Overview and Justification
It is estimated that each year there are nearly 662,000 new cases of cervical cancer worldwide and more than 348,000 individuals die from the disease.1 In the United States, the National Cancer Institute estimated that 13,820 new cases of cervical cancer were diagnosed in 2024, and 4,360 individuals died from the disease.2 Currently, the five-year relative survival rate for localized cervical cancer is 91.1%; the overall (i.e., all stages combined) five-year survival rate is approximately 67.4%.2
Cervical cancer was once one of the most common causes of cancer death among women in the United States.3 The annual incidence and mortality rate of cervical cancer has decreased significantly since the 1970s due to the routine use of the Papanicolaou or Pap test and the introduction of human papillomavirus vaccination in 2006.3-7 A Pap test is a screening procedure that identifies changes in the cervix before cancer develops and can also identify early stages of cancer. Evidence has also shown a significant decrease in cervical cancer incidence among young women in the United States.6
According to cervical cancer screening recommendations from the U.S. Preventive Services Task Force, women 21 to 29 years should be screened for cervical cancer with cervical cytology (i.e., a Pap test) alone every three years.7 Women 30 to 65 years should be screened every three years with cervical cytology alone, every five years with high-risk HPV testing alone or every five years with hrHPV testing combined with cytology (known as co-testing). The American Academy of Family Physicians supports the USPSTF’s recommendations.8
Among women 21 to 65 years, 72.4% were up-to-date with cervical cancer screening in 2021.9 In the United States, Pap tests are ordered or provided in approximately 14.3 million physician office visits each year, and HPV testing is ordered in approximately five million visits.10 Although limited data are available on how many cervical cancer screening tests yield abnormal results, a study found that among more than 6,700 patients 30 to 65 years who were compliant with cervical cancer screening guidelines, 16.4% had an abnormal result, with 10.9% reporting an abnormal Pap test, 2.8% reporting an abnormal hrHPV test and 2.7% reporting abnormal co-testing results.11
Colposcopy is a procedure used to evaluate individuals at increased risk for cervical dysplasia, including those who have abnormal or inconclusive cervical cancer screening tests.12 It involves examining features of the cervical epithelium under magnified illumination after applying normal saline, 3% to 5% dilute acetic acid and Lugol’s iodine solution in successive steps.13 A green filter highlights vascular patterns. If abnormal tissue is present, biopsy sampling allows for a histologic diagnosis to distinguish a patient who requires treatment from one for whom cytological surveillance is appropriate.14 It is estimated that hundreds of thousands of colposcopies are performed in the United States every year.
The 2019 ASCCP Risk-based Management Consensus Guidelines for Abnormal Cervical Cancer Screening Tests and Cancer Precursors recommendations for follow up and treatment are founded on risk-based management algorithms drawn from a combination of current screening test results and past screening history.15,16 The American Society of Colposcopy and Cervical Pathology recognizes that guidelines can rapidly become outdated. These guidelines are designed to be enduring, with a standing consensus committee comprised of representatives from professional medical societies, federal agencies and patient advocacy organizations.17 The committee applies the principle of “equal management for equal risk,” the Clinical Action Thresholds of the 2019 guidelines and any new technologies and approaches to incorporate into new guidelines as they become available.
Scope of Practice for Family Physicians
Family medicine is a specialty based on comprehensive care encompassing a wide range of medical services. Family physicians practice among diverse populations and in geographically varied settings, including rural communities. Family physicians provide roughly one-third of all outpatient care for women over 30 years and are sometimes the only clinician in underserved areas.18
Each family physician chooses a personal scope of practice based on their training, experience, current competencies and the needs of their patient populations. Therefore, each family physician must assess the appropriateness of performing a colposcopy by considering their training and level of comfort with the procedure, the expertise of staff members, practice setting, equipment availability, local standards of care and economic implications. Broadly speaking, the following indicates that colposcopy is within the current scope of family medicine:
The AAFP advocates for the development and use of patient-centered, evidence-based clinical practice guidelines that adhere to principles based on the following: the National Academy of Medicine’s Clinical Practice Guidelines We Can Trust and the Council on Medical Specialty Societies’ Principles for the Development of Specialty Society Clinical Guidelines and Code for Interactions With Companies.23 When clinical practice guidelines address the issue of who should provide care, they should emphasize appropriate specific competencies rather than a clinician’s specialty designation.
