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Cervical cancer screening for individuals at average risk: 2020 guideline update from the American Cancer Society. ​

Literature Information ​

DOI10.3322/caac.21628
PMID32729638
JournalCA: a cancer journal for clinicians
Impact Factor232.4
JCR QuartileQ1
Publication Year2020
Times Cited406
Keywordscervical neoplasms, cervix neoplasms, guideline, mass screening, prevention and control
Literature TypeJournal Article, Practice Guideline
ISSN0007-9235
Pages321-346
Issue70(5)
AuthorsElizabeth T H Fontham, Andrew M D Wolf, Timothy R Church, Ruth Etzioni, Christopher R Flowers, Abbe Herzig, Carmen E Guerra, Kevin C Oeffinger, Ya-Chen Tina Shih, Louise C Walter, Jane J Kim, Kimberly S Andrews, Carol E DeSantis, Stacey A Fedewa, Deana Manassaram-Baptiste, Debbie Saslow, Richard C Wender, Robert A Smith

TL;DR ​

The American Cancer Society has updated its cervical cancer screening guidelines, recommending that individuals with a cervix begin screenings at age 25 with primary HPV testing every 5 years, emphasizing this as the preferred method, while allowing for cotesting and cytology as alternatives where necessary. These changes mark a shift from previous recommendations, particularly by increasing the starting age for screening and promoting the transition to primary HPV testing, which aims to enhance early detection and prevention of cervical cancer.

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cervical neoplasms · cervix neoplasms · guideline · mass screening · prevention and control

Abstract ​

The American Cancer Society (ACS) recommends that individuals with a cervix initiate cervical cancer screening at age 25 years and undergo primary human papillomavirus (HPV) testing every 5 years through age 65 years (preferred); if primary HPV testing is not available, then individuals aged 25 to 65 years should be screened with cotesting (HPV testing in combination with cytology) every 5 years or cytology alone every 3 years (acceptable) (strong recommendation). The ACS recommends that individuals aged >65 years who have no history of cervical intraepithelial neoplasia grade 2 or more severe disease within the past 25 years, and who have documented adequate negative prior screening in the prior 10 years, discontinue all cervical cancer screening (qualified recommendation). These new screening recommendations differ in 4 important respects compared with the 2012 recommendations: 1) The preferred screening strategy is primary HPV testing every 5 years, with cotesting and cytology alone acceptable where access to US Food and Drug Administration-approved primary HPV testing is not yet available; 2) the recommended age to start screening is 25 years rather than 21 years; 3) primary HPV testing, as well as cotesting or cytology alone when primary testing is not available, is recommended starting at age 25 years rather than age 30 years; and 4) the guideline is transitional, ie, options for screening with cotesting or cytology alone are provided but should be phased out once full access to primary HPV testing for cervical cancer screening is available without barriers. Evidence related to other relevant issues was reviewed, and no changes were made to recommendations for screening intervals, age or criteria for screening cessation, screening based on vaccination status, or screening after hysterectomy. Follow-up for individuals who screen positive for HPV and/or cytology should be in accordance with the 2019 American Society for Colposcopy and Cervical Pathology risk-based management consensus guidelines for abnormal cervical cancer screening tests and cancer precursors.

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Primary Questions Addressed ​

  1. How do the new guidelines for cervical cancer screening address the needs of populations with limited access to primary HPV testing?
  2. What evidence supports the change in the recommended age to start cervical cancer screening from 21 to 25 years?
  3. In what ways do the 2020 guidelines differ from the previous recommendations regarding the management of abnormal cervical cancer screening tests?
  4. How might the transition to primary HPV testing impact the overall rates of cervical cancer diagnosis and mortality in the average-risk population?
  5. What are the implications of discontinuing cervical cancer screening for individuals over 65 with a history of adequate negative prior screenings?

Key Findings ​

1. Research Background and Purpose: Cervical cancer remains a significant public health issue, and effective screening strategies are vital for early detection and prevention. The American Cancer Society (ACS) aims to provide updated guidelines to optimize cervical cancer screening for individuals at average risk. This update is driven by advancements in understanding human papillomavirus (HPV) testing and its implications for cervical cancer prevention. The primary purpose of this guideline update is to improve screening protocols, ensuring they reflect the latest evidence and are accessible to the population.

