Screening standards for cervical cancer have changed over the past two decades, including several updates since the first consensus guidelines, published in 2001 by the American Society of Colposcopy and Cervical Pathology (ASCCP). The 2020 revision is based on data showing that patients’ risk of developing cervical precancer or cancer can be estimated using screening test results, biopsy results, and consideration of personal patient factors.1

The new guidelines are for the management of cervical screening abnormalities and accommodate the available cervical screening techniques, such as primary human papillomavirus (HPV) screening, co-testing with HPV testing and cervical cytology, and cervical cytology alone.

“Thirty years ago, there were only Pap smear pathology screening, and if you found something, you followed people carefully to make sure they’re clear of disease,” says Naomi Jay, RN, NP, PhD, assistant clinical professor of nursing at the University of California, San Francisco School of Nursing. Jay is a former member of the ASCCP board and is the immediate past president of the International Anal Neoplasia Society (IANS). “Over the years, the standards have built on changes in technology and changes in the understanding of the natural history of the disease.”

Endometrial cancer is rare in premenopausal patients who do not have any risk factors. But the prevalence of premenopausal endometrial cancer is on the rise.1

Endometrial cancer also has increased for postmenopausal women, ages 50 to 74 years, research shows. One study revealed that the endometrial cancer rate increased 10% from 2006 to 2012.2

Researchers studying cervical cancer and HPV found that some HPV infections spontaneously resolve, Jay says.

“What we learned was we could do less referrals to treatment,” she explains. “When I started [practice], we treated everything, including mild dysplasia and warts.” Now, clinicians have learned they do not need to treat mild dysplasia.

The new risk-based management guidelines for cervical cancer advise clinicians to refer patients for a colposcopy based on the patient’s risk of high-grade dysplasia or cancer. “A lot of hybrid dysplasia will never progress to cancer,” she explains. “What we want to do in this field is the least amount of harm, and part of the way we can do that is by only referring people to colposcopy when they absolutely need it.”

Patients with high-grade dysplasia would be treated, while those who do not need those exams would be spared that experience. “The paradigm shift in these guidelines is it’s shifting us from basing our clinical actions on the results to a threshold on what the patient’s actual risk is to have severe dysplasia or cancer,” Jay says. “Colposcopies are expensive, uncomfortable, involve biopsies. It’s overtesting, unnecessarily.”

The guideline change treats this screening like other tests, such as colonoscopies, that are recommended based on a person’s age and risk factors. “If you have a colonoscopy and there’s an abnormal result, you come back in three years, five years, or one year,” Jay says.

If there are no concerning results, then people do not have to come back for 10 years. “It’s the same idea that we’re trying to do the least harm, and the least harm is doing as few of these extra procedures as possible,” Jay says. “A lot of colposcopies turn out to be unnecessary. If there’s a lesion in a 26-year-old, it might go away by itself; you would worry about it in a 35-year-old differently than in a 22-year-old.”

The guidelines provide clear recommendations based on risk, including the grade of cervical intra-epithelial neoplasia (CIN). The new risk-based guidance says colposcopy can be deferred for patients with minor screening abnormalities indicating HPV infection with a low risk of underlying CIN 3.1

ASCCP also recommends excisional treatment instead of ablative treatment for histologic HSIL (high-grade squamous intraepithelial lesion), CIN 2, or CIN 3.

Another change in the revised guidelines is the suggestion to continue surveillance with HPV testing or co-testing at three-year intervals for at least 25 years after treatment and initial post-treatment management of histologic HSIL, CIN 2, CIN 3, or adenocarcinoma in situ. Surveillance at three-year intervals beyond age 25 is acceptable.

“The 2012 guidelines recommended return to five-year screening intervals and did not specify when screening should cease. New evidence indicates that risk remains elevated for at least 25 years, with no evidence that treated patients ever return to risk levels compatible with five-year intervals,” the guidelines state.1

“The decision algorithms are based on a woman’s risk rather than her results,” Jay says. “The guidance is very simple with examples, so the clinician always is going to be making decisions because not everyone will fall neatly into algorithms, and patients are going to have a say about it.”

The main takeaway message of the revised guidelines is that clinicians can perform fewer colposcopies and increase HPV testing.

“HPV testing is taking over Pap smears as the better tool,” she adds. “It’s looking at whether the woman has a high-risk HPV strain, vs. looking at the cellular level as a Pap smear does.”

Evidence and subsequent guidelines on HPV screening and Pap smears have changed over the past decade in terms of which screening test should be used for women being seen in a clinic for cervical cancer screening, Jay says.


  1. Perkins RB, Guido RS, Castle PE, et al. 2019 ASCCP risk-based management consensus guidelines for abnormal cervical cancer screening tests and cancer precursors. J Low Genit Tract Dis 2020;24:102-131.
  2. Constantine GD, Kessler G, Graham S, et al. Increased incidence of endometrial cancer following the Women’s Health Initiative: An assessment of risk factors. J Womens Health (Larchmt) 2019;28:237-243.