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Clinical Guidelines |

Cervical Cancer Screening in Average-Risk Women: Best Practice Advice From the Clinical Guidelines Committee of the American College of PhysiciansCervical Cancer Screening in Average-Risk Women FREE

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*
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* This paper, written by George F. Sawaya, MD; Shalini Kulasingam, PhD; Thomas D. Denberg, MD, PhD; and Amir Qaseem, MD, PhD, MHA, was developed for the Clinical Guidelines Committee of the American College of Physicians. Individuals who served on the Clinical Guidelines Committee from initiation of the project until its approval were Thomas D. Denberg, MD, PhD (Chair); Paul Shekelle, MD, PhD (Immediate Past Chair); Michael J. Barry, MD; Roger Chou, MD; Molly Cooke, MD; Paul Dallas, MD; Nick Fitterman, MD; Mary Ann Forciea, MD; Russell P. Harris, MD, MPH; Linda L. Humphrey, MD, MPH; Devan Kansagara, MD, MCR; Robert M. McLean, MD; Tanveer P. Mir, MD; Amir Qaseem, MD, PhD, MHA; Holger J. Schünemann, MD, PhD; J. Sanford Schwartz, MD; Donna E. Sweet, MD; and Timothy Wilt, MD, MPH. Approved by the ACP Board of Regents on 15 November 2014.

This article was published online first at www.annals.org on 30 April 2015.


From the University of California, San Francisco, Center for Healthcare Value, San Francisco, California; University of Minnesota School of Public Health, Minneapolis, Minnesota; Carilion Clinic, Roanoke, Virginia; and American College of Physicians, Philadelphia, Pennsylvania.

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 All ACP best practice advice papers are considered automatically withdrawn or invalid 5 years after publication or once an update has been issued.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.


Ann Intern Med. 2015;162(12):851-859. doi:10.7326/M14-2426
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Description: 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.

Methods: The evidence reviewed in this work is a distillation of relevant publications (including systematic reviews) used to support current guidelines.

Best Practice Advice 1: Clinicians should not screen average-risk women younger than 21 years for cervical cancer.

Best Practice Advice 2: 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).

Best Practice Advice 3: Clinicians should not screen average-risk women for cervical cancer with cytology more often than once every 3 years.

Best Practice Advice 4: 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.

Best Practice Advice 5: Clinicians should not perform HPV testing in average-risk women younger than 30 years.

Best Practice Advice 6: 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.

Best Practice Advice 7: Clinicians should not screen average-risk women of any age for cervical cancer if they have had a hysterectomy with removal of the cervix.


In 2015, an estimated 12 900 U.S. women will be diagnosed with cervical cancer, and 4100 will die of the disease (1). Over the past several decades, incidence and mortality have steadily decreased; the current estimated incidence rate is 7.8 cases per 100 000 women per year (2). These decreases have been largely attributed to widespread screening. Although the benefits have been substantial, cervical cancer screening is costly. In 2010, the direct medical cost for screening and follow-up was estimated at $6.6 billion (3) and was probably greater because patient time and out-of-pocket expenditures were not included in the analysis.

Cervical cancer screening is commonly done in the United States; an estimated 89% of the target population of about 70 million women report having been screened in the past 5 years (4). Recent evidence-based guidelines for screening have refined the approach in an effort to minimize harms and maximize benefits. In general, the approach has focused on increasing the age at which to begin screening, lengthening the screening interval, and discontinuing screening in women at low risk for future cervical cancer. Overuse of screening contributes to higher health care costs without improving patient outcomes.

The purpose of this best practice advice article from the Clinical Guidelines Committee of the American College of Physicians (ACP) is to describe the indications for screening for cervical cancer. The target audience is all clinicians, and the target patient population is asymptomatic, average-risk women aged 21 years or older. This article is supported by the American Congress of Obstetricians and Gynecologists (ACOG) and endorsed by the American Society for Clinical Pathology (ASCP).

This article is not based on a formal systematic review but instead seeks to provide practical advice based on the best available evidence, including systematic reviews and recent guidelines. The focus is on primary screening rather than management of abnormal screening test results. The advice applies to average-risk women, defined as those with no history of a precancerous lesion (cervical intraepithelial neoplasia [CIN] grade 2 or a more severe lesion) or cervical cancer, those who are not immunocompromised (including being HIV-infected), and those without in utero exposure to diethylstilbestrol.

Cervical cancer is believed to be the long-delayed consequence of infection with high-risk (or oncogenic) types of human papillomavirus (HPV) (5). Human papillomavirus infections are common, and most are transient. Persistent high-risk HPV infection can lead to cervical precancerous lesions known as cervical intraepithelial neoplasia, which can become invasive. Identification and treatment of CIN lesions through screening lead to reductions in cervical cancer incidence, morbidity, and mortality. Detection of early-stage asymptomatic cancer also contributes to decreased morbidity by making women eligible for treatments with lower morbidity.

Harms can occur at any and all points along the sequence of care: collection of cervical specimens, diagnostic evaluation, cervical treatments, and posttreatment surveillance. Collection of cervical samples is generally well-tolerated by women (67). Abnormal screening test results can cause short-term anxiety, including concerns about sexually transmissible infections and their consequences (5).

The likelihood of abnormal test results varies by age, test, and setting. Because the prevalence of high-risk HPV infection peaks shortly after initiation of sexual intercourse, rates of positive HPV test results are highest among women younger than 25 years and decrease with advancing age (5). Positive results occur in about 30% of women aged 21 to 24 years compared with about 12% of those aged 30 to 34 years and 5% of those aged 60 to 64 years (89). Rates of cytologic abnormalities also decrease with age: About 13% of women aged 21 to 24 years have abnormalities (9) compared with about 7% of those aged 30 to 34 years and 3% of those aged 60 to 64 years (8). In the setting of a prepaid health plan, about 9% of women aged 30 to 64 years had either an abnormal cytologic test result or a positive HPV test result (8).

The prevalence of underlying CIN grade 2 or a more severe lesion follows similar age-related patterns, ranging from 12% among women aged 21 to 24 years to 2.4% among those older than 50 years (9). The most severe cytologic abnormalities (squamous cell cancer and high-grade squamous intraepithelial lesion) are uncommon but carry a predicted 5-year risk of about 85% for CIN grade 2 or a more severe lesion. In contrast, the less severe but more common abnormal finding of a normal cytologic test result with a positive HPV test result carries a predicted 5-year risk of about 10% (10).