2. Main Methods and Findings: The ACS conducted a comprehensive review of existing literature and guidelines to inform their recommendations. The key findings of this update include a shift in the preferred screening method to primary HPV testing every 5 years for individuals aged 25 to 65 years. If primary HPV testing is unavailable, cotesting (HPV and cytology) every 5 years or cytology alone every 3 years is considered acceptable. The guideline also recommends starting cervical cancer screening at age 25 rather than 21, thereby aligning the initiation of screening with the age of increased HPV prevalence. Furthermore, the recommendation for discontinuation of screening for individuals over 65 years who meet specific criteria remains unchanged.

3. Key Conclusions: The updated guidelines represent a significant shift in cervical cancer screening practices, emphasizing the superiority of primary HPV testing. The transition towards a more evidence-based approach is evident, as the ACS seeks to phase out cotesting and cytology alone once widespread access to HPV testing is achieved. This strategic recommendation aims to enhance the effectiveness of cervical cancer screening and align practices with contemporary evidence while still providing alternatives where necessary.

4. Research Significance and Impact: The updated ACS guidelines have profound implications for public health policy and cervical cancer prevention strategies. By advocating for primary HPV testing as the preferred method, the guidelines aim to streamline cervical cancer screening, improve detection rates, and ultimately reduce cervical cancer incidence and mortality. Additionally, the inclusion of age-specific recommendations ensures that screening is performed at the most appropriate times, enhancing the overall effectiveness of cervical cancer prevention efforts. As these guidelines are implemented, they may influence healthcare practices and policies, promoting better health outcomes for individuals at average risk. This update underscores the importance of adapting medical guidelines based on ongoing research and evidence, further emphasizing the role of HPV in cervical cancer prevention.

Literatures Citing This Work ​

  1. Are CIN3 risk or CIN3+ risk measures reliable surrogates for invasive cervical cancer risk? - R Marshall Austin;Agnieszka Onisko;Chengquan Zhao - Journal of the American Society of Cytopathology (2020)
  2. Screening for Cervical Cancer. - Terresa J Eun;Rebecca B Perkins - The Medical clinics of North America (2020)
  3. Cervical Cancer Screening Guidelines in the Postvaccination Era: Review of the Literature. - Carlo A Liverani;Jacopo Di Giuseppe;Luca Giannella;Giovanni Delli Carpini;Andrea Ciavattini - Journal of oncology (2020)
  4. Cotesting in Cervical Cancer Screening. - Douglas P Malinowski;Molly Broache;Laurence Vaughan;Jeff Andrews;Devin Gary;Harvey W Kaufman;Damian P Alagia;Zhen Chen;Agnieszka Onisko;R Marshall Austin - American journal of clinical pathology (2021)
  5. Cervical Screening Performance. - Mark Schiffman;Nicolas Wentzensen - American journal of clinical pathology (2021)
  6. The relationship of human papillomavirus and cytology co-testing results with endometrial and ovarian cancer diagnoses. - Philip E Castle;Alexander Locke;Ana I Tergas;Brian Befano;Nancy Poitras;Nina R Shah;Mark Schiffman;Nicolas Wentzensen;Howard D Strickler;Megan A Clarke;Thomas Lorey - Gynecologic oncology (2021)
  7. Summary of Current Guidelines for Cervical Cancer Screening and Management of Abnormal Test Results: 2016-2020. - Rebecca B Perkins;Richard L Guido;Mona Saraiya;George F Sawaya;Nicolas Wentzensen;Mark Schiffman;Sarah Feldman - Journal of women's health (2002) (2021)
  8. Too soon or too late? Choosing the right screening test intervals. - James A Dickinson;Guylène Thériault;Harminder Singh;Roland Grad;Neil R Bell;Olga Szafran - Canadian family physician Medecin de famille canadien (2021)
  9. PMID: 33608370 - James A Dickinson;Guylène Thériault;Harminder Singh;Roland Grad;Neil R Bell;Olga Szafran - Canadian family physician Medecin de famille canadien (2021)
  10. The next horizon in precision oncology: Proteogenomics to inform cancer diagnosis and treatment. - Henry Rodriguez;Jean Claude Zenklusen;Louis M Staudt;James H Doroshow;Douglas R Lowy - Cell (2021)

... (396 more literatures)

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