Practice Bulletin No. 157

Abstract

The incidence of cervical cancer in the United States has decreased more than 50% in the past 30 years because of widespread screening. In 1975, the rate was 14.8 per 100,000 women. By 2011, it decreased to 6.7 per 100,000 women. Mortality from the disease has undergone a similar decrease from 5.55 per 100,000 women in 1975 to 2.3 per 100,000 women in 2011 (). The American Cancer Society (ACS) estimated that there would be 12,900 new cases of cervical cancer in the United States in 2015, with 4,100 deaths from the disease (). Cervical cancer is much more common worldwide, particularly in countries without screening programs, with an estimated 527,624 new cases of the disease and 265,672 resultant deaths each year (). When cervical cancer screening programs have been introduced into communities, marked reductions in cervical cancer incidence have followed ().New technologies for cervical cancer screening continue to evolve, as do recommendations for managing the results. In addition, there are different risk-benefit considerations for women at different ages, as reflected in age-specific screening recommendations. In 2011, the ACS, the American Society for Colposcopy and Cervical Pathology (ASCCP), and the American Society for Clinical Pathology (ASCP) updated their joint guidelines for cervical cancer screening (), as did the U.S. Preventive Services Task Force (USPSTF) (). Subsequently, in 2015, ASCCP and the Society of Gynecologic Oncology (SGO) issued interim guidance for the use of a human papillomavirus (HPV) test for primary screening for cervical cancer that was approved in 2014 by the U.S. Food and Drug Administration (FDA) (). The purpose of this document is to provide a review of the best available evidence regarding the prevention and early detection of cervical cancer.

Primary HPV testing recommendations of US providers, 2015

“…In prior research, internists were found to be less compliant with cervical cancer screening guidelines than other providers (Corbelli et al, 2014). Similarly, internists in the present study more often recommended primary HPV testing annually or every 2 years for women of all ages (despite SGO/ASCCP interim guidance and ACOG recommendations that primary HPV testing be administered every 3 years and reserved for women ≥25 years (Huh et al, 2015; American College of Obstetricians and Gynecologists, 2016)). It should also be noted that more than half of internists (55.9%) who participated in the 2015 DocStyles survey on which the present study was based were excluded from the analyses because they did not perform cervical cancer screening.…”

“…This result was surprising given the recency of SGO/ASCCP (Huh et al, 2015) and ACOG (American College of Obstetricians and Gynecologists, 2016) recommendations for primary HPV testing, and the absence of guidelines on this screening strategy from ACS (Saslow et al, 2012) and USPSTF (US Preventive Services Task Force, 2012). However, prior national surveys of US providers found widespread agreement that the HPV test administered alone is an effective screening modality in 2012 (79.5%–91.8%, depending on provider specialty) and 2009 (75.3%–86.1%) (Cooper and Saraiya, 2015).…”

“…Most providers who endorsed primary HPV testing in our survey recommended it for women of all ages, despite guidance to limit this strategy to women ≥25 years old (Huh et al, 2015; American College of Obstetricians and Gynecologists, 2016). The rationale for extending primary HPV testing to younger women is not clear, but may be indicative of a universal screening mentality or a lack of understanding that the HPV infection in teenagers and women in their early 20’s often resolves or clears without intervention (Boardman and Robison, 2013).…”

“…The rationale for extending primary HPV testing to younger women is not clear, but may be indicative of a universal screening mentality or a lack of understanding that the HPV infection in teenagers and women in their early 20’s often resolves or clears without intervention (Boardman and Robison, 2013). Many providers also followed an annual or 2-year screening interval for primary HPV testing, despite recommendations for a 3-year interval (Huh et al, 2015; American College of Obstetricians and Gynecologists, 2016) and evidence in other countries which supports the effectiveness of even longer intervals, up to 10 years (Peto and Gilham, 2017; Elfström et al, 2014; Dillner et al, 2008; Gage et al, 2014; Isidean et al, 2016). This preference for more frequent screening may reflect a lack of familiarity with screening recommendations (Isidean et al, 2016), concerns about maintaining visit volume (Henderson et al, 2014) or patient preference (Teoh et al, 2015; Gerend et al, 2017).…”

“…In 2015, the American Society for Colposcopy and Cervical Pathology (ASCCP) and the Society of Gynecology Oncology (SGO) issued clinical guidance recommending primary HPV testing every 3 years for women ≥25 years old as one of several screening strategies (Huh et al, 2015), and the American College of Obstetricians and Gynecologists (ACOG) recommended this screening strategy in 2016 (American College of Obstetricians and Gynecologists, 2016). However, primary screening with the HPV test has not been recommended by the American Cancer Society (ACS) (Saslow et al, 2012) and the US Preventive Services Task Force (USPSTF) (US Preventive Services Task Force, 2012), which endorse two screening options: 1) Papanicolaou (Pap) testing every 3 years for women 21–65 years old and 2) Pap testing every 3 years for women 21–29 years old followed by testing with both the Pap test and the HPV test (co-testing) administered every 5 years for women 30–65 years old.…”