Cervical cancer screening guidelines from the American Academy of Family Practice recommend the following:
- For women ages 21-29, cytology (Pap test) alone every 3 years.
- For women ages 30-65, co-testing with cytology and HPV testing every 5 years or cytology alone every 3 years.
- Nearly all cervical cancers are caused by persistent infection with high-risk HPV genotypes like HPV-16 and HPV-18. Screening aims to detect precancerous lesions that may develop due to prolonged HPV infection so they can be treated before developing into invasive cancer.
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Current cervical cancer screening guidelines 2018
1. Cervical Cancer Screening Guidelines
American Academy of Family Practice, 2018
MSL Candidate
Brenda Roberts, M.D.
2. OUTLINE
• Background
• Risk Factors for Cervical Cancer
• Clinically Important Human Papilloma Virus (HPV) Genotypes
• Pathogenesis of HPV infections
• Cervical Cancer Screening Recommendations
• Management of Abnormal Test Results
3. Background
• Nearly 13,000 cases of cervical cancer are diagnosed each year, with more
than 4,000 deaths
• This number has decreased nearly 50% since 1975, primarily because of
the widespread use of cytology (Papanicolaou [Pap] test)
• Of women diagnosed with cervical cancer, 50% did not receive any
screening prior to their diagnosis
• 10% of those diagnosed, had not been screened in the previous 5 years
Rerucha CM, Carnall, CR. Cervical Cancer Screening. AFP. 2018;97(7):441-448.
4. Risk Factors
Risk Factors For Cervical Cancer:
Multiple sex partners
Age at first intercourse <18 years
Multiple full term pregnancies
History of sexually transmitted diseases
Smoking
Oral contraceptives for 5 years or more
Family History (genetic susceptibility)
Immunosuppression
Black or Hispanic race
Low socioeconomic status
Wipperman J, Neil T, Williams T. Cervical Cancer: Evaluation and Management. AFP. 2018;97(7):449-454.
5. High Risk Human Papilloma Virus (HPV)
Genotypes
• HPV infections cause 99.7% of cervical cancers
• Most cervical HPV infections are transient and clear within 6-24
months
• HPV 16 & 18 cause over 70% of all cervical cancers
• The progression from persistent HPV infection to invasive cervical
disease takes 10-20 years
Rerucha CM, Carnall, CR. Cervical Cancer Screening. AFP. 2018;97(7):441-448.
6. Clinically Important HPV Genotypes
Genotype Pathogenesis
High Risk (oncogenic):
Type 16 Causes 50% of cervical cancers
Type 18 Causes 20% of cervical cancers
Other High Risk HPV types:
31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, 68 All types combined cause 25% of cervical cancers
Low risk HPV types (wart causing):
Types 6 and 11 Cause 90-95% of anogenital warts
HPV = Human Papilloma Virus
Rerucha CM, Carnall, CR. Cervical Cancer Screening. AFP. 2018;97(7):441-448.
7. Pathogenesis
Wipperman J, Neil T, Williams T. Cervical Cancer: Evaluation and Management. AFP. 2018;97(7):449-454.
CIN = Cervical Intraepithelial Neoplasia. CIN1 involves 1/3 of cell wall. CIN2 involves 2/3 of cell wall. CIN3 involves entire cell
• >50% of adults 20-24 years of age are currently infected with HPV
• 50% will clear the HPV infection within 6 months
• 90% will clear the HPV infection within 2 years
• HPV Infections that persist can lead to dysplastic changes – Cervical
Intraepithelial Neoplasia (CIN):
• CIN1 low-grade dysplasia (usually regresses)
• CIN2-CIN3 high-grade dysplasia (20% progress to invasive cervical cancer within 5
years if untreated)
8. Cervical Cancer Screening Recommendations
Patient Age/Population Recommendations
<21 yrs Screening is not recommended
21– 29 yrs Cytology (pap test) alone every 3 yrs
30 – 65 yrs Cytology (pap test) + HPV testing every 5 yrs (preferred)
or cytology alone every 3 yrs
>65 yrs Screening not recommended if low risk - no history of
CIN2 or higher within the past 20 yrs and no risk factors
Hysterectomy for benign reasons Screening not recommended
Women who have received HPV
vaccine
Routine screening
HPV = Human Papilloma Virus. CIN2 = Cervical Intra-epithelial Neoplasia 2 (involves 2/3 of the cell wall)
Rerucha CM, Carnall, CR. Cervical Cancer Screening. AFP. 2018;97(7):441-448.
9. Management of Abnormal Cytology (Pap test)
and/or Positive HPV
Cytology (Pap Test) Results HPV Results Management
Normal Negative HPV Routine screening
Normal Positive HPV, low risk*
Positive HPV, high risk**
Routine screeing
Co-test in 1 year
Cervical Intraepithelial Neoplasia 1,
CIN1
Negative HPV
Positive HPV, low risk*
Positive HPV, high risk**
Co-test in 1 year
Co-test in 1 year
Refer for colposcopy
CIN2/CIN3 Positive HPV, low* or high risk** Refer for colposcopy
Fontaine P, Saslow D, King V. ACS/ASCCP/ASCP Guidelines for the Early Detection of Cervical Cancer. AFP. 2012;86(6):501-508.
Rerucha CM, Carnall, CR. Cervical Cancer Screening. AFP. 2018;97(7):441-448. HPV = Human Papilloma Virus