Rationale for Screening Recommendations

Impact of Screening on Cancer Incidence and Mortality^{1 2 3 4}

The Pap test is an effective and cost-effective cancer screening method. Since its introduction in the U.S. in the 1950s, cervical cancer deaths in the U.S. have decreased 74%. Most cases of invasive cancer are preventable with regular screening and follow-up of abnormal results. About 50% to 64% of invasive cancer cases are among women who have never been screened or have suboptimal screening (screening intervals longer than 5 years).

Decreased incidence of cervical cancer will be best achieved by improving screening practices among those women who have never been screened or who are screened infrequently, and increasing HPV vaccination.

HPV Testing

Screening with the co-test (HPV test with the Pap test) is an option for women between the ages of 30 and 65 years. HPV co-testing is not recommended for women under 30 years of age, since most infections in this age group are transient.

HPV testing has—

• Higher sensitivity for diagnosis of high-grade squamous intraepithelial lesions (HSIL), squamous cell carcinoma, and adenocarcinomas.
• Lower specificity than Pap testing alone.
• More false positives compared to Pap testing.

Pap testing or HPV co-testing is not recommended prior to HPV vaccination at any age.⁵

HPV testing should be performed only to detect the presence of high-risk HPV. There is no role for testing for low-risk genotypes, and tests for low-risk HPV should not be performed.

HPV testing identifies current HPV infections only, not past infections.

HPV Test Result Outcomes

A single HPV-positive test result in women 30 years of age or older provides a marker of increased risk for cervical cancer development. However, the positive predictive value of a single test is around 20% for precancer and even less for cancer.

HPV-negative test results offer greater assurance of protection from precancer or cancer than normal cytology—

• HPV-negative co-testing offers protection for about 3 to 6 years.
• HPV-negative alone offers protection for about 3 years.
• Negative Pap testing offers protection for about 3 years.

Test Combination Outcomes	Risk for Cancer	What to Do Next
Normal Pap Negative HPV	Very low risk for CIN3 or cancer in next 3+ years.	Rescreen in 5 years.
Normal Pap Positive HPV	Risk of cervical intraepithelial neoplasia (CIN) 3 or cancer within 10 years: • 13.5% in younger (22 to 32 year-old) women • 21.2% in older (40 to 50 year-old) women	Repeat co-testing in 1 year or triage immediately based on the HPV DNA typing result. HPV DNA typing tests for the specific type of HPV (16, 18) present, rather than just the presence of any high-risk HPV. If 16/18 negative, repeat co-test in 1 year. If 16/18 positive, go to colposcopy.

HPV status also helps guide management of abnormal cytology after colposcopy or biopsy.⁶

Continued Screening Is Still Needed After HPV Vaccination

Cervical cancer cytology screening recommendations remain unchanged for women who have been vaccinated for HPV because 10% to 30% of cervical cancer is caused by HPV types not included in the vaccine, and sexually active women could have been infected prior to vaccination.

References

¹Bos AB, Rebolj M, Habbema JD, van Ballegooijen M. Nonattendance is still the main limitation for the effectiveness of screening for cervical cancer in the Netherlands. International Journal of Cancer 2006;119(10):2372–2375.

²Holcomb K, Runowicz CD. Cervical cancer screening. Surgical Oncology Clinics of North America 2005;14(4):777–797.

³Janerich DT, Hadjimichael O, Schwartz PE, Lowell DM, Meigs JW, Merino MJ, Flannery JT, Polednak AP. The screening histories of women with invasive cervical cancer, Connecticut. American Journal of Public Health 1995;85(6):791–794.

⁴Centers for Disease Control and Prevention (CDC). Cancer screening—United States, 2010. MMWR 2012;61(3):41–45.

⁵Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-Preventable Diseases. Chapter 11: Human Papillomavirus.[PDF-271KB] Hamborsky J, Kroger A, Wolfe S, eds. 13th ed. Washington D.C. Public Health Foundation, 2015.

⁶American Society for Colposcopy and Cervical Pathology. Algorithms: Updated Consensus Guidelines for Managing Abnormal Cervical Cancer Screening Tests and Cancer Precursors. [PDF-324KB] Accessed August 3, 2015.