With the use of current management algorithms (11), immediate colposcopy is recommended to about 4% of screened women after 1 round of screening (10), most of whom have biopsies performed. Among women who have colposcopy with biopsy, about 28% report moderate or more severe pain and 22% report postprocedure bleeding of at least moderate severity (12).

Cervical treatment harms vary depending on treatment type. Excisional treatments (cone biopsies and loop electrosurgical excision procedures) have short-term risks for pain, bleeding, and infection. Evidence has implicated excisional procedures in longer-term risk, including a 70% increase in risk for subsequent preterm delivery (1315). In fact, a 90% increase in neonatal mortality due to severe prematurity has been noted with cone biopsies (16). A recent analysis, however, suggested that the effect of loop excision (the most commonly performed excisional procedure [17]) on preterm birth has been overestimated due to selection of study control participants (18). Ablational treatments (such as cryotherapy and laser) are not always feasible but have similar efficacy (19) and have not been associated with adverse obstetric outcomes (15).

Although the treatment threshold in the United States is CIN grade 2, this regresses in about 40% of women over a 6-month period (2021). Thus, overdiagnosis and overtreatment can be expected in a substantial proportion of women treated for precancerous lesions. Of note, women with abnormal screening test results or cervical findings that do not lead to treatment (such as CIN grade 1 or persistently positive HPV test results) are placed under surveillance, which can be prolonged and can lead to further testing, life disruptions, out-of-pocket expenses, and anxiety (5).

In 2012, the U.S. Preventive Services Task Force (USPSTF) (22); the ACOG (23); and the American Cancer Society (ACS), in collaboration with the American Society for Colposcopy and Cervical Pathology (ASCCP) and the ASCP (24), released revised recommendations for cervical cancer screening (Table). For the first time, these guidelines agree about the populations to whom the recommendations apply, the ages at which to begin and end screening, the appropriate screening intervals, and the appropriate tests to be used.

Table Jump PlaceholderTable. 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 

The scientific rationale for these recommendations is outlined in detail in all of the guideline documents and can be summarized as follows. Cytologic abnormalities are common in women younger than 21 years, yet clinically important cervical lesions are rare (5). Thus, if screened, many women in this age group will have colposcopy and biopsy, and some will be treated for lesions that have a high likelihood of regression. To minimize this harm, screening before age 21 years is not recommended, regardless of sexual history. Annual screening is no longer recommended because too-frequent screening leads to higher rates of false-positive results, with little effect on subsequent cervical cancer because of the long time between cervical precancerous lesions and invasion. The estimated average time for a high-grade precancerous lesion to progress to cervical cancer is 10 years (25), which allows ample time for identification and treatment of such lesions. Ending screening is important because cervical cancer is uncommon among older women with normal prior screening results, yet the chance of false-positive results and subsequent invasive interventions persists (26). Ending screening before age 65 years in women with life-limiting comorbid conditions seems reasonable, although the process by which an evidence-based recommendation can be made is unclear. Surgical removal of the cervix reduces risk for cervical cancer to zero, making screening after total hysterectomy extremely low-value.

All 3 guidelines endorse the strategy of cytology plus testing for high-risk HPV types (known as cotesting) in women aged 30 to 65 years as an alternative to cytology alone. The rationale behind cotesting is that women with normal cytologic test results and no evidence of high-risk HPV constitute a particularly low-risk group in which screening intervals may be safely lengthened to every 5 years; the cumulative risk for being diagnosed with CIN grade 2 or a more severe lesion over the subsequent 5 years is estimated at 0.34% (27). The guidelines also agree that HPV tests alone (2223) or in combination with cytology (2224) should not be used for primary screening in women younger than 30 years, in part because of the high prevalence of HPV infection among women in this age group. In fact, the USPSTF issued a grade D recommendation for HPV testing in this age group, indicating at least moderate certainty that there is no net benefit or that the harms outweigh the benefits.

Although these guidelines are largely concordant, a few differences are notable. The ACS/ASCCP/ASCP guideline specifically states that annual testing should not be performed in women of any age. It also states that the strategy of HPV testing plus cytology is preferred to cytology alone among women aged 30 to 65 years, although this is a "weak recommendation," indicating substantial uncertainty about the balance of benefits and harms. The ACOG agrees that cotesting is preferred, citing evidence that HPV testing improves detection of adenocarcinoma, which comprises about 20% (28) of all cervical cancer histologic types. The USPSTF states that both strategies are acceptable; cotesting is not preferred and should be applied only to women who would like to extend intervals to every 5 years. This recommendation was based in part on a decision analysis showing that these strategies confer similar benefits (cancer cases and cancer deaths prevented) and harms (false-positive test results and colposcopies) (29). From a population perspective, extending intervals to 5 years among cotested women is important to balance the effect of positive HPV test results (30). Of note, the cost-effectiveness of these 2 strategies has not been sufficiently explored to fully understand whether one is preferred from an economic and societal perspective (10).

Clinician surveys have been useful in monitoring adherence to guidelines. Although it is too soon to know how clinician behaviors have changed since the publication of the 2012 guidelines, past results have been discouraging. Clinicians have poor adherence to cervical cancer screening guidelines (3133) and begin screening too early (34), perform screening too often (3437), and do not end screening in women who are at low risk on the basis of age criteria (31, 3839) or because they have had hysterectomy (4041). Moreover, nonadherence to guidelines for the management of women with mild screening test abnormalities—specifically, more intensive surveillance than is deemed necessary—has also been reported (33, 35).

There is much room for improvement. Recent self-reported estimates suggest that approximately 60% of women have been screened by age 21 years (40) and approximately 53% of women aged 75 to 79 years and 38% of those aged 80 years or older have been recently screened (38). Although recent reports have suggested that the age of screening initiation is increasing (42) and cervical cancer screening visits for women aged 65 years or older are decreasing (39), it is unclear whether these changes are due to clinician adherence to guidelines, evolving patient acceptance of less screening, or changes in reimbursement for services that are not endorsed by guidelines.

Increasing the age of first screening from 18 to 21 years has been shown to result in cost savings, with small differences in discounted average quality-adjusted life expectancy (43) due to a higher relative burden of low-grade precancerous lesions, most of which resolve spontaneously (44). Further increasing the age of first screening to 25 years results in additional cost savings and small differences in average quality-adjusted life expectancy (compared with initiating screening at age 18 years) due to a slight increase in cancer incidence among women aged 20 to 24 years compared with those younger than 20 years (43, 45).

