George F. Sawaya, MD; Shalini Kulasingam, PhD; Thomas D. Denberg, MD, PhD; Amir Qaseem, MD, PhD, MHA; for the Clinical Guidelines Committee of the American College of Physicians *
Note: Best practice advice papers are "guides" only and may not apply to all patients and all clinical situations. Thus, they are not intended to override clinicians' judgment. All ACP best practice advice papers are considered automatically withdrawn or invalid 5 years after publication or once an update has been issued.
Disclaimer: The authors of this article are responsible for its contents, including any clinical or treatment recommendations.
Financial Support: Financial support for the development of this paper comes exclusively from the ACP operating budget.
Disclosures: Dr. Sawaya reports that he was commissioned by the American College of Physicians to write this manuscript and received an honorarium. Dr. Kulasingam reports personal fees from the American College of Physicians during the conduct of the study. Dr. Barry reports grants, personal fees, and nonfinancial support from the Informed Medical Decisions Foundation/Healthwise and personal fees and nonfinancial support from Massachusetts General Hospital/Harvard Medical School outside the submitted work. Dr. Schünemann reports that he played a critical role in the World Health Organization cervical cancer screening and treatment guidelines for low- and middle-income countries. Authors not named here have disclosed no conflicts of interest. Authors followed the policy regarding conflicts of interest described at www.annals.org/article.aspx?articleid=745942. Disclosures can also be viewed at www.acponline.org/authors/icmje/Conflict OfInterestForms.do?msNum=M14-2426. A record of conflicts of interest is kept for each Clinical Guidelines Committee meeting and conference call and can be viewed at www.acponline.org/clinical_information/guidelines/guidelines/conflicts_cgc.htm.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer.
Requests for Single Reprints: George F. Sawaya, MD, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, 550 16th Street, Floor 7, Box 0132, San Francisco, CA 94158.
Current Author Addresses: Dr. Sawaya: Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, 550 16th Street, Floor 7, Box 0132, San Francisco, CA 94158.
Dr. Kulasingam: University of Minnesota, School of Public Health, Division of Epidemiology and Community Health, 1300 South 2nd Street, West Bank Office Building, Suite 300, Minneapolis, MN 55454.
Dr. Denberg: Carilion Clinic, PO Box 13727, Roanoke, VA 24036.
Dr. Qaseem: American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106.
Author Contributions:Conception and design: G.F. Sawaya, T. Denberg, A. Qaseem.
Analysis and interpretation of the data: G.F. Sawaya, S. Kulasingam, T. Denberg, A. Qaseem.
Drafting of the article: G.F. Sawaya, S. Kulasingam, T. Denberg, A. Qaseem.
Critical revision of the article for important intellectual content: G.F. Sawaya, S. Kulasingam, T. Denberg, A. Qaseem.
Final approval of the article: G.F. Sawaya, S. Kulasingam, T. Denberg, A. Qaseem.
Obtaining of funding: A. Qaseem.
Administrative, technical, or logistic support: G.F. Sawaya, A. Qaseem.
The purpose of this best practice advice article is to describe the indications for screening for cervical cancer in asymptomatic, average-risk women aged 21 years or older.
The evidence reviewed in this work is a distillation of relevant publications (including systematic reviews) used to support current guidelines.
Clinicians should not screen average-risk women younger than 21 years for cervical cancer.
Clinicians should start screening average-risk women for cervical cancer at age 21 years once every 3 years with cytology (cytologic tests without human papillomavirus [HPV] tests).
Clinicians should not screen average-risk women for cervical cancer with cytology more often than once every 3 years.
Clinicians may use a combination of cytology and HPV testing once every 5 years in average-risk women aged 30 years or older who prefer screening less often than every 3 years.
Clinicians should not perform HPV testing in average-risk women younger than 30 years.
Clinicians should stop screening average-risk women older than 65 years for cervical cancer if they have had 3 consecutive negative cytology results or 2 consecutive negative cytology plus HPV test results within 10 years, with the most recent test performed within 5 years.
Clinicians should not screen average-risk women of any age for cervical cancer if they have had a hysterectomy with removal of the cervix.
Table. Current Cervical Cancer Screening Guidelines for Average-Risk Women* From the U.S. Preventive Services Task Force, American Cancer Society/American Society for Colposcopy and Cervical Pathology/American Society for Clinical Pathology, and American Congress of Obstetricians and Gynecologists
Summary of the American College of Physicians best practice advice on cervical cancer screening in average-risk women.
HPV = human papillomavirus.
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Video news story about ACP's Best Practice Advice for the proper time, test, and interval for cervical cancer screening featuring Dr. Tanveer Mir, a member of ACP's Clinical Guidelines Committee.
Andrew Olson and Hanna Bloomfield
Department of Medicine, University of Minnesota Medical School and Minneapolis VA Medical Center
May 4, 2015
Conflict of Interest:
Dr. Bloomfield is an investigator at the Minneapolis VA Evidence Synthesis Program.
