Cervical cancer screening recommended every two years for women between 21 and 29

New clinical management guidelines issued today call for decreasing the frequency of cervical cancer screening from once a year to once every two years for women aged 21 to 29.

The guidelines, issued by the American College of Obstetricians and Gynecologists and published in the December issue of Obstetrics & Gynecology, said that women aged 30 and older who have had three consecutive negative results for intraepithelial lesions and malignancy may reduce screening to once every three years.

It was also recommended that women younger than age 21 should avoid screening because “it may lead to unnecessary and harmful evaluation and treatment in women at very low risk of cancer.”

According to the guideline, screening can be discontinued for women aged between 65 and 70 who have had at least three consecutive negative cytology test results and no abnormal test results in the previous 10 years. Women who have had a total hysterectomy for benign indications and have no prior history of high-grade cervical intraepithelial neoplasia (CIN) can also dispense with routine cytology testing.

Due in part to widespread screening with both liquid-based and conventional screening methods, the incidence of cervical cancer in the United States has dropped from 14.8 per 100,000 to 6.5 per 100,000 in the past 30 years. Disease-specific mortality has similarly decreased by half during the same time.

Nonetheless, the college said there is no evidence supporting annual screening for most women.

“Studies over the past several decades have shown that in an organized program of cervical cancer screening, annual cytology examinations offer little advantage over screening performed at two-year or three-year intervals,” the guidelines said. “One study that did show an increase in relative risk of cancer with screening at a three-year vs. one-year interval found no significant difference between screening at two-years vs. three-years.”

The college still recommended annual screening for some high-risk women. Women with HIV should be screened twice within a year of diagnosis and annually thereafter. Women treated in the past for cancer or CIN 2 or CIN 3 remain at risk and should undergo annual screenings for at least 20 years.

Additionally, women who are immunosuppressed or who were exposed to diethylstilbestrol in utero should undergo annual screening.

The college did not recommend simultaneous testing for HPV and cervical cytology for women younger than 30 because of the high rate of high-risk HPV infections in sexually active women in their 20s. However, women aged at least 30 with negative test results for both cervical cytology and high-risk type HPV DNA have been shown to be at extremely low risk of developing CIN 2 or CIN 3 within the next four to six years. Consequently, the college said those women should not be screened again for at least three years.

“Regardless of the frequency of cervical cytology screening, physicians also should inform their patients that annual gynecologic examinations may still be appropriate even if cervical cytology is not performed at each visit,” the guidelines state. – by Jason Harris

Obstet Gynecol. 2009;114:1409-1420.

These are very well-thought out, very well-considered, appropriate modifications of the existing guidelines based on very solid evidence. These guidelines do NOT say screening isn't necessary, only that screening doesn't need to happen as frequently assuming no abnormality is found. This is a general recommendation. For the general population, these recommendations are perfectly reasonable.

– Maurