Virginia A. Moyer, MD, MPH; on behalf of the U.S. Preventive Services Task Force*
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This article has been corrected. The original version (PDF) is appended to this article as a supplement.
Update of the 2003 U.S. Preventive Services Task Force (USPSTF) recommendation statement on screening for cervical cancer.
The USPSTF reviewed new evidence on the comparative test performance of liquid-based cytology and the benefits and harms of human papillomavirus (HPV) testing as a stand-alone test or in combination with cytology. In addition to the systematic evidence review, the USPSTF commissioned a decision analysis to help clarify the age at which to begin and end screening, the optimal interval for screening, and the relative benefits and harms of different strategies for screening (such as cytology and co-testing).
This recommendation statement applies to women who have a cervix, regardless of sexual history. This recommendation statement does not apply to women who have received a diagnosis of a high-grade precancerous cervical lesion or cervical cancer, women with in utero exposure to diethylstilbestrol, or women who are immunocompromised (such as those who are HIV positive).
The USPSTF recommends screening for cervical cancer in women aged 21 to 65 years with cytology (Papanicolaou smear) every 3 years or, for women aged 30 to 65 years who want to lengthen the screening interval, screening with a combination of cytology and HPV testing every 5 years. See the Clinical Considerations for discussion of cytology method, HPV testing, and screening interval (A recommendation).
The USPSTF recommends against screening for cervical cancer in women younger than age 21 years (D recommendation).
The USPSTF recommends against screening for cervical cancer in women older than age 65 years who have had adequate prior screening and are not otherwise at high risk for cervical cancer. See the Clinical Considerations for discussion of adequacy of prior screening and risk factors (D recommendation).
The USPSTF recommends against screening for cervical cancer in women who have had a hysterectomy with removal of the cervix and who do not have a history of a high-grade precancerous lesion (cervical intraepithelial neoplasia grade 2 or 3) or cervical cancer (D recommendation).
The USPSTF recommends against screening for cervical cancer with HPV testing, alone or in combination with cytology, in women younger than age 30 years (D recommendation).
Screening for cervical cancer: clinical summary of U.S. Preventive Services Task Force recommendation.
Pap = Papanicolaou.
Table 1. What the USPSTF Grades Mean and Suggestions for Practice
Table 2. Levels of Certainty Regarding Net Benefit
Ji Young Bang MBBS MPH, Azeem Majeed MD FRCGP FFPH
Department of Primary Care & Public Health, Imperial College Faculty of Medicine, London, W6 8RP, UK
July 5, 2012
Screening for Cervical Cancer: U.S. Preventive Services Task Force Recommendation Statement
As in the USA, cervical cancer incidence and mortality have fallen in England since the introduction of cervical screening.[1,2] For the full benefits of screening to be achieved, uptake of screening should be as high as possible. However, despite the evidence about its effectiveness and even though the health system in England offers universal health care through the National Health Service (NHS) that is free at the point of delivery to all its residents, including preventive programs, cervical screening coverage varies widely among English primary care organizations. Standardized collection of data on cervical screening nationally and the availability of other data on primary care trusts (the organizations in England’s NHS responsible for overseeing local health services) allow examination of primary care practice and population factors that influence the uptake of cervical screening.We carried out a national cross-sectional study using data from 8,229 general practices in 152 primary care trusts; including data on cervical screening uptake, primary care quality scores, primary care staffing, and population characteristics such as area socioeconomic status. We found that cervical screening uptake among women aged 25-64 years (the target population for screening in England) ranged from 65.8 to 85.8% in English primary care trusts (median 79.6%). In a multiple regression model, factors such as area socioeconomic score, percentage of women aged 25-49 years, and percentage of patients from ethnic minority groups were also associated with lower uptake of cervical screening at primary care trust level. At general practice level, these variables were also associated with lower screening rates. In addition, at general practice level, practice quality scores and a higher proportion of women aged 50-64 were associated with higher uptake rates. The findings from England are helpful in identifying the groups of women in which cervical screening attendance should be improved. The findings also illustrate that performance measurements such as cervical screening uptake can be substantially influenced by population factors such as age, ethnicity and socioeconomic status. Therefore, using crude performance data to determine the quality of care provided in primary care can be misleading. Improving cervical screening uptake is a challenging task and requires a multi-faceted approach involving collaboration between patients, physicians, primary care organizations and policy-makers to be successful.References1. 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;880-91.2. Quinn M, Babb P, Jones J et al. Effect of screening on incidence of and mortality from cancer of cervix in England: evaluation based on routinely collected statistics. Br Med J 1999;318(7188):904–8.3. Majeed A. Sources, uses, strengths and limitations of data collected in primary care in England. Health Statistics Quarterly 2004; 21: 5-14.4. Bang JY, Yadegarfar G, Soljak M, Majeed A. Primary care factors associated with cervical screening coverage in England. J Pub Health 2012 Apr 18. [Epub ahead of print].
