Cervical Cancer Screening

Aka: Cervical Cancer Screening, Pap Smear Intervals, ASCCP Calculated Risk Based Protocol

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II. Precautions

  1. Up to 15-20% of U.S. Cervical Cancer is due to adenocarcinoma (not associated with HPV infection in 25% of cases)

III. Protocol: ASCCP Calculated Risk Based Protocol

  1. Background
    1. Asymptomatic patients are stratified to testing based on risk of CIN 3 or worse (e.g. in situ, invasive Cervical Cancer)
    2. Specific risk based approach is preferred over less nuanced approach described below
  2. Risk Calculator Tools
    1. ASCCP Web Application (free with email registration)
      1. https://app.asccp.org/
    2. ASCCP Mobile Application
      1. https://www.asccp.org/mobile-app
  3. Immediate CIN 3 or greater (CIN 3+) Risk < 4%
    1. Five year CIN 3+ Risk <0.15%
      1. HPV-based testing 5 years
    2. Five year CIN 3+ Risk 0.15 to 0.54%
      1. HPV-based testing 3 years
    3. Five year CIN 3+ Risk <0.54%
      1. HPV-based testing 1 years
  4. Immediate CIN 3 or greater (CIN 3+) Risk >= 4%
    1. Immediate CIN 3+ Risk 4 to 24%
      1. Colposcopy
    2. Immediate CIN 3+ Risk 25 to 59%
      1. Expedited treatment or Colposcopy
    3. Immediate CIN 3+ Risk >60%
      1. Expedited treatment
  5. References
    1. Cheung (2020) J Low Genit Tract Dis 24(2): 90-101 [PubMed]
    2. Perkins (2020) J Low Genit Tract Dis 24(2): 102-31 [PubMed]
    3. Egeman (2020) J Low Genit Tract Dis 24(2): 132-43 [PubMed]

IV. Management: Extremely Low Risk Patients - Pap Smear not necessary

  1. Age under 21 years old
  2. Hysterectomy for benign disease (see below)
    1. Recent studies suggest no further Pap Smears needed
  3. Age 65-70 or over (AAFP and USPTF recommend age 65)
    1. Two consecutive negative Pap Smears with HPV Testing, with most recent test within last 5 years OR
    2. Three normal consecutive Pap Smears and no abnormal Pap Smears in the last 10 years (ACS)

V. Management: Average Risk Patients

  1. Protocol (varies by ACS, ACOG and USPHS)
    1. Initial screening age 21 to 30 years old
      1. Thin Prep Pap Smear cytology without HPV Testing once every 3 years for those under 30 years
      2. Do not test HPV with Pap Smear for those under age 25 years (high Prevalence)
        1. Those age 25-30 years may benefit from HPV Testing every 3 years
    2. Age 30 to 65 years old (with intact Uterus and Cervix)
      1. Cytology alone every 3 years (ACOG, ACP, USPTF, AAFP) OR
      2. Cotesting with Cytology and HPV Testing every 5 years (ACOG, ACP, USPTF, AAFP) OR
      3. Primary HPV Testing without cytology every 3 years (ASCCP) or 5 years (USPTF)
        1. If Genotype 16, 18 or 31 positive, then reflex to Colposcopy
        2. If Genotype 11 or 12 positive (or pooled, non-typed HPV positive), reflex to Cervical Cytology
          1. Obtain Colposcopy if abnormal Cervical Cytology (ASCUS or more)
        3. References
          1. Perkins (2020) J Low Genit Tract Dis 24(2): 102-31 [PubMed]
    3. Age over 65 years old
      1. No screening needed if adequate negative Pap Smear history
  2. Criteria: Average Risk
    1. Cervical Cancer Screening starts at age 21 years regardless of sexual activity
    2. Cervical Cancer Screening is not needed in very low risk patients (see above)
    3. High risk patients require more specific screening (see below)

VI. Management: High Risk Patients

  1. Protocol
    1. Start screening immunosuppressed patients within one year of onset sexual activity
    2. Specific protocols exist for history Cervical Dysplasia or cancer, high risk HPV findings
  2. High risk criteria
    1. Significant Cervical Dysplasia (CIN2, CIN3, CIS) or Cervical Cancer history
    2. In Utero Diethylstilbestrol Exposure
    3. Immunocompromised patients
    4. HIV positive
  3. Other higher risk criteria that may prompt closer monitoring
    1. Sexual activity onset before age 20 years
      1. Screen and prevent Sexually Transmitted Diseases
    2. Patients with three or more lifetime sexual partners
    3. History of HPV or other Sexually Transmitted Disease
    4. Tobacco Abuse

VII. Management: After Hysterectomy with Cervix removed

  1. Total Hysterectomy without uterine or Cervical Cancer
    1. No further Cervical Cancer Screening
  2. Total Hysterectomy related to cancer history
    1. Continue screening for 20 years
    2. Obtain vaginal cytology every 3 years (or cotesting with HPV every 5 years)

VIII. Efficacy: Pap Smear Screening for Cervical Cancer

  1. USPSTF Strength of Recommendation: A
  2. Original slide testing had issue of False NegativePap Smears
    1. Importance
      1. Accounts for 30% of U.S. Cervical Cancer cases/years
      2. Accounts for 3,700 Cervical Cancer cases/year
    2. Causes
      1. Incomplete transformation zone sampling
      2. Poorly prepared slide (e.g. drying artifact)
      3. Cytotechnologist failure to detect abnormality
        1. Now limited to 100 slides per day for review
        2. Now 10% of "normal" slides re-screened
  3. Adjunctive methods to decrease False Negative Rate
    1. General
      1. Adjuncts identify more LGSIL lesions, but may lead to over-testing
    2. Liquid-Based/Thin-Layer Preparation
      1. Improves cell sample and fixation
      2. Commercial Tests
        1. Thin Prep
        2. AutoCyte Prep (TriPath)
    3. Computer-Assisted Screening
      1. AutoPap: Scores slide on likeliood of abnormality
      2. AutoCyte: Presents cell images to cytopathologist
    4. HPV Testing
      1. Hybrid Capture II detects 13 high risk HPV types
      2. Not recommended outside age of 25 to 65 years old, or if Immunocompromised
  4. References
    1. Nuovo (2001) Am Fam Physician 64:780-6 [PubMed]

IX. Resources

  1. ASCCP Risk Tools
    1. https://www.asccp.org/mobile-app

X. References

  1. (2002) JAMA 287:2120 [PubMed]
  2. (2002) CA Cancer J Clin 52:342-62 [PubMed]
  3. (1995) Int J Gynaecol Obstet 49:210-11 [PubMed]
  4. Burness (2020) Am Fam Physician 102(1): 39-48 [PubMed]
  5. Rerucha (2018) Am Fam Physician 97(7): 441-8 [PubMed]
  6. Sawaya (2015) Ann Intern Med 162(12):851-9 +PMID: 25928075 [PubMed]
  7. Smith (2000) CA Cancer J Clin 50:34-49 [PubMed]
  8. Zoorob (2001) Am Fam Physician 63(6):1101-12 [PubMed]
  9. Woolf (1996) USPSTF Clinical Preventive Services, p.105
  10. (1997) ACOG Opinion, no. 185

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