The economic implications of screening before age 21 years are substantial. If we assume that screening is restricted to young women who are sexually active and correct for self-reporting (4648), we estimate that approximately 290 000 women younger than 21 years are screened annually. The estimated annual screening costs range from $21.7 million to nearly $40 million. These estimates are conservative because they do not include costs of follow-up or costs for the small proportion of young women who are not sexually active but may be screened nonetheless (32).

The cost-effectiveness of screening for cervical cancer has been shown to exceed $500 000 per quality-adjusted life-year (QALY) gained when screening is conducted annually, whether with cytology alone or cytology in combination with HPV DNA testing (4950). Depending on the type of strategy modeled, biennial screening has been associated with incremental cost-effectiveness ratios of approximately $150 000 to $200 000 per QALY gained (43, 5051). The high cost-effectiveness ratios associated with frequent screening are due to a linear increase in costs for screening, follow-up, and treatment (when the same strategy is compared with a fixed sensitivity and specificity) but incrementally smaller gains in averted cervical cancer cases. Most lesions detected at the more frequent intervals would typically regress if left untreated. In contrast, the cost-effectiveness ratio of screening every 3 to 5 years has been shown to be less than $100 000 per QALY gained (43, 52). All QALY analyses, however, are limited by the lack of a comprehensive set of utilities capturing women's preferences for health states that follow from various strategies, including those incorporating HPV testing (53).

Of the currently recommended strategies, cytology alone has the lowest sensitivity but the highest specificity for detection of CIN grade 2 or a more severe lesion, including cancer. Cost-effectiveness analyses suggest that strategies that include HPV tests and cytology can achieve similar gains in quality-adjusted life expectancy compared with cytology alone at a similar or lower lifetime cost if conducted at a less frequent interval (50). In other words, a strategy with a higher sensitivity and lower specificity can achieve similar or greater reductions in cancer because the costs associated with a lower specificity are offset by fewer overall screening tests.

For women aged 65 years or older who have been screened according to recommendations and have prior normal test results, the burden of continued screening due to false-positive test results (including unnecessary colposcopies) is predicted to be high relative to further benefits (44). After correcting for the high prevalence of hysterectomy in this age group (54), we estimate that the annual cost of screening women aged 65 to 75 years ranges from approximately $50 million to $90 million. This is probably an overestimate because it does not account for the unknown proportion of unscreened and underscreened women for whom screening would be recommended.

For women who have received all 3 doses of an HPV vaccine per the recommended schedule before the onset of sexual activity (when vaccine efficacy is highest), delaying the first screening to age 25 years and using a screening interval of 5 years is predicted to be cost-effective (43). Screening this group at an earlier age (18 or 21 years) and a more frequent interval (1 to 2 years) is predicted to result in incremental cost-effectiveness ratios exceeding $500 000 per QALY (43). However, current recommendations are to continue screening vaccinated women by using the same strategies as those for unvaccinated women given the lack of observed data to confirm model predictions about several key parameters for a vaccinated population, including continued participation in screening, performance of screening tests, and reductions in cancer (55).

Clinician Factors

The success of public health campaigns promoting cancer screening is bolstered by their ability to deliver clear, simple messages. "Get a Pap test every year" was easy for women to remember and for clinicians to implement as part of an annual well-woman examination. Long-held beliefs are difficult to change. A recent nationwide survey of U.S. obstetrician-gynecologists (42) provides insight into their concerns about lengthening the intervals between gynecologic examinations, including cytologic tests: About three quarters believed that lengthening intervals would decrease patient health, well-being, and satisfaction. Nearly 80% expected financial reimbursements to decrease. Fear of litigation is often cited as a deterrent to less frequent screening, although most lawsuits are not successful as long as care is based on evidence.

Patient Expectations

Although some women prefer less frequent pelvic examination, especially those with a history of sexual trauma (56), many others have expressed a preference for frequent testing to prevent cancer, even if this results in anxiety due to false-positive test results or unnecessary procedures (5758). A nationally representative survey of women aged 40 years or older that asked about cytology-based cervical cancer screening revealed that women prefer annual screening and that few expect to stop having cytologic tests before age 80 years (58) or ever (59). Patients also expressed the view that recommendations to screen for cancer less frequently are driven by efforts by insurance companies and government payers to save money (58, 60).

Physicians and other health care providers can play a major role in reducing overuse of cervical cancer screening. They must first know current guidelines and should understand the reasoning behind the recommendation for less testing. The desire to find the right balance between benefits and harms should be familiar to all physicians steeped in a tradition of doing no harm. One way to explain these new guidelines to women reluctant to be screened less frequently is to be frank about the expected balance of benefits and harms: "I am concerned that if we screen you more frequently than is recommended, we will be doing more harm than good. In your case, I have a professional obligation to let you know that the harms of screening are likely to outweigh the benefits." Recent studies have shown that physicians are willing to screen less frequently than every year (36) and that women accept less screening if recommended by their clinicians (59).

Clinicians should be aware of recent statements made by professional societies about less cervical cancer screening. As part of the Choosing Wisely initiative of the American Board of Internal Medicine (61), in which national organizations of medical specialists were asked to identify 5 commonly used tests or procedures in their field that should be questioned, the ASCP suggested that clinicians not order testing for low-risk cervical HPV types because the results have no effect on clinical management. The American Academy of Family Physicians advised against screening women younger than 21 years, women who have had hysterectomy for noncancerous conditions, and low-risk women older than 65 years. It also recommended not using HPV testing alone or in combination with cytology in women younger than 30 years. The ACOG recommended against annual screening of low-risk women aged 30 to 65 years. Finally, the American Society of Nephrology suggested that routine screening for cancer, including cervical cancer, not be performed in patients with end-stage renal disease who are receiving dialysis and have limited life expectancy.

Health care systems can play an important role in encouraging adherence to evidence-based guidelines. Adherence to guidelines seems to be higher in prepaid health plans than in fee-for-service settings, suggesting that characteristics of the practice setting may have an important effect (37). It has long been hoped that adoption of electronic medical records would allow opportunities for clinicians to be reminded of current guidelines and even specifically prompted when ordering tests that have a high likelihood of not being indicated. Electronic medical records have been shown to be useful in identifying low-value cervical cancer screening (62), and evidence suggests that tools based on electronic medical records can decrease inappropriate cervical cancer screening (63).

