Cervical cancer is a common gynecologic malignancy and a major cause of cancer deaths in low- and middle-resource countries (1, 2). Effective screening and prevention methods are available and have been proven to reduce cervical cancer incidence and mortality (3, 4).
Cervical cancer screening is recommended for all women in the United States, with variations across major medical organizations regarding the starting age, choice of tests, and frequency of screening.
In 2020, the World Health Organization (WHO) initiated a global strategy to eliminate cervical cancer as a public health problem, with the following goals to be met by 2030 (see WHO: Cervical Cancer Elimination Initiative):
90% of girls are fully vaccinated with HPV vaccine by age 15 years
70% of women are screened with a high-performance test by age 35 and again by 45
90% of women identified with cervical disease (precancer or invasive cancer) receive treatment
General references
1. Sung H, Ferlay J, Siegel RL, et al: Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 71 (3):209–249, 2021. doi: 10.3322/caac.21660
2. Bhatla N, Aoki D, Sharma DN, Sankaranarayanan R: Cancer of the cervix uteri: 2021 update. Int J Gynaecol Obstet 155 Suppl 1(Suppl 1):28-44, 2021. doi:10.1002/ijgo.13865
3. Koliopoulos G, Nyaga VN, Santesso N, et al: Cytology versus HPV testing for cervical cancer screening in the general population. Cochrane Database Syst Rev 8(8):CD008587, 2017. Published 2017 Aug 10. doi:10.1002/14651858.CD008587.pub2
4. Arbyn M, Xu L, Simoens C, Martin-Hirsch PP: Prophylactic vaccination against human papillomaviruses to prevent cervical cancer and its precursors. Cochrane Database Syst Rev 5(5):CD009069, 2018. Published 2018 May 9. doi:10.1002/14651858.CD009069.pub3
Screening for Cervical Cancer
Routine cervical cancer screening effectively detects preinvasive and early-stage disease and decreases cervical cancer incidence and mortality rates.
Two types of screening tests for cervical abnormalities are used:
Testing for high-risk HPV genotypes
Pap test (cervical cytology)
Cervical screening guidelines vary somewhat; general guidelines include (see table Cervical Cancer Screening):
21 to 25 years: Starting age for screening
21 to 29 years: Options include Pap test alone every 3 years (preferred by the United States Preventive Services Task Force [USPSTF, 1]); HPV test alone every 5 years (preferred by the American Cancer Society [ACS, 2]); or Pap and HPV co-testing every 5 years
20 to 65 years: Options include Pap and HPV co-testing every 5 years (preferred by USPSTF); HPV test alone every 5 years (preferred by ACS); or Pap test alone every 3 years
> 65 years: Testing is stopped if an adequate series of previous tests have been normal across the preceding 10 years; testing should be continued if women have not had adequate normal test results, or started if they have not been screened previously
For patients screened with a Pap test alone, if the cytology result is ASCUS (atypical squamous cells of undetermined significance), which is an inconclusive finding, HPV testing is the preferred method of follow-up evaluation; this approach is called reflex HPV testing. If HPV testing is negative, screening tests should be repeated in 3 years. If HPV testing is positive, colposcopy should be done.
For women who have had a total hysterectomy (cervix and uterus removed) and do not have a history of cervical cancer or high-grade cervical intraepithelial neoplasia, further screening is not indicated.
Cervical Cancer Screening
Age Group | ACS 2020 Recommendations* | USPSTF 2018 Recommendations* |
|---|---|---|
Age 21‒24 | No screening | Cervical cytology alone every 3 years |
Age 25–29 | One of the following:
| Cervical cytology alone every 3 years |
Age 30‒65 | One of the following:
| One of the following:
|
Age > 65 | Discontinuation of screening if adequate negative prior screening‡ For women without documentation of prior screening, continued screening until criteria for stopping are met | Discontinuation of screening if adequate negative prior screening† and not at high risk of cervical cancer |
† A test FDA-approved for primary HPV testing should be used for primary screening. | ||
‡ Adequate negative prior screening is currently defined as 2 consecutive negative primary HPV tests or 2 negative Pap/HPV cotests or 3 negative Pap (cytology) tests within the past 10 years, with the most recent test occurring within the past 3–5 years. | ||
ACS = American Cancer Society; FDA = US Food and Drug Administration; HPV = human papillomavirus; hrHPV = high-risk HPV; Pap = Papanicolaou; USPSTF = US Preventive Task Force. | ||
The Papanicolaou test (cervical cytology) was developed in 1928 and was a major advancement in screening for cervical cancer. Cervical cytology results are reported using standardized terminology, the Bethesda System (see table Bethesda Classification of Cervical Cytology).
