Lee Shulman, MD
The US Preventive Services Task Force (USPSTF) issued new guidelines recommending that women aged 30 to 65 years at average risk for cervical cancer can choose to receive a Pap smear alone every 3 years or screening with the high-risk human papillomavirus (hrHPV) test alone or cotesting every 5 years. Women aged 21 to 29 years should receive a Pap test every 3 years.
This new guideline updates recommendations issued in 2012. This the first time the USPSTF has recommended hrHPV screening alone.
“This action by the USPSTF to recommend HPV testing alone represents a milestone in women's health, because it shows that US clinical guidelines are catching up to science and to the rest of the world,” Lee Shulman, MD, professor in Obstetrics and Gynecology and chief of the Division of Clinical Genetics at the Feinberg School of Medicine at Northwestern University, said in a release.
“Multiple studies have shown that you get the same benefit from HPV testing alone that you do from cotesting, but at a lower cost,” he added. “This recommendation moves the United States closer to common ground with all of the major countries in Europe and Australia who began implementing primary HPV screening programs some time ago.”
The USPSTF concluded that “there are no clinically important differences between liquid-based cytology and conventional cytology.” Furthermore, a variety of hrHPV tests—including in situ hybridization, polymerase chain reaction, and hybrid capture technology—have been shown to accurately detect the HPV types 16 and 18, the strains associated with cervical cancer. hrHPV testing can be used for primary screening, in combination with cytology, and for follow-up testing of positive cytology results.
These recommendations are meant for asymptomatic women regardless of sexual history or HPV vaccination status. As in the previous guideline, the Task Force recommends against screening for average-risk women younger than 21 years, older than 65 years who have had adequate prior screening, or women who have had a hysterectomy with removal of the cervix and do not have a history of high-grade precancerous lesions.
Women older than 65 years who were exposed to diethylstilbestrol in utero and those with a compromised immune system or a history of high-grade precancerous lesions or cervical cancer may need to continue screening. The recommendations do not cover women who are at high risk for cervical cancer, such as those who were previously diagnosed with a high-grade precancerous cervical lesion.
Cervical cancer deaths have declined from 2.8 per 100,000 population in 2000 to 2.3 deaths per 100,000 in 2015, thanks in part to widespread screening. Women who have not received adequate screening account for most cervical cancer–related deaths, and the USPSTF said that delivering adequate screening and follow-up care to those women can further reduce incidence and mortality.
“Screening for cervical cancer saves lives and identifies the condition early when it is treatable,” USPSTF member Carol Mangione, MD, said in a release. She serves as chief of General Internal Medicine and Health Services Research at the David Geffen School of Medicine at UCLA. “There are several effective screening strategies available, so women should talk to their doctor about which one is right for them.”
As many as 25% of women aged 45 to 64 years may have an inadequate or unknown screening history. In the United States, women with limited access to care and women of color are less likely to get adequate screening.
The cervical cancer mortality rate is 10.1 per 100,000 among African American women, more than twice that of white women (4.7 per 100,000) after adjusting for hysterectomy rate.2
Furthermore, while the cervical cancer mortality rate is lowest among non-Hispanic white women, the rate is much higher than average among white women in geographically isolated and medically underserved areas, particularly Appalachia.
In the general population, 11.4% of women said they had not received a Pap smear in the previous 5 years compared with 23.1% of women without health insurance and 25.5% of women without a regular healthcare provider. Recent Asian immigrants are also less likely to get screened, possibly due to language or cultural barriers.
“We know that some populations are affected by cervical cancer more than others,” USPSTF vice chair Douglas K. Owens, MD, director of the Center for Primary Care and Outcomes Research in the Stanford University School of Medicine and the Center for Health Policy in the Freeman Spogli Institute for International Studies, said in a statement. “We need more research to determine how we can effectively reduce disparities among these women, and ultimately, help save more lives.”
- U.S. Preventive Services Task Force. Screening for cervical cancer: U.S. Preventive Services Task Force recommendation statement [published online August 21, 2018]. JAMA. doi:10.1001/jama.2018.10897.
- Beavis AL, Gravitt PE, Rositch AF. Hysterectomy-corrected cervical cancer mortality rates reveal a larger racial disparity in the United States. Cancer. doi: 10.1002/cncr.30507.