Cervical Cancer Screening

Up to 15-20% of U.S. Cervical Cancer is due to adenocarcinoma (not associated with HPV infection in 25% of cases)

Background
1. Asymptomatic patients are stratified to testing based on risk of CIN 3 or worse (e.g. in situ, invasive Cervical Cancer)
2. Specific risk based approach is preferred over less nuanced approach described below
Risk Calculator Tools
1. ASCCP Web Application (free with email registration)
  1. https://app.asccp.org/
2. ASCCP Mobile Application
  1. https://www.asccp.org/mobile-app
Immediate CIN 3 or greater (CIN 3+) Risk < 4%
1. Five year CIN 3+ Risk <0.15%
  1. HPV-based testing 5 years
2. Five year CIN 3+ Risk 0.15 to 0.54%
  1. HPV-based testing 3 years
3. Five year CIN 3+ Risk <0.54%
  1. HPV-based testing 1 years
Immediate CIN 3 or greater (CIN 3+) Risk >= 4%
1. Immediate CIN 3+ Risk 4 to 24%
  1. Colposcopy
2. Immediate CIN 3+ Risk 25 to 59%
  1. Expedited treatment or Colposcopy
3. Immediate CIN 3+ Risk >60%
  1. Expedited treatment
References

Age under 21 years old
Hysterectomy for benign disease (see below)
1. Recent studies suggest no further Pap Smears needed
Age 65-70 or over (AAFP and USPTF recommend age 65)
1. Two consecutive negative Pap Smears with HPV Testing, with most recent test within last 5 years OR
2. Three normal consecutive Pap Smears and no abnormal Pap Smears in the last 10 years (ACS)

Protocol (varies by ACS, ACOG and USPHS)
1. Initial screening age 21 to 30 years old
  1. Thin Prep Pap Smear cytology without HPV Testing once every 3 years for those under 30 years
  2. Do not test HPV with Pap Smear for those under age 25 years (high Prevalence)
    1. Those age 25-30 years may benefit from HPV Testing every 3 years
2. Age 30 to 65 years old (with intact Uterus and Cervix)
  1. Cytology alone every 3 years (ACOG, ACP, USPTF, AAFP) OR
  2. Cotesting with Cytology and HPV Testing every 5 years (ACOG, ACP, USPTF, AAFP) OR
  3. Primary HPV Testing without cytology every 3 years (ASCCP) or 5 years (USPTF)
    1. If Genotype 16, 18 or 31 positive, then reflex to Colposcopy
    2. If Genotype 11 or 12 positive (or pooled, non-typed HPV positive), reflex to Cervical Cytology
      1. Obtain Colposcopy if abnormal Cervical Cytology (ASCUS or more)
    3. References
      1. Perkins (2020) J Low Genit Tract Dis 24(2): 102-31 [PubMed]
3. Age over 65 years old
  1. No screening needed if adequate negative Pap Smear history
Criteria: Average Risk
1. Cervical Cancer Screening starts at age 21 years regardless of sexual activity
2. Cervical Cancer Screening is not needed in very low risk patients (see above)
3. High risk patients require more specific screening (see below)

Protocol
1. Start screening immunosuppressed patients within one year of onset sexual activity
2. Specific protocols exist for history Cervical Dysplasia or cancer, high risk HPV findings
High risk criteria
1. Significant Cervical Dysplasia (CIN2, CIN3, CIS) or Cervical Cancer history
2. In Utero Diethylstilbestrol Exposure
3. Immunocompromised patients
4. HIV positive
Other higher risk criteria that may prompt closer monitoring
1. Sexual activity onset before age 20 years
  1. Screen and prevent Sexually Transmitted Diseases
2. Patients with three or more lifetime sexual partners
3. History of HPV or other Sexually Transmitted Disease
4. Tobacco Abuse

Total Hysterectomy without uterine or Cervical Cancer
1. No further Cervical Cancer Screening
Total Hysterectomy related to cancer history
1. Continue screening for 20 years
2. Obtain vaginal cytology every 3 years (or cotesting with HPV every 5 years)