The National Committee for Quality Assurance has long had a measure for cervical cancer screening in the Healthcare Effectiveness Data and Information Set that addresses whether cervical cancer screening has been performed within the target population. In 2014, a new performance measure was proposed to address in appropriate screening. The measure, entitled "non-recommended cervical cancer screening in adolescent females," would capture the percentage of adolescent females aged 16 to 20 years who are unnecessarily screened for cervical cancer (64). This measure is directly derived from the 2012 guidelines that discourage screening before age 21 years. It is hoped that by adding overscreening as a measure of poor-quality care, clinicians and the health systems in which they work will have greater incentives to adhere to current guidelines.

Clinicians can expect future guidelines to include more sophisticated targeting of women at highest and lowest risk for cervical cancer to further maximize screening benefits and minimize harms. Specifically, the age of screening initiation may increase as HPV vaccination becomes widespread. Vaccination should also decrease the incidence of cervical cancer precursors, thus further minimizing screening harms. Screening intervals may be further lengthened and screening may end earlier if women can be stratified by molecular and cytologic test results that can predict even lower risk status. Current guidelines do not address ending screening among women with limited life expectancy due to medical comorbid conditions, but such guidance would be useful.

In 2014, the U.S. Food and Drug Administration approved high-risk HPV testing alone (9) as a primary screening test, and recent interim guidance from a group of experts recommended triennial screening beginning at age 25 years (65). This decision will be controversial given current recommendations to avoid HPV testing in women younger than 30 years, due in part to the relatively high prevalence of HPV among women aged 25 to 29 years (21%) (9). Of note, the major guideline groups cited earlier have not issued recommendations about this strategy.

As new screening strategies emerge, so will a critical need for comparative effectiveness analyses that delineate the economic implications of choosing one strategy over another. Such analyses will be useful in directing clinicians and women to high-value screening options (54). Finally, amid enthusiasm for new screening tests, clinicians should be aware that providing women with affordable and easily accessible screening (regardless of method), coupled with streamlined follow-up of abnormal test results and timely treatment, will realize the highest impact of screening on cervical cancer incidence and mortality.

As clinicians adhere more strongly to guidelines, it is anticipated that the harms and costs of cervical cancer screening will be minimized and the benefits will be maximized.

Best Practice Advice 1: Clinicians should not screen average-risk women younger than 21 years for cervical cancer.

Best Practice Advice 2: Clinicians should start screening average-risk women for cervical cancer at age 21 years once every 3 years with cytology (cytologic tests without HPV tests).

Best Practice Advice 3: Clinicians should not screen average-risk women for cervical cancer with cytology more often than once every 3 years.

Best Practice Advice 4: 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.

Best Practice Advice 5: Clinicians should not perform HPV testing in average-risk women younger than 30 years.

Best Practice Advice 6: 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.

Best Practice Advice 7: Clinicians should not screen average-risk women of any age for cervical cancer if they have had a hysterectomy with removal of the cervix.

The Figure summarizes the recommendations and clinical considerations.

Grahic Jump Location
Figure.

Summary of the American College of Physicians best practice advice on cervical cancer screening in average-risk women.

HPV = human papillomavirus.

Grahic Jump Location
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PubMed
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Arbyn M, Kyrgiou M, Simoens C, Raifu AO, Koliopoulos G, Martin-Hirsch P, et al. Perinatal mortality and other severe adverse pregnancy outcomes associated with treatment of cervical intraepithelial neoplasia: meta-analysis. BMJ. 2008; 337:a1284.
PubMed
CrossRef
 
Patel DA, Saraiya M, Copeland G, Cote ML, Datta SD, Sawaya GF. Treatment patterns for cervical carcinoma in situ in Michigan, 1998–2003. J Registry Manag. 2013; 40:84-92.
PubMed
 
Conner SN, Frey HA, Cahill AG, Macones GA, Colditz GA, Tuuli MG. Loop electrosurgical excision procedure and risk of preterm birth: a systematic review and meta-analysis. Obstet Gynecol. 2014; 123:752-61.
PubMed
CrossRef
 
Martin-Hirsch PP, Paraskevaidis E, Bryant A, Dickinson HO, Keep SL. Surgery for cervical intraepithelial neoplasia. Cochrane Database Syst Rev. 2010; CD001318.
PubMed
 
ASCUS-LSIL Triage Study (ALTS) Group. Results of a randomized trial on the management of cytology interpretations of atypical squamous cells of undetermined significance. Am J Obstet Gynecol. 2003; 188:1383-92.
PubMed
CrossRef
 
Grimm C, Polterauer S, Natter C, Rahhal J, Hefler L, Tempfer CB, et al. Treatment of cervical intraepithelial neoplasia with topical imiquimod: a randomized controlled trial. Obstet Gynecol. 2012; 120:152-9.
PubMed
CrossRef
 
Moyer VA, U.S. Preventive Services Task Force. Screening for cervical cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012; 156:880-91, W312.
CrossRef
 
Committee on Practice Bulletins—Gynecology. ACOG Practice Bulletin Number 131: Screening for cervical cancer. Obstet Gynecol. 2012; 120:1222-38.
PubMed
 
Saslow D, Solomon D, Lawson HW, Killackey M, Kulasingam SL, Cain J, et al, ACS-ASCCP-ASCP Cervical Cancer Guideline Committee. American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer. CA Cancer J Clin. 2012; 62:147-72.
PubMed
CrossRef
 
Baseman JG, Koutsky LA. The epidemiology of human papillomavirus infections. J Clin Virol. 2005; 32 Suppl 1:S16-24.
PubMed
CrossRef
 
Sawaya GF. Should routine screening Papanicolaou smears be done for women older than 65 years? Arch Intern Med. 2004; 164:243-5.
PubMed
CrossRef
 
Gage JC, Schiffman M, Katki HA, Castle PE, Fetterman B, Wentzensen N, et al. Reassurance against future risk of precancer and cancer conferred by a negative human papillomavirus test. J Natl Cancer Inst.. 2014; 106.
PubMed
 
Galic V, Herzog TJ, Lewin SN, Neugut AI, Burke WM, Lu YS, et al. Prognostic significance of adenocarcinoma histology in women with cervical cancer. Gynecol Oncol. 2012; 125:287-91.
PubMed
CrossRef
 
Kulasingam SL, Havrilesky L, Ghebre R, Myers ER. Screening for Cervical Cancer: A Decision Analysis for the U.S. Preventive Services Task Force. AHRQ publication no. 11-05157-EF-1. Rockville, MD: Agency for Healthcare Research and Quality; 2011.
 
