- ACRONYMS AND DEFINITIONS
- ACOG - American College of Obstetricians and Gynecologists
- ACP - American College of Physicians
- ACS - American Cancer Society
- ASCCP - American Society for Colposcopy and Cervical Pathology
- ASCP - American Society for Clinical Pathology
- HPV - Human papillomavirus
- USPSTF - United States Preventive Service Task Force
- TERMINOLOGY
- General
- Colposcopy - procedure where the cervix is visualized and coated with acetic acid. Acetic acid causes dysplastic cervical cells to appear white. Biopsies of the white cells are taken and sent for examination under a microscope.
- Cotesting - performing cytology and high-risk HPV testing at the same time
- Cytology - typically referred to as "PAP smear." Cytology involves looking at a sample of cells from the cervix under a microscope.
- Dysplasia - term that means abnormal cell development. Dysplasia may be mild, moderate, or severe. Dysplasia may progress to cancer.
- HPV testing - testing for the presence of human papillomavirus (HPV) in a cervical cell sample. HPV testing detects the presence of "high-risk" genotypes which are known to cause cervical cancer. See human papillomavirus for more.
- Primary HPV screening - screening with HPV testing only (no cytology)
- PAP smear results
- ASCUS - Atypical Squamous Cells of Undetermined Significance. Mild cellular changes seen.
- CIN 1 - Cervical Intraepithelial Neoplasia 1 | Low level of dysplasia seen
- CIN 2 - Cervical Intraepithelial Neoplasia 2 | Moderate level of dysplasia seen
- CIN 3 - Cervical Intraepithelial Neoplasia 3 | Severe level of dysplasia seen
- Bethesda system
- ASCUS - Atypical Squamous Cells of Undetermined Significance. Mild cellular changes seen.
- LSIL or LGSIL - Low-Grade Squamous Intraepithelial Lesion - corresponds to CIN 1
- HSIL or HGSIL - High-Grade Squamous Intraepithelial Lesion - corresponds to CIN 2 and 3
- Other findings
- AGC or AGUS - Atypical Glandular Cells. Less common finding. Patients with AGUS should be referred for colposcopy
- SCREENING RECOMMENDATIONS
- Overview
- The guidelines presented in the table below and are endorsed by the ASCCP, ASCP, USPSTF, ACOG, and ACP
- In 2020, the ACS changed its primary recommendation for cervical cancer screening to HPV testing only. See screening with high-risk HPV testing only below.
Cervical Cancer Screening Recommendations |
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Women younger than 21 years
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Women 21 - 29 years
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Women 30 - 65 years
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Women > 65 years
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Women who have had a hysterectomy
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- SCREENING WITH HIGH-RISK HPV TESTING ONLY (NO CYTOLOGY)
- Overview
- In 2014, the FDA approved the first primary HPV test for cervical cancer screening in women ≥ 25 years old. There are currently two tests approved (cobas® HPV and BD Onclarity™ HPV), and they detect 14 high-risk HPV types in a sample of cells taken from the cervix.
- In 2020, the ACS changed its primary cervical cancer screening recommendations to HPV high-risk screening only. Those recommendations are given in the table below.
ACS 2020 Cervical Cancer Screening Recommendations |
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Women < 25 years
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Women 25 - 65 years
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Women > 65 years
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After hysterectomy
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Managing HPV results
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- MANAGEMENT OF ABNORMAL RESULTS
- Abnormal results are managed according to guidelines set forth by the ASCCP
- A pdf version of the guidelines is available here - ASCCP Guidelines (pdf)
- An app is also available that makes it easier to navigate the recommendations. It is available for download ($9.99) on Apple and Android devices. See ASCCP mobile app for more information.
- STUDIES
- The HPV FOCAL trial enrolled 19,009 women 25 - 65 years old with no history of CIN2+ in the past 5 years
Main inclusion criteria
- Age 25 - 65 years
- No PAP smear in last 12 months
- No history of CIN2+ in past 5 years
Main exclusion criteria
- HIV positive
- Receiving immunosuppressive therapy
- Total hysterectomy
Baseline characteristics
- Average age - 45 years
- Received HPV vaccine - 0.6%
Randomized screening groups
- Group 1 (9552 patients): Cervical HPV testing
- Group 2 (9457 patients): Cytology
- At baseline, all patients underwent screening with the method from their assigned group
- Patients in Group 1 with a negative test returned for follow-up at 48 months
- Patients in Group 2 with a negative test returned for follow-up in 24 months
- In both groups, positive tests were treated and followed-up per standard recommendations
- All patients had HPV and cytology done at 48 months with appropriate workup for their final study diagnosis
Primary outcome: Rate of CIN 3 or worse at 48 months
Results
Duration: 48 months | |||
Outcome | HPV testing (rate per 1000) |
Cytology (rate per 1000) |
Comparisons |
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CIN3+ at 48 months | 2.3 | 5.5 | RR 0.42, 95%CI[0.25 - 0.69] p<0.001 |
CIN2+ at 48 months | 5.0 | 10.6 | RR 0.47, 95%CI[0.34 - 0.67] p<0.001 |
CIN2+ at baseline screening | 15.4 | 9.6 | RR 1.61, 95%CI[1.24 - 2.09] p<0.001 |
Findings: Among women undergoing cervical cancer screening, the use of primary HPV testing compared with cytology testing resulted in a significantly lower
likelihood of CIN3+ at 48 months. Further research is needed to understand long-term clinical outcomes as well as cost-effectiveness.
- BIBLIOGRAPHY
- 1 - PMID 22431528 - American Cancer Society PAP screening guidelines 2012
- 2 - PMID 25569009 - Use of primary high-risk human papillomavirus testing for cervical cancer screening: Interim clinical guidance
- 3 - PMID 22431528 - 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, Am J Clin Pathol (2012)
- 4 - PMID 32729638 - Cervical cancer screening for individuals at average risk: 2020 guideline update from the American Cancer Society, CA Cancer J clin (2020)