Bethesda Classification of Cervical Cytology*
Category | Specifics | Comments |
|---|---|---|
Specimen type | Conventional (Papanicolaou [Pap] test), liquid-based preparation, or other | Type of test is noted. |
Adequacy of the specimen | Satisfactory for evaluation | Any quality indicators (eg, presence or absence of endocervical/transformation zone component, partially obscuring blood, inflammation) are described. |
Unsatisfactory for evaluation (rejected and not processed) | Reason is specified. | |
Unsatisfactory for evaluation but processed and evaluated | Reason is specified. | |
General categorization (optional) | Negative for intraepithelial lesion or cancer Epithelial cell abnormalities Other findings | Findings are stated or described under Interpretation, below. |
Interpretation of negative (nonmalignant) abnormalities† | Organisms | Possible findings include the following:
|
Nonneoplastic findings (reporting is optional) | Possible findings include the following:
| |
Interpretation of epithelial cell abnormalities | Squamous cell | Possible findings include the following:
|
Glandular cell | Possible findings include the following:
| |
Interpretation of other abnormalities | Endometrial cells (in a woman > 45)* | Whether sample is negative for squamous intraepithelial lesion is specified. |
Other cancers | — | Type is specified. |
* Use of an automated device for scanning should be reported, as should adjunctive tests (eg, HPV) and their results. | ||
† If there is no cellular evidence of neoplasia, the report should state negative for intraepithelial lesion or malignancy here or in the general categorization. | ||
‡ Cellular changes of HPV infection—previously called koilocytosis, koilocytotic atypia, and condylomatous atypia—are included in the category of low-grade squamous intraepithelial lesion. | ||
CIN = cervical intraepithelial neoplasia; CIS = carcinoma in situ; HPV = human papillomavirus; IUD = intrauterine device; NOS = not otherwise specified. | ||
Adapted from the Bethesda System 2014, National Institutes of Health. | ||
Screening references
1. US Preventive Services Task Force, Curry SJ, Krist AH, et al: Screening for Cervical Cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2018;320(7):674-686. doi:10.1001/jama.2018.10897
2. Fontham ETH, Wolf AMD, Church TR, et al: Cervical cancer screening for individuals at average risk: 2020 guideline update from the American Cancer Society. CA Cancer J Clin 70(5):321-346, 2020. doi:10.3322/caac.21628
Prevention of Cervical Cancer
(See also Human Papillomavirus (HPV) Vaccine and the Centers for Disease Control and Prevention: Human Papillomavirus (HPV) Vaccination Information for Clinicians.)
Several preventive HPV vaccines are available worldwide (1):
A bivalent vaccine that protects against subtypes 16 and 18 (which cause most cervical cancers)
A quadrivalent vaccine that protects against subtypes 16 and 18 plus 6 and 11
A 9-valent vaccine that protects against the same subtypes as the quadrivalent plus subtypes 31, 33, 45, 52, and 58 (which cause about 15% of cervical cancers)
Subtypes 6 and 11 cause > 90% of visible genital warts.
The vaccines aim to prevent cervical cancer but do not treat it. All three types of vaccines are most effective if given before first sexual activity and potential exposure to HPV.
The HPV vaccine is recommended for all people, ideally before they become sexually active. The standard recommendation is to vaccinate beginning at age 11 to 12 years, but vaccination may begin at age 9.
Prevention reference
1. World Health Organization: Immunization, Vaccines and Biologicals: Human papillomavirus vaccines (HPV)
