New cervical cancer screening guidelines signal major shift

Since screening for cervical cancer was first initiated in the 1950s, the number of deaths from this disease has been drastically reduced. Nevertheless, nearly 14,000 women will be diagnosed with invasive cervical cancer in 2020, and about one-third of those cases will be fatal.
Clearly, screening remains one of the most important health measures a woman can take for the early detection and prevention of this disease — but what kind of screening should you have, at what age and how often? The American Cancer Society (ACS) recently updated and published its 2020 cervical cancer screening guidelines, and there are some significant changes in their recommendations.
Ernest S. Han, M.D., Ph.D.
Ernest Han, M.D., Ph.D.
“These guidelines are going to be a major shift in the way we screen patients for cervical cancer,” said Ernest Han, M.D., Ph.D., a gynecologic oncology surgeon at City of Hope. “This is a pretty significant change.”
Typically, physicians have done co-testing, administering two procedures at the same time. The first is a cytology test, better known as a Pap smear, which looks for cellular abnormalities. The second is a test for human papillomavirus (HPV), the main cause of cervical cancer.
According to the new guidelines, however, a Pap smear is no longer required if a primary HPV test is available — “primary” meaning a test that the Federal Drug Administration (FDA) has approved for use on its own for screening.
In addition, the starting age for screenings is now 25 instead of 21, as previously recommended. And screening should be continued every five years until age 65 — discontinuing if, at that age, there has been no history of the disease for the last 25 years and normal screening results for the previous 10 years.
If a primary HPV test isn’t available, the age recommendations remain the same, 25 to 65, but co-testing with cytology and HPV tests should be done every five years. A cytology test alone, every three years, is acceptable.
The guidelines also recommend that anyone with a cervix should be screened, including transgender people. People who have had their cervix removed are excluded, but only if the surgery was not performed for cancer-related reasons. And even those who have had the HPV vaccine should be screened.
Follow-up for individuals who test positive for HPV and/or have an abnormal Pap smear should continue to follow the risk-based management guidelines set in 2019 by the American Society for Colposcopy and Cervical Pathology. These recommendations take into account many factors that determine a person’s risk of cervical cancer and pre-cancer, such as their age and past test results.

Why the Guidelines Have Changed

These new guidelines are all about balancing benefit with harm.
Scientific evidence from clinical trials demonstrated that HPV-based cervical cancer screening is better at finding women who actually have disease, while not generating as many false-negative results as cytology testing alone. In addition, a primary HPV test was more efficient as a screening test compared to the co-test, which means fewer total tests done.
Many women find cervical cancer screenings uncomfortable. What’s more, the precancerous cells found in Pap smears and HPV infections often clear up on their own, especially in younger women — yet such test results do require follow-up.
“Follow-up can involve such procedures as a cone biopsy, where you excise a piece of abnormal cervical tissue, and that can be concerning, especially for young women of childbearing age,” said Han. “If you keep excising a portion of the cervix, it can lead to problems with pregnancy, such as preterm birth, not to mention the cost and the discomfort associated with the procedure itself.”
“Cervical cancer is really driven by HPV for the most part,” said Han. “When you don’t have a positive HPV result, the likelihood that you’re going to get cervical cancer is very low. But one needs to adhere to the recommended screening guidelines.”

Some Considerations About the New Guidelines

Primary HPV tests are not yet widely available, the Society of Gynecologic Oncology has not yet issued an official statement about the new ACS guidelines, and some physicians have reservations about them.
City of Hope does have an FDA-approved primary HPV test and will now use it for all screenings. However, the other guidelines — eliminating cytology testing, screening every five years instead of three, and adopting the new age guidelines — are still under discussion. In addition, the new guideline update applies to average-risk adults who are starting their screening or have had prior normal cervical screening results in the past.
“At City of Hope, we treat many different patients with all types of cancers. We have a significant high-risk population of patients who are immunosuppressed, and these guidelines do not apply to them,” Han said.
High-risk patients, he explained, include those who have undergone solid organ or stem cell transplantation, have tested positive for HIV, or have immunosuppression from other causes.
One consideration is that, according to the ACS, while cervical cancer is most common in women in their 30s, 40s and 50s, women over 65 account for more than 15% of cases.
“I’ve found women over 65 with cervical cancer that might have been detected earlier if they had gotten screened,” Han said. “And I’ve also seen some very young patients diagnosed with it.”
In general, though, he does feel the move toward fewer and less invasive procedures is a good one, but the most important thing is to get screened.
“We’re still seeing patients come in with a cancer that could have been prevented with appropriate screening,” said Han. “The biggest factor in cervical cancer is not getting screened at all.”