Cervical Cancer Screening: USPSTF Summary
Response to Public Comments
In October 2011, I previously posted about the draft cervical cancer screening recommendations being considered by the USPSTF and ASC/ASCCP/ASCP. The information was available for public comment on the USPSTF Web site from October 19, 2011, through November 30, 2011. Of note, in decreasing order of commentary, the following points were raised:
- Many comments pointed out a lack of clarity about the harms of false-positive results and the harms of screening with cytology more often than every 3 years or screening women younger than age 21 years.
- Many comments urged the USPSTF to reconsider its draft recommendation on HPV co-testing and review new evidence published since its deliberation.
- Several comments requested clarification on how information about sexual history may affect screening.
- Some comments importantly highlighted reaching women who are not being screened at all.
In response to these comments, the USPSTF provided much information in the recommendations about the harms that would occur from screening too often and in women younger than age 21 years. The USPSTF also clarified that this recommendation statement applies to women regardless of sexual history. The USPSTF agrees that the greatest effect on cervical cancer incidence and mortality would result from efforts to screen women who have not been adequately screened. Following the closure of the public comment period, the USPSTF considered new evidence published since its first meeting (refer to the update of the POBASCAM results and the study by Katki et. al.). As a result of this new evidence, the USPSTF decided to recommend HPV testing combined with cytology (co-testing) as a reasonable alternative for women age 30 to 65 years who wish to extend the screening interval beyond 3 years.
Update of Previous USPSTF Recommendation
The March 2012 USPSTF published recommendation on cervical cancer screening updates the earlier 2003 recommendation. It differs from the previous recommendation in:
- it recommends cytology screening every 3 years among women age 21 to 65 years.
- includes more guidance on the proper age ranges and frequency of screening, "…a new recommendation that women younger than age 21 years not be screened because the evidence shows no net benefit. The earlier recommendation suggested that most of the benefit of screening could be obtained by beginning screening within 3 years of onset of sexual activity or age 21 years (whichever comes first) and screening at least every 3 years. This recommendation reaffirms the previous recommendations against screening in adequately screened women older than age 65 years and in women who have had a total hysterectomy with removal of the cervix. "
- it includes new evidence on the comparative test performance of liquid-based versus conventional cytology, indicating no significant difference in test performance for detection of CIN2+/CIN3+.
- "...[i]t includes more guidance on the appropriate use of HPV testing in cervical cancer screening, including a new recommendation that women younger than age 30 years not be screened with HPV testing. The USPSTF found new evidence that addressed the gaps identified in the previous recommendation and allowed the USPSTF to recommend HPV testing combined with cytology as an acceptable screening strategy for women age 30 to 65 years who prefer to lengthen their screening interval beyond 3 years."
Explanation of Evidence Terms
In May 2007, the U.S. Preventive Services Task Force (USPSTF) changed its definitions of grade and practice recommendations following a change in methods of evidence-based review. Each recommendation is assigned one of five letter grades (A, B, C, D, or I). In addition, the available evidence is assigned one of three levels of certainty.
The mindmap shown provides a summary of changes before and after the 2007 USPSTF modifications. By clicking on the Before 2007 area on the map, a separate mindmap will open in a new browser window; and similarly, when you click on the After 2007 branch on the mindmap, a new browser window will open with an After 2007 mindmap. (If you would like the full mindmap, please Contact Me).
In a Nutshell
The USPSTF cervical cancer screening guidelines are similar to those of the ACS/ASCCP/ASCP. The ACS/ASCCP/ASCP recommend that women age 21 to 29 years be screened with cytology (cervical cytology testing or Pap testing) alone every 3 years. Women age 30 to 65 years should be screened with cytology and HPV testing (co-testing) every 5 years or cytology alone every 3 years. The guidelines further state that no woman should be screened every year and that women age 21 to 29 years should not be screened with HPV testing or combined cytology and HPV testing.
- The USPSTF recommends women aged 21 to 65 should be screened with cytology (commonly known as Pap smear) every 3 years. As an alternative, women aged 30 to 65 who want to be screened less frequently may choose the combination of cytology and human papillomavirus (HPV) testing every 5 years, which offers similar benefits to cytology only. (A recommendation).
- The USPSTF recommends against screening women who have had a hysterectomy with removal of the cervix, women younger than age 21, or women older than age 65 who previously have been adequately screened. (D recommendations). Evidence showed that the expected harms (such as unnecessary procedures, false positives, and possible problems with future pregnancies) of screening these populations outweighed the potential benefits.
- The USPSTF recommends against cervical cancer screening using HPV testing in women younger than age 30. (D recommendation). Evidence showed that the expected harms (such as unnecessary procedures, false positives, and possible problems with future pregnancies) of this screening in this group outweighed the potential benefits.
The American Congress of Obstetricians and Gynecologists (ACOG) and the American Academy of Family Physicians (AAFP) are both evaluating new evidence, as well as the findings published in the USPSTF cervical cancer screening guidelines prior to updating their previously published guidelines.