Communicating Value: Discussing Pelvic Examinations with Patients
To the Editor:The recently published guideline (1) by Sawaya et al on behalf of the ACP provides clear guidance for providers about performing appropriate cervical cancer screening and avoid wasteful screening in women who are unlikely to benefit from the intervention. The guideline provides specific advice to providers about how to discuss less frequent screening to women who may be anxious about the harms of less frequent screening and also recommends that there be electronic medical record based solutions for identifying and decreasing inappropriate cervical cancer screening.We believe that the authors’ advice to explain to patients that over-screening for cervical cancer screening is more likely to result in harm than benefit should include information that the pelvic examination alone is also unlikely to result in benefit and should be foregone as a screening test in average risk, asymptomatic women. (2,3) The consensus in the present guideline about cervical cancer screening is in stark contrast to the discord (4) surrounding ACP’s recommendation that the pelvic examination not be performed as a screening test in asymptomatic, average risk women. However, the evidence remains clear that screening pelvic examinations (performed for purposes other than collection of specimens for cervical cytology testing) do not result in decreased morbidity or mortality for women and thus should not be routinely performed. Providers should be empowered to have this discussion with women and focus on providing screening and other preventive measures that will result in improved health outcomes.1. Sawaya GF, Kulasingam S, Denberg T, Qaseem A. Cervical Cancer Screening in Average-Risk Women: Best Practice Advice From the Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med. [Epub ahead of print 30 April 2015] doi:10.7326/M14-24262. Bloomfield HE, Olson A, Greer N, Cantor A, MacDonald R, Rutks I, et al. Screening Pelvic Examinations in Asymptomatic, Average-Risk Adult Women: An Evidence Report for a Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2014;161:46-53. doi:10.7326/M13-28813. Qaseem A, Humphrey LL, Harris R, Starkey M, Denberg TD, for the Clinical Guidelines Committee of the American College of Physicians. Screening Pelvic Examination in Adult Women: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2014;161:67-72. doi:10.7326/M14-07014. Jennings JC, Blake J. Screening Pelvic Examinations in Asymptomatic, Average-Risk Adult Women. Ann Intern Med. 2014;161:924. doi:10.7326/L14-5034
Terence J. Colgan, Robert Marshall Austin
Mount Sinai Hospital, Toronto, Canada and Magee-Women’s Hospital of UPMC, Pittsburgh, PA
July 17, 2015
Risk assessment and cervical screening
We read with interest The Best Practice Advice “Cervical Cancer Screening in Average-Risk Women” by the Clinical Guidelines Committee (1). Although the concept of clinical risk assessment may be useful in other screening procedures, revival of the concept of clinical risk assessment in cervical screening may have unintended consequences. Earlier screening guidelines did define clinical risk groups based upon sexual history to guide cervical screening recommendation. For example, the 1976 Canadian task force identified an “at risk” group and a high risk group: those who had had intercourse at an early age and those who had had multiple partners (2) Six years later, however, it was recognized that the role of the male vector and changing sexual activity negated the identification of a high risk group and only a single “at risk” group was recognized (3) The Committee correctly recognizes that women with a history of HSIL or cancer, an immunocompromised state, or in utero exposure to diethylstilbestrol should be excluded from broadly applied screening guidelines. Although other risk factors such as absent or infrequent prior cervical screening and infection with the highest risk HPV16 genotype (4) do increase the risk of finding significant disease, use of the phrase “average risk women” is inappropriate since it could encourage reliance on misleading clinical risk profiling or assessment by clinicians - a practice that has been long discarded.References 1. Sawaya GF, Kulasingam S, Denberg T, Qaseem A. Cervical Cancer Screening in Average-Risk Women: Best Practice Advice From the Clinical Guidelines Committee of the American College of Physicians. Ann Int Med 2015; Apr 30. doi: 10.7326/M14-2426. [Epub ahead of print]2. Task Force convened by the Department of National Health and Welfare of Canada. Cervical cancer screening programs. CMAJ 1976; 114: 1003 -1033.3. Task Force convened by the Department of National Heath and Welfare of Canada. Cervical cancer screening programs: summary of the 1982 Canadian task force report. CMAJ, 1982; 127: 581.4. Schiffman M, Burk RD, Boyle S et al. A Study of Genotyping for the Management of Human Papillomavirus-Positive, Cytology-Negative Cervical Screening Results. J Clin Microbiol 2015; 53: 52-59.
Sawaya GF, Kulasingam S, Denberg TD, Qaseem A, for the Clinical Guidelines Committee of the American College of Physicians. Cervical Cancer Screening in Average-Risk Women: Best Practice Advice From the Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med. 2015;162:851–859. doi: 10.7326/M14-2426
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Published: Ann Intern Med. 2015;162(12):851-859.
Cancer Screening/Prevention, Guidelines, Hematology/Oncology, High Value Care, Prevention/Screening.
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