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Level I – Cervical Cancer Screening

Level I Services: Preventive services for which clinicians and health systems must assess the need. These services must be recommended to each patient, as they have the highest value and are worthy of attention at every opportunity.

The USPSTF recommendations are fully endorsed by the ICSI Preventive Services work group.
Grade of Recommendation and Level of Certainty as Evaluated by USPSTF
  1. “Screening for cervical cancer in women ages 21 to 65 years with cytology (Pap smear) every 3 years or, for women ages 30 to 65 years who want to lengthen the screening interval, screening with a combination of cytology and human papillomavirus (HPV) testing every 5 years. See the Clinical Considerations for discussion of cytology method, HPV testing and screening interval.”
  2. “Against screening for cervical cancer in women younger than age 21 years. ”
  3. “Against screening for cervical cancer in women older than age 65 years who have had adequate prior screening and are not otherwise at high risk for cervical cancer. See the Clinical Considerations for discussion of adequacy of prior screening and risk factors. ”
  4. “Against screening for cervical cancer in women who have had a hysterectomy with removal of the cervix and who do not have a history of a high-grade precancerous lesion (e.g., cervical intraepithelial neoplasia [CIN] grade 2 or 3) or cervical cancer. ”
  5. “Against screening for cervical cancer with HPV testing, alone or in combination with cytology, in women younger than age 30 years.”
(USPSTF Last Revised 2012)
Grade of Recommendation:
  1. A
  2. D
  3. D
  4. D
  5. D

Level of Certainty:

  1. High
  2. Moderate
  3. Moderate
  4. Moderate
  5. Moderate
“Benefits:
Women Ages 21 to 65 Years
There is convincing evidence that screening women ages 21 to 65 years with cytology every three years substantially reduces cervical cancer incidence and mortality. Among women ages 30 to 65 years, there is adequate evidence that screening with a combination of cytology and HPV testing (co-testing) every five years provides benefits similar to those seen with cytology screening alone every three years.
Among women younger than age 30 years, there is adequate evidence that screening with HPV testing (alone or in combination with cytology) confers little to no benefit.
Women Younger Than Age 21 Years
There is adequate evidence that screening women younger than age 21 years (regardless of sexual history) does not reduce cervical cancer incidence and mortality compared with beginning screening at age 21 years.
Women Older Than Age 65 Years
There is adequate evidence that screening women older than age 65 years who have had adequate prior screening and are not otherwise at high risk provides little to no benefits.
Women After Hysterectomy
There is convincing evidence that continued screening after hysterectomy with removal of the cervix for indications other than a high-grade precancerous lesion or cervical cancer provides no benefits.
Harms:
Screening with cervical cytology or HPV testing can lead to harm, and the harms of screening can take many forms. Abnormal test results can lead to more frequent testing and invasive diagnostic procedures, such as colposcopy and cervical biopsy. Evidence from randomized, controlled trials and observational studies indicates that harms from these diagnostic procedures include vaginal bleeding, pain, infection and failure to diagnose (due to inadequate sampling). Abnormal screening test results are also associated with mild psychological harms; short-term increases in anxiety, distress, and concern about health have been reported with cytology and HPV testing.
Harms of Treatment of Screening – Detected Disease
The harms of treatment include risks from the treatment procedure itself and the potential downstream consequences of treatment. Summary evidence from observational studies indicates that some treatments for precancerous lesions (such as cold-knife conization and loop excision) are associated with adverse pregnancy outcomes, such as preterm delivery, that can lead to low birth weight in infants and perinatal death. Evidence is convincing that many precancerous cervical lesions will regress and that other lesions are so indolent and slow growing that they will not become clinically important over a woman's lifetime; identification and treatment of these lesions constitute over-diagnosis. It is difficult to estimate the precise magnitude of over-diagnosis associated with any screening or treatment strategy, but it is of concern because it confers no benefit and leads to unnecessary surveillance, diagnostic tests and treatments with the associated harms.
Women Ages 21 to 65 Years
There is adequate evidence that the harms of screening for cervical cancer with cytology alone or in combination with HPV testing in women age 30 to 65 years are moderate. Positive screening results are more common with strategies that include HPV testing than with strategies that use cytology alone. Therefore, the likelihood of prolonged surveillance and overtreatment may increase with strategies that incorporate HPV testing. Cervical treatments may increase the risk for adverse pregnancy outcomes (for example, cervical insufficiency and preterm delivery) in women who have not yet completed childbearing.
Women Younger Than Age 30 Years
There is adequate evidence that the harms of HPV testing (alone or in combination with cytology) in women younger than age 30 years are moderate.
Women Younger Than Age 21 Years
There is adequate evidence that the harms of screening in women younger than age 21 years are moderate.
Women Older Than Age 65 Years
There is adequate evidence that the harms of screening in women older than age 65 years who have had adequate prior screening and are not otherwise at high risk are at least small.
Women After Hysterectomy
There is adequate evidence that screening after hysterectomy among women who do not have a history of a high-grade precancerous lesion or cervical cancer is associated with harms.
Benefits-Harms Assessment:
For women younger than age 21 years, regardless of sexual history, there is moderate certainty that the harms of screening outweigh the benefits.
Assessment of Risk:
It is well established that HPV infection is associated with nearly all cases of cervical cancer. Other factors that put a woman at increased risk for cervical cancer include HIV infection, a compromised immune system, in utero exposure to diethylstilbestrol, and previous treatment of a high-grade precancerous lesion or cervical cancer.
Women who have had a hysterectomy with removal of the cervix and who do not have a history of a high-grade precancerous lesion or cervical cancer are not at risk for cervical cancer and should not be screened. Women who had their cervix removed during surgery for ovarian or endometrial cancers are not at high risk for cervical cancer and would not benefit from screening. Clinicians should confirm through review of surgical records or direct examination that the cervix was removed.”
Relevant Resources:
http://www.uspreventiveservicestaskforce.org/uspstf/uspscerv.htm
Implementation Tools and Strategies:
Screening for Cervical Cancer