Sawaya GF. Adding human papillomavirus testing to cytology for primary cervical cancer screening: shooting first and asking questions later [Editorial]. Ann Intern Med. 2008; 148:557-9.
CrossRef
 
Saint M, Gildengorin G, Sawaya GF. Current cervical neoplasia screening practices of obstetrician/gynecologists in the US. Am J Obstet Gynecol. 2005; 192:414-21.
PubMed
CrossRef
 
Corbelli J, Borrero S, Bonnema R, McNamara M, Kraemer K, Rubio D, et al. Differences among primary care physicians' adherence to 2009 ACOG guidelines for cervical cancer screening. J Womens Health (Larchmt). 2014; 23:397-403.
PubMed
CrossRef
 
Perkins RB, Jorgensen JR, McCoy ME, Bak SM, Battaglia TA, Freund KM. Adherence to conservative management recommendations for abnormal Pap test results in adolescents. Obstet Gynecol. 2012; 119:1157-63.
PubMed
CrossRef
 
Roland KB, Soman A, Benard VB, Saraiya M. Human papillomavirus and Papanicolaou tests screening interval recommendations in the United States. Am J Obstet Gynecol. 2011; 205:447.
PubMed
CrossRef
 
Berkowitz Z, Saraiya M, Sawaya GF. Cervical cancer screening intervals, 2006 to 2009: moving beyond annual testing [Letter]. JAMA Intern Med. 2013; 173:922-4.
PubMed
CrossRef
 
Meissner HI, Tiro JA, Yabroff KR, Haggstrom DA, Coughlin SS. Too much of a good thing? Physician practices and patient willingness for less frequent Pap test screening intervals. Med Care. 2010; 48:249-59.
PubMed
CrossRef
 
Saraiya M, Berkowitz Z, Yabroff KR, Wideroff L, Kobrin S, Benard V. Cervical cancer screening with both human papillomavirus and Papanicolaou testing vs Papanicolaou testing alone: what screening intervals are physicians recommending? Arch Intern Med. 2010; 170:977-85.
PubMed
CrossRef
 
Bellizzi KM, Breslau ES, Burness A, Waldron W. Prevalence of cancer screening in older, racially diverse adults: still screening after all these years. Arch Intern Med. 2011; 171:2031-7.
PubMed
CrossRef
 
Kale MS, Bishop TF, Federman AD, Keyhani S. Trends in the overuse of ambulatory health care services in the United States. JAMA Intern Med. 2013; 173:142-8.
PubMed
CrossRef
 
Centers for Disease Control and Prevention (CDC). Cervical cancer screening among women by hysterectomy status and among women aged ≥65 years—United States, 2000–2010. MMWR Morb Mortal Wkly Rep. 2013; 61:1043-7.
PubMed
 
Sirovich BE, Welch HG. Cervical cancer screening among women without a cervix. JAMA. 2004; 291:2990-3.
PubMed
CrossRef
 
Henderson JT, Saraiya M, Martinez G, Harper CC, Sawaya GF. Changes to cervical cancer prevention guidelines: effects on screening among U.S. women ages 15–29. Prev Med. 2013; 56:25-9.
PubMed
CrossRef
 
Goldhaber-Fiebert JD, Stout NK, Salomon JA, Kuntz KM, Goldie SJ. Cost-effectiveness of cervical cancer screening with human papillomavirus DNA testing and HPV-16,18 vaccination. J Natl Cancer Inst. 2008; 100:308-20.
PubMed
CrossRef
 
Kulasingam SL, Havrilesky LJ, Ghebre R, Myers ER. Screening for cervical cancer: a modeling study for the US Preventive Services Task Force. J Low Genit Tract Dis. 2013; 17:193-202.
PubMed
CrossRef
 
Howlader N, Noone AM, Krapcho M, Garshell J, Neyman N, Altekruse SF, et al, eds.  SEER Cancer Statistics Review, 1975–2010. Bethesda, MD: National Cancer Institute; 2013. Accessed at http://seer.cancer.gov/csr/1975_2010 on 3 April 2015.
 
Saraiya M, McCaig LF, Ekwueme DU. Ambulatory care visits for Pap tests, abnormal Pap test results, and cervical cancer procedures in the United States. Am J Manag Care. 2010; 16:e137-44.
PubMed
 
Howard M, Agarwal G, Lytwyn A. Accuracy of self-reports of Pap and mammography screening compared to medical record: a meta-analysis. Cancer Causes Control. 2009; 20:1-13.
PubMed
CrossRef
 
Rauscher GH, Johnson TP, Cho YI, Walk JA. Accuracy of self-reported cancer-screening histories: a meta-analysis. Cancer Epidemiol Biomarkers Prev. 2008; 17:748-57.
PubMed
CrossRef
 
Kim JJ, Wright TC, Goldie SJ. Cost-effectiveness of alternative triage strategies for atypical squamous cells of undetermined significance. JAMA. 2002; 287:2382-90.
PubMed
CrossRef
 
Goldie SJ, Kim JJ, Wright TC. Cost-effectiveness of human papillomavirus DNA testing for cervical cancer screening in women aged 30 years or more. Obstet Gynecol. 2004; 103:619-31.
PubMed
CrossRef
 
Mandelblatt JS, Lawrence WF, Womack SM, Jacobson D, Yi B, Hwang YT, et al. Benefits and costs of using HPV testing to screen for cervical cancer. JAMA. 2002; 287:2372-81.
PubMed
CrossRef
 
Kim JJ, Sharma M, Ortendahl J. Optimal interval for routine cytologic screening in the United States [Letter]. JAMA Intern Med. 2013; 173:241-2.
PubMed
CrossRef
 
Sawaya GF, Kuppermann M. Identifying a "range of reasonable options" for cervical cancer screening [Editorial]. Obstet Gynecol. 2015; 125:308-10.
PubMed
CrossRef
 
Merrill RM. Hysterectomy surveillance in the United States, 1997 through 2005. Med Sci Monit. 2008; 14:CR24-31.
PubMed
 
Canfell K, Chesson H, Kulasingam SL, Berkhof J, Diaz M, Kim JJ. Modeling preventative strategies against human papillomavirus-related disease in developed countries. Vaccine. 2012; 30 Suppl 5:F157-67.
PubMed
CrossRef
 
Weitlauf JC, Frayne SM, Finney JW, Moos RH, Jones S, Hu K, et al. Sexual violence, posttraumatic stress disorder, and the pelvic examination: how do beliefs about the safety, necessity, and utility of the examination influence patient experiences? J Womens Health (Larchmt). 2010; 19:1271-80.
PubMed
CrossRef
 