Clinical Indications for Colposcopy
The main indication for colposcopy is the evaluation of individuals at increased risk for cervical dysplasia, including those with the following12:
The 2019 ASCCP Risk-based Management Consensus Guidelines for Abnormal Cervical Cancer Screening Tests and Cancer Precursors establish the threshold for referral to colposcopy, biopsies and potential treatment at a 4% estimated immediate risk of cervical intraepithelial neoplasia 3+.15,24 The patient's risk of CIN 3+ (which includes CIN 3, adenocarcinoma in situ and cancer) is determined by patient history and current test results. Staying up to date with the latest algorithms and clinical recommendations from ASCCP and others is important for guiding evidence-based decisions on the management of abnormal Pap tests and appropriate use of colposcopy.
Training Methodology
The ASCCP defines a colposcopist as “a clinician who has undergone specialized training to develop proficiency in the performance of colposcopy and additional skills needed to accurately diagnose lower genital tract neoplasia. These skills must be accompanied by a comprehensive knowledge of the cervical cancer screening process, lower genital tract disease and evidence-based management of abnormal screening and diagnostic tests.”12
Family physicians often acquire the skills and knowledge to perform colposcopy during their family medicine residency through didactic instruction followed by clinical preceptorship.21 AAFP policy states, “family medicine residencies should strive to teach residents all procedures within the scope of family medicine. They should, at a minimum, teach residents those procedures commonly done by practicing family physicians both in the ambulatory and inpatient settings. Whenever possible, family physician faculty should teach these procedures to all interested learners.”25
Ideally, a family physician will continue a lifelong learning program, participating in intermediate and advanced colposcopy courses, which the ASCCP and other organizations and institutions offer. Membership in societies actively developing evidence-based practice guidelines and standards for colposcopy may also be beneficial.
Credentialing and Privileging
Colposcopy is typically performed in private physician offices, academic centers and community-based clinics. There is no national standard for the number of colposcopies required to demonstrate competence, nor is there a formal certificate or accreditation of competence for the procedure in the United States.26 The AAFP believes that privileging should be based on training experience and current competence.27 Physician privileging should allow all combinations of competencies in adult, pediatric and obstetric care for inpatient and outpatient settings. The AAFP recommends that family physicians document all significant training and experience.
The ASCCP developed evidence-based colposcopy resources that may be useful for family physicians who perform colposcopies and want to maintain and/or demonstrate their competence. In 2017, the ASCCP released a core set of evidence-based recommendations for U.S. colposcopists to “provide guidance for colposcopy terminology, practice and documentation and lay the groundwork for future quality improvement efforts.”14 The recommendations establish minimum and comprehensive colposcopy practice standards for the following six major components of the procedure28:
The minimum practice standards describe baseline requirements for performing a colposcopy adequately and safely. Although this level of competence is acceptable for individuals who perform colposcopy infrequently, the ASCCP states that most colposcopists in the United States should be able to practice at the comprehensive level.
Evidence suggests that new approaches to cervical cancer screening, updated colposcopy guidelines and increased HPV vaccination have resulted in a downward trend in the number of colposcopies performed, particularly those involving lesions associated with HPV 16, which are typically easier to visualize.29-31
Since family physicians are likely performing fewer colposcopies overall and a higher percentage of the colposcopies they perform are more challenging, focusing on quality improvement is key in training new colposcopists and helping existing colposcopists maintain proficiency. Therefore, the ASCCP has identified 11 quality indicators related to documentation, biopsy protocols and follow-up intervals, with minimum and comprehensive target percentages for each indicator.30
Miscellaneous Issues
Family physicians should receive high-quality didactic and procedural training in colposcopy. AAFP policy states, “the AAFP seeks to work collaboratively with other specialty societies, when appropriate, concerning issues of procedure skills, including but not limited to: training, privileging and credentialing, and joint political action.”32 Productive areas for research on colposcopy include an improved definition of the competency-based measures for performing colposcopies and analyzing outcomes in family medicine compared with other specialties. It would be ideal if the AAFP and other specialty organizations could work together to improve patient care by disseminating information to educate all physicians.
Primary prevention through risk-factor identification and patient education, including advocacy for HPV vaccination and education is as important in reducing the prevalence of cervical cancer as secondary prevention by identifying cervical dysplasia at the time of colposcopy.
It is not known whether the performance of colposcopy by family physicians saves money and other resources at the societal level. However, it may offer the following benefits:
Following published guidelines for expedited treatment at the point of care after shared decision making may also convey the following benefits, including saving patient's time and decreasing anxiety about medical visits, lowering costs and reducing the risk of loss to follow-up care, especially among transient populations and patients in settings with limited resources.13,33
References
(1998) (October 2025 COD)