder M, et al. Screening for Cervical Cancer: A Systematic Evidence Review for the US Preventive Services Task Force: Evidence Synthesis No. 86. Rockville, MD: Agency for Healthcare Research and Quality; 2011.