Women's Preventive Services Initiative Guidelines Supersede Other Cervical Cancer Screening Guidelines

To the Editor: We appreciated the cervical cancer screening article by Drs. Wiser and Quinlan.¹ It focused on updated guidelines from the US Preventive Services Task Force (USPSTF) and the American Cancer Society; however, the Women's Preventive Services Initiative (WPSI) guidelines published in January 2026 have become the new standard for cervical cancer screening in the United States. This is in part because these recommendations are approved by the Health Resources and Services Administration and linked to insurance coverage with no out-of-pocket costs for cervical cancer screening.² Critical points in the guidelines include a preference for primary human papillomavirus (HPV) screening over cotesting for asymptomatic, average-risk women 30 to 65 years of age and offering all patients the option of self-collection.

Although the article suggests that primary HPV screening increases colposcopies compared with cotesting, it does not. Instead, the modeling report commissioned for the USPSTF found that cotesting results in 60% more tests performed for the same outcomes and causes harm by directing falsely positive women to more colposcopies for which they have a nontrivial out-of-pocket cost.³

Primary HPV screening simplifies the algorithms: patients who are HPV negative should have repeat testing in 5 years (regardless of collection technique), those who are positive for HPV 16 or 18 warrant colposcopy, and those positive for HPV that is not 16 or 18 (about 7% of screening tests) require a triage test. Triage testing is moving toward dual staining biomarkers (p16/Ki67) and away from cytology. Biomarker testing is simpler for the clinician to interpret and significantly more cost-effective than cytology.⁴

Family physicians screen nearly 60% of women who are screened for cervical cancer.⁵ With the self-collection option, family physicians can offer all asymptomatic, average-risk women screening, without the need for a pelvic examination.

For the United States to reach the World Health Organization (WHO) cervical cancer elimination goal of an overall incidence of less than 4 per 100,000 women with cervical cancer, both HPV vaccination and self-collection are needed.⁶ HPV vaccination in the United States has already reduced the cervical cancer incidence to 3.1 per 100,000 among women 18 to 34 years of age.⁷ Implementing self-collection can increase adherence to cervical cancer screening from the current rate of 70% to the WHO goal of 90%. If family physicians can reach 90% of all US women, we can reduce the time needed to reach the 4 per 100,000 goal within a decade!⁶

We encourage all family physicians to step up and provide patient-centered cervical cancer screening by implementing the WPSI guidelines in their practices and health systems without delay.

In Reply: We thank the authors for their thoughtful response to our article. We appreciate the work put into the development of the WPSI guidelines; however, they were not yet published at the time our article was written. We agree that they are likely to inform screening for cervical cancer moving forward.

Although the USPSTF's modeling study found that cotesting results in more tests and colposcopies than a primary HPV screening strategy, their draft evidence report on 11 comparative studies with concurrent controls does not support this conclusion.³ In six randomized controlled trials (n = 563,818), primary HPV screening was associated with an increase in colposcopies compared with cytology (relative risk = 1.23 [95% CI, 1.16–1.31] to 3.05 [95% CI, 2.75–3.38]). Two studies (n = 161,228) demonstrated reduced use of colposcopies; however, these studies had lower test positivity overall and used a more conservative referral protocol, which likely led to these results. Finally, in two trials (n = 69,684), cotesting increased colposcopies compared with cytology. These data seem to support an increased risk of colposcopy with primary HPV screening. We look forward to postimplementation data to determine the real-world impact of primary HPV screening on the use of colposcopy and other harms.

Author Disclosure: Dr. Wiser disclosed a relationship with Merck as a consultant on HPV vaccination. All other individuals in a position to control content for this activity have indicated that they have no relevant financial relationships to disclose.