Cervical Cancer Screening

 

Am Fam Physician. 2018 Apr 1;97(7):441-448.

  Related article: Cervical Cancer: Evaluation and Management

  Patient information: A handout on this topic is available at https://familydoctor.org/condition/cervical-cancer/.

Author disclosure: No relevant financial affiliations.

Screening in women has decreased the incidence and mortality of cervical cancer. Precancerous cervical lesions (cervical intraepithelial neoplasias) and cervical carcinomas are strongly associated with sexually-transmitted high-risk human papillomavirus (HPV) infection, which causes more than 99% of cervical cancers. Screening methods include cytology (Papanicolaou test) and HPV testing, alone or in combination. The American Academy of Family Physicians and the U.S. Preventive Services Task Force recommend starting screening in immunocompetent, asymptomatic women at 21 years of age. Women 21 to 29 years of age should be screened every three years with cytology alone. Women 30 to 65 years of age should be screened every five years with cytology plus HPV testing or every three years with cytology alone. Screening is not recommended for women younger than 21 years or in women older than 65 years with an adequate history of negative screening results. The U.S. Preventive Services Task Force is in the process of updating its guidelines. In 2015, the American Society for Colposcopy and Cervical Pathology and the Society of Gynecologic Oncology published interim guidance for the use of primary HPV testing.

Cervical cancer is responsible for more than 7% of all cancer-related deaths in women worldwide.1 Most cases of cervical cancer (85%) occur in developing countries that have ineffective screening programs.2 Total cancer-related deaths in American women declined by more than 80% from 1930 to 2012, primarily because of widespread use of cytology (Papanicolaou [Pap] test).3 The annual incidence and mortality rate of cervical cancer have decreased nearly 50% since 1975; there were reportedly 7.5 cases per 100,000 women from 2009 to 2013, and 2.3 deaths per 100,000 women in 2011.4,5 The most common types of cervical cancer are squamous cell carcinoma and adenocarcinoma.2 The American Cancer Society projected that there would be 12,820 new cases of cervical cancer diagnosed in 2017 in the United States, with 4,210 deaths.3

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Cervical cancer screening in women before 21 years of age leads to more harms than benefits and does not reduce cervical cancer incidence or mortality.

A

4, 14, 16, 18, 20

Average-risk women 21 to 29 years of age should be screened every three years with cytology alone.

A

4, 16, 18, 20

Average-risk women 30 to 65 years of age should be screened every three years with cytology alone or every five years with a combination of cytology and HPV testing.

A

4, 16, 18, 20

Cervical cancer screening should be discontinued in women older than 65 years with an adequate history of negative screening results.

C

4, 16, 18, 20

Annual cervical cancer screening is not recommended for average-risk women of any age.

A

4, 16, 18, 20

Women with a hysterectomy unrelated to cancer should not be screened for cervical cancer.

C

4, 16, 18, 20

Women with a hysterectomy related to a history of cancer should be screened for cervical cancer for 20 years after the hysterectomy.

C

4, 16, 18, 20

Primary HPV testing may be considered for cervical cancer screening every three years in women 25 years and older.

B

4, 15, 23


HPV = human papillomavirus.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Cervical cancer screening in women before 21 years of age leads to more harms than benefits and does not reduce cervical cancer incidence or mortality.

A

4, 14, 16, 18, 20

Average-risk women 21 to 29 years of age should be screened every three years with cytology alone.

A

4, 16, 18, 20

Average-risk women 30 to 65 years of age should be screened every three years with cytology alone or every five years with a combination of cytology and HPV testing.

A

4, 16, 18, 20

Cervical cancer screening should be discontinued in women older than 65 years with an adequate history of negative screening results.

C

4, 16, 18, 20

Annual cervical cancer screening is not recommended for average-risk women of any age.

A

4, 16, 18, 20

Women with a hysterectomy unrelated to cancer should not be screened for cervical cancer.

C

4, 16, 18, 20

Women with a hysterectomy related to a history of cancer should be screened for cervical cancer for 20 years after the hysterectomy.

C

4, 16, 18, 20

Primary HPV testing may be considered for cervical cancer screening every three years in women 25 years and older.

B

4, 15, 23


HPV = human papillomavirus.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice,

The Authors

show all author info

CAITLYN M. RERUCHA, MD, FAAFP, is an assistant professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences, Bethesda, Md. She is also a clinical assistant professor in the Department of Family Medicine at Texas A&M College of Medicine, Temple, and is a faculty member in the Family Medicine Residency Program at Carl R. Darnall Army Medical Center, Fort Hood, Tex....

REBECCA J. CARO, DO, is an assistant professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences and a staff physician at Bassett Army Community Hospital, Fort Wainwright, Alaska. At the time this article was written, she was an obstetrics fellow in the Department of Family Medicine at Carl R. Darnall Army Medical Center.

VERNON L. WHEELER, MD, FAAFP, is an assistant professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences. He is also a clinical assistant professor in the Department of Family Medicine at Texas A&M College of Medicine and a faculty member in the Family Medicine Obstetrics Fellowship Program at Carl R. Darnall Army Medical Center Family Medicine Residency.

Address correspondence to Caitlyn M. Rerucha, MD, Carl R. Darnall Army Medical Center, 36000 Darnall Loop, Fort Hood, TX 76544 (e-mail: cmreruchamd@gmail.com). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

show all references

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