Shalini Rajaram MD, Director Professor, Parul Agarwal, MD, Senior Resident
Department of Obstetrics and Gynecology University College of Medical Sciences and, Guru Teg Bahadur Hospital, Delhi-110095, India
August 2, 2012
Screening for cervical cancer at 21 years regardless of sexual activity?
SirThis letter is in reference to the ‘Clinical Guideline’ published recently on screening for cervical cancer by Moyer VA entitled ‘Screening for Cervical Cancer: U.S. Preventive Services Task Force Recommendation Statement’ . While we agree that screening should not be started earlier than 21 years of age as cervical cancer in this age group is extremely rare, we need to comprehend the recommendation that cervical cancer screening should be started at ‘21 years regardless of sexual activity’. For example in a women who has never initiated sexual activity by this age or maybe even later why is it necessary to begin screening at 21? In earlier recommendations both American Cancer Society and American College of Obstetrics & Gynecologists recommended that screening should begin 3 years after coitarche but not before 21 years of age [2,3]. This definitely seems more logical and acceptable to both the woman and her health care provider. Why does the U.S. Preventive Services Task Force (USPSTF) not recommend this approach? Is it because majority of American girls are sexually active early? If so, a mention in the guideline stating that the ‘recommendation is for American women’ will be helpful. While we understand that guidelines are usually country specific, many regions of the world that do not have their own strategies look to influential bodies like USPTF, ACS, ACOG etc for recommendations.
This letter follows an argument regarding when to initiate cervical cancer screening in a post-graduate OBGYN teaching class recently and the current USPSTF statement was quoted and endorsed. Recommendations for screening in the Asia Oceania region are published with guidelines for implementation but are not yet widely advocated. Screening beginning at 30 years is supported in resource poor settings . This may not be appropriate for women living in urban settings with life style factors approaching that of developed countries. We eagerly await a response from the author for clarifications and a better understanding of the guideline.
1. Moyer VA. Screening for Cervical Cancer: U.S. Preventive Services Task Force Recommendation Statement. Ann Int Med 2012, 156(12): 880-891
2. Saslow D, Runowicz CD, Solomon D et al American Cancer Society guidelines for early detection of cervical neoplasia and cancer CA Cancer J Clin 2002; 52: 342-62
3. ACOG Practice bulletin: clinical management guidelines for obstetrician- gynecologists Number 45, August 2003. Cervical cytology screening
4. Ngan HY, Garland SM, Bhatla N, Pagliusi SR, Chan KK, Cheung AN et al Asia oceania guidelines for the implementation of programs for cervical cancer prevention and control. J Cancer Epidemiol 2011; 2011: 794861. Epub 2011 Apr 13, doi: 10.1155/2011/794861
Moyer VA, on behalf of the U.S. Preventive Services Task Force*. Screening for Cervical Cancer: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2012;156:880–891. doi: https://doi.org/10.7326/0003-4819-156-12-201206190-00424
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Published: Ann Intern Med. 2012;156(12):880-891.
Cancer Screening/Prevention, Guidelines, Hematology/Oncology, Prevention/Screening.
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