Schwartz LM, Woloshin S, Fowler FJ Jr, Welch HG. Enthusiasm for cancer screening in the United States. JAMA. 2004; 291:71-8.
PubMed
CrossRef
 
Sirovich BE, Woloshin S, Schwartz LM. Screening for cervical cancer: will women accept less? Am J Med. 2005; 118:151-8.
PubMed
CrossRef
 
Huang AJ, Pérez-Stable EJ, Kim SE, Wong ST, Kaplan CP, Walsh JM, et al. Preferences for human papillomavirus testing with routine cervical cancer screening in diverse older women. J Gen Intern Med. 2008; 23:1324-9.
PubMed
CrossRef
 
Schleifer D, Rothman DJ. "The ultimate decision is yours": exploring patients' attitudes about the overuse of medical interventions. PLoS One. 2012; 7:e52552.
PubMed
CrossRef
 
Choosing Wisely Web site. Philadelphia: ABIM Foundation; 2015. Accessed at www.choosingwisely.org on 26 January 2015.
 
Mathias JS, Gossett D, Baker DW. Use of electronic health record data to evaluate overuse of cervical cancer screening. J Am Med Inform Assoc. 2012; 19:e96-e101.
PubMed
CrossRef
 
White P, Kenton K. Use of electronic medical record-based tools to improve compliance with cervical cancer screening guidelines: effect of an educational intervention on physicians' practice patterns. J Low Genit Tract Dis. 2013; 17:175-81.
PubMed
CrossRef
 
National Committee for Quality Assurance.  NCQA Updates HEDIS Measures. Washington, DC: National Committee for Quality Assurance; 2013. Accessed at www.ncqa.org/Newsroom/NewsArchive/2013NewsArchive/NewsReleaseJuly32013.aspx on 10 April 2015.
 
Huh WK, Ault KA, Chelmow D, Davey DD, Goulart RA, Garcia FA, et al. Use of primary high-risk human papillomavirus testing for cervical cancer screening: interim clinical guidance. Obstet Gynecol. 2015; 125:330-7.
PubMed
CrossRef
 

Figures

Grahic Jump Location
Figure.

Summary of the American College of Physicians best practice advice on cervical cancer screening in average-risk women.

HPV = human papillomavirus.

Grahic Jump Location

Tables

Table Jump PlaceholderTable. 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 

Videos

Video News Release - ACP's Best Practice Advice for Cervical Cancer Screening

References

American Cancer Society.  What are the key statistics about cervical cancer? Atlanta, GA: American Cancer Society; 2015. Accessed at www.cancer.org/cancer/cervicalcancer/detailedguide/cervical-cancer-key-statistics on 10 April 2015.
 
National Cancer Institute.  SEER Stat Fact Sheets: Cervix Uteri Cancer. Bethesda, MD: National Cancer Institute; 2015. Accessed at http://seer.cancer.gov/statfacts/html/cervix.html on 26 January 2015.
 
Chesson HW, Ekwueme DU, Saraiya M, Watson M, Lowy DR, Markowitz LE. Estimates of the annual direct medical costs of the prevention and treatment of disease associated with human papillomavirus in the United States. Vaccine. 2012; 30:6016-9.
PubMed
CrossRef
 
Centers for Disease Control and Prevention.  Vital Signs: Cervical Cancer Incidence, Mortality, and Screening—United States, 2007–2012. Atlanta, GA: Centers for Disease Control and Prevention; 2014. Accessed at www.cdc.gov/mmwr/preview/mmwrhtml/mm63e1105a1.htm?s_cid=mm63e1105a1_w on 26 January 2015.
 
Vesco KK, Whitlock EP, Eder M, Lin J, Burda BU, Senger CA, et al. Screening for Cervical Cancer: A Systematic Evidence Review for the U.S. Preventive Services Task Force. Evidence synthesis no. 86. AHRQ publication no. 11-05156-EF-1. Rockville, MD: Agency for Healthcare Research and Quality; 2011.
 
Hill DA, Lamvu G. Effect of lubricating gel on patient comfort during vaginal speculum examination: a randomized controlled trial. Obstet Gynecol. 2012; 119:227-31.
PubMed
CrossRef
 
Uygur D, Guler T, Yayci E, Atacag T, Comunoglu C, Kuzey GM. Association of speculum lubrication with pain and Papanicolaou test accuracy. J Am Board Fam Med. 2012; 25:798-804.
PubMed
CrossRef
 
Castle PE, Fetterman B, Poitras N, Lorey T, Shaber R, Kinney W. Five-year experience of human papillomavirus DNA and Papanicolaou test cotesting. Obstet Gynecol. 2009; 113:595-600.
PubMed
CrossRef
 
Wright TC Jr, Stoler MH, Behrens CM, Apple R, Derion T, Wright TL. The ATHENA human papillomavirus study: design, methods, and baseline results. Am J Obstet Gynecol. 2012; 206:46.
PubMed
CrossRef
 
Schiffman M, Solomon D. Clinical practice. Cervical-cancer screening with human papillomavirus and cytologic cotesting. N Engl J Med. 2013; 369:2324-31.
PubMed
CrossRef
 
Massad LS, Einstein MH, Huh WK, Katki HA, Kinney WK, Schiffman M, et al, 2012 ASCCP Consensus Guidelines Conference. 2012 updated consensus guidelines for the management of abnormal cervical cancer screening tests and cancer precursors. Obstet Gynecol. 2013; 121:829-46.
PubMed
CrossRef
 
Sharp L, Cotton S, Cochran C, Gray N, Little J, Neal K, et al, TOMBOLA (Trial Of Management of Borderline and Other Low-grade Abnormal smears) Group. After-effects reported by women following colposcopy, cervical biopsies and LLETZ: results from the TOMBOLA trial. BJOG. 2009; 116:1506-14.
PubMed
CrossRef
 
Bruinsma FJ, Quinn MA. The risk of preterm birth following treatment for precancerous changes in the cervix: a systematic review and meta-analysis. BJOG. 2011; 118:1031-41.
PubMed
CrossRef
 
Crane J. Review: excisional, and perhaps ablative treatments for precancerous cervical changes increase the risk for preterm birth. Evid Based Med. 2012; 17:92-3.
PubMed
CrossRef
 
Kyrgiou M, Koliopoulos G, Martin-Hirsch P, Arbyn M, Prendiville W, Paraskevaidis E. Obstetric outcomes after conservative treatment for intraepithelial or early invasive cervical lesions: systematic review and meta-analysis. Lancet. 2006; 367:489-98.
PubMed
CrossRef
 
Arbyn M, Kyrgiou M, Simoens C, Raifu AO, Koliopoulos G, Martin-Hirsch P, et al. Perinatal mortality and other severe adverse pregnancy outcomes associated with treatment of cervical intraepithelial neoplasia: meta-analysis. BMJ. 2008; 337:a1284.
PubMed
CrossRef
 
Patel DA, Saraiya M, Copeland G, Cote ML, Datta SD, Sawaya GF. Treatment patterns for cervical carcinoma in situ in Michigan, 1998–2003. J Registry Manag. 2013; 40:84-92.
PubMed
 
Conner SN, Frey HA, Cahill AG, Macones GA, Colditz GA, Tuuli MG. Loop electrosurgical excision procedure and risk of preterm birth: a systematic review and meta-analysis. Obstet Gynecol. 2014; 123:752-61.
PubMed
CrossRef
 
Martin-Hirsch PP, Paraskevaidis E, Bryant A, Dickinson HO, Keep SL. Surgery for cervical intraepithelial neoplasia. Cochrane Database Syst Rev. 2010; CD001318.
PubMed
 
ASCUS-LSIL Triage Study (ALTS) Group. Results of a randomized trial on the management of cytology interpretations of atypical squamous cells of undetermined significance. Am J Obstet Gynecol. 2003; 188:1383-92.
PubMed
CrossRef
 
Grimm C, Polterauer S, Natter C, Rahhal J, Hefler L, Tempfer CB, et al. Treatment of cervical intraepithelial neoplasia with topical imiquimod: a randomized controlled trial. Obstet Gynecol. 2012; 120:152-9.
PubMed
CrossRef
 
Moyer VA, U.S. Preventive Services Task Force. Screening for cervical cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012; 156:880-91, W312.
CrossRef
 
Committee on Practice Bulletins—Gynecology. ACOG Practice Bulletin Number 131: Screening for cervical cancer. Obstet Gynecol. 2012; 120:1222-38.
PubMed
 
Saslow D, Solomon D, Lawson HW, Killackey M, Kulasingam SL, Cain J, et al, ACS-ASCCP-ASCP Cervical Cancer Guideline Committee. American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer. CA Cancer J Clin. 2012; 62:147-72.
PubMed
CrossRef
 
Baseman JG, Koutsky LA. The epidemiology of human papillomavirus infections. J Clin Virol. 2005; 32 Suppl 1:S16-24.
PubMed
CrossRef
 
Sawaya GF. Should routine screening Papanicolaou smears be done for women older than 65 years? Arch Intern Med. 2004; 164:243-5.
PubMed
CrossRef
 
Gage JC, Schiffman M, Katki HA, Castle PE, Fetterman B, Wentzensen N, et al. Reassurance against future risk of precancer and cancer conferred by a negative human papillomavirus test. J Natl Cancer Inst.. 2014; 106.
PubMed
 
Galic V, Herzog TJ, Lewin SN, Neugut AI, Burke WM, Lu YS, et al. Prognostic significance of adenocarcinoma histology in women with cervical cancer. Gynecol Oncol. 2012; 125:287-91.
PubMed
CrossRef
 
Kulasingam SL, Havrilesky L, Ghebre R, Myers ER. Screening for Cervical Cancer: A Decision Analysis for the U.S. Preventive Services Task Force. AHRQ publication no. 11-05157-EF-1. Rockville, MD: Agency for Healthcare Research and Quality; 2011.
 
Sawaya GF. Adding human papillomavirus testing to cytology for primary cervical cancer screening: shooting first and asking questions later [Editorial]. Ann Intern Med. 2008; 148:557-9.
CrossRef
 
Saint M, Gildengorin G, Sawaya GF. Current cervical neoplasia screening practices of obstetrician/gynecologists in the US. Am J Obstet Gynecol. 2005; 192:414-21.
PubMed
CrossRef
 
Corbelli J, Borrero S, Bonnema R, McNamara M, Kraemer K, Rubio D, et al. Differences among primary care physicians' adherence to 2009 ACOG guidelines for cervical cancer screening. J Womens Health (Larchmt). 2014; 23:397-403.
PubMed
CrossRef
 
Perkins RB, Jorgensen JR, McCoy ME, Bak SM, Battaglia TA, Freund KM. Adherence to conservative management recommendations for abnormal Pap test results in adolescents. Obstet Gynecol. 2012; 119:1157-63.
PubMed
CrossRef
 
Roland KB, Soman A, Benard VB, Saraiya M. Human papillomavirus and Papanicolaou tests screening interval recommendations in the United States. Am J Obstet Gynecol. 2011; 205:447.
PubMed
CrossRef
 
Berkowitz Z, Saraiya M, Sawaya GF. Cervical cancer screening intervals, 2006 to 2009: moving beyond annual testing [Letter]. JAMA Intern Med. 2013; 173:922-4.
PubMed
CrossRef
 
Meissner HI, Tiro JA, Yabroff KR, Haggstrom DA, Coughlin SS. Too much of a good thing? Physician practices and patient willingness for less frequent Pap test screening intervals. Med Care. 2010; 48:249-59.
PubMed
CrossRef
 
Saraiya M, Berkowitz Z, Yabroff KR, Wideroff L, Kobrin S, Benard V. Cervical cancer screening with both human papillomavirus and Papanicolaou testing vs Papanicolaou testing alone: what screening intervals are physicians recommending? Arch Intern Med. 2010; 170:977-85.
PubMed
CrossRef
 
Bellizzi KM, Breslau ES, Burness A, Waldron W. Prevalence of cancer screening in older, racially diverse adults: still screening after all these years. Arch Intern Med. 2011; 171:2031-7.
PubMed
CrossRef
 
Kale MS, Bishop TF, Federman AD, Keyhani S. Trends in the overuse of ambulatory health care services in the United States. JAMA Intern Med. 2013; 173:142-8.
PubMed
CrossRef
 
Centers for Disease Control and Prevention (CDC). Cervical cancer screening among women by hysterectomy status and among women aged ≥65 years—United States, 2000–2010. MMWR Morb Mortal Wkly Rep. 2013; 61:1043-7.
PubMed
 
Sirovich BE, Welch HG. Cervical cancer screening among women without a cervix. JAMA. 2004; 291:2990-3.
PubMed
CrossRef
 
Henderson JT, Saraiya M, Martinez G, Harper CC, Sawaya GF. Changes to cervical cancer prevention guidelines: effects on screening among U.S. women ages 15–29. Prev Med. 2013; 56:25-9.
PubMed
CrossRef
 
Goldhaber-Fiebert JD, Stout NK, Salomon JA, Kuntz KM, Goldie SJ. Cost-effectiveness of cervical cancer screening with human papillomavirus DNA testing and HPV-16,18 vaccination. J Natl Cancer Inst. 2008; 100:308-20.
PubMed
CrossRef
 
Kulasingam SL, Havrilesky LJ, Ghebre R, Myers ER. Screening for cervical cancer: a modeling study for the US Preventive Services Task Force. J Low Genit Tract Dis. 2013; 17:193-202.
PubMed
CrossRef
 
Howlader N, Noone AM, Krapcho M, Garshell J, Neyman N, Altekruse SF, et al, eds.  SEER Cancer Statistics Review, 1975–2010. Bethesda, MD: National Cancer Institute; 2013. Accessed at http://seer.cancer.gov/csr/1975_2010 on 3 April 2015.
 
Saraiya M, McCaig LF, Ekwueme DU. Ambulatory care visits for Pap tests, abnormal Pap test results, and cervical cancer procedures in the United States. Am J Manag Care. 2010; 16:e137-44.
PubMed
 
Howard M, Agarwal G, Lytwyn A. Accuracy of self-reports of Pap and mammography screening compared to medical record: a meta-analysis. Cancer Causes Control. 2009; 20:1-13.
PubMed
CrossRef
 
Rauscher GH, Johnson TP, Cho YI, Walk JA. Accuracy of self-reported cancer-screening histories: a meta-analysis. Cancer Epidemiol Biomarkers Prev. 2008; 17:748-57.
PubMed
CrossRef
 
Kim JJ, Wright TC, Goldie SJ. Cost-effectiveness of alternative triage strategies for atypical squamous cells of undetermined significance. JAMA. 2002; 287:2382-90.
PubMed
CrossRef
 
Goldie SJ, Kim JJ, Wright TC. Cost-effectiveness of human papillomavirus DNA testing for cervical cancer screening in women aged 30 years or more. Obstet Gynecol. 2004; 103:619-31.
PubMed
CrossRef
 
Mandelblatt JS, Lawrence WF, Womack SM, Jacobson D, Yi B, Hwang YT, et al. Benefits and costs of using HPV testing to screen for cervical cancer. JAMA. 2002; 287:2372-81.
PubMed
CrossRef
 
Kim JJ, Sharma M, Ortendahl J. Optimal interval for routine cytologic screening in the United States [Letter]. JAMA Intern Med. 2013; 173:241-2.
PubMed
CrossRef
 
Sawaya GF, Kuppermann M. Identifying a "range of reasonable options" for cervical cancer screening [Editorial]. Obstet Gynecol. 2015; 125:308-10.
PubMed
CrossRef
 
Merrill RM. Hysterectomy surveillance in the United States, 1997 through 2005. Med Sci Monit. 2008; 14:CR24-31.
PubMed
 
Canfell K, Chesson H, Kulasingam SL, Berkhof J, Diaz M, Kim JJ. Modeling preventative strategies against human papillomavirus-related disease in developed countries. Vaccine. 2012; 30 Suppl 5:F157-67.
PubMed
CrossRef
 
Weitlauf JC, Frayne SM, Finney JW, Moos RH, Jones S, Hu K, et al. Sexual violence, posttraumatic stress disorder, and the pelvic examination: how do beliefs about the safety, necessity, and utility of the examination influence patient experiences? J Womens Health (Larchmt). 2010; 19:1271-80.
PubMed
CrossRef
 
Schwartz LM, Woloshin S, Fowler FJ Jr, Welch HG. Enthusiasm for cancer screening in the United States. JAMA. 2004; 291:71-8.
PubMed
CrossRef
 
Sirovich BE, Woloshin S, Schwartz LM. Screening for cervical cancer: will women accept less? Am J Med. 2005; 118:151-8.
PubMed
CrossRef
 
Huang AJ, Pérez-Stable EJ, Kim SE, Wong ST, Kaplan CP, Walsh JM, et al. Preferences for human papillomavirus testing with routine cervical cancer screening in diverse older women. J Gen Intern Med. 2008; 23:1324-9.
PubMed
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Schleifer D, Rothman DJ. "The ultimate decision is yours": exploring patients' attitudes about the overuse of medical interventions. PLoS One. 2012; 7:e52552.
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Choosing Wisely Web site. Philadelphia: ABIM Foundation; 2015. Accessed at www.choosingwisely.org on 26 January 2015.
 
Mathias JS, Gossett D, Baker DW. Use of electronic health record data to evaluate overuse of cervical cancer screening. J Am Med Inform Assoc. 2012; 19:e96-e101.
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National Committee for Quality Assurance.  NCQA Updates HEDIS Measures. Washington, DC: National Committee for Quality Assurance; 2013. Accessed at www.ncqa.org/Newsroom/NewsArchive/2013NewsArchive/NewsReleaseJuly32013.aspx on 10 April 2015.
 
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Letters

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Communicating Value: Discussing Pelvic Examinations with Patients
Posted on May 4, 2015
Andrew Olson and Hanna Bloomfield
Department of Medicine, University of Minnesota Medical School and Minneapolis VA Medical Center
Conflict of Interest: Dr. Bloomfield is an investigator at the Minneapolis VA Evidence Synthesis Program.
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/M14-2426
2. 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/M13-2881
3. 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/M14-0701
4. Jennings JC, Blake J. Screening Pelvic Examinations in Asymptomatic, Average-Risk Adult Women. Ann Intern Med. 2014;161:924. doi:10.7326/L14-5034
Risk assessment and cervical screening
Posted on July 17, 2015
Terence J. Colgan, Robert Marshall Austin
Mount Sinai Hospital, Toronto, Canada and Magee-Women’s Hospital of UPMC, Pittsburgh, PA
Conflict of Interest: None Declared
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.
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Summary for Patients

Cervical Cancer Screening in Average-Risk Women

The full report is titled "Cervical Cancer Screening in Average-Risk Women: Best Practice Advice From the Clinical Guidelines Committee of the American College of Physicians." It is in the 16 June 2015 issue of Annals of Internal Medicine (volume 162, pages 851-859). The authors are G.F. Sawaya, S. Kulasingam, T.D. Denberg, and A. Qaseem, for the Clinical Guidelines Committee of the American College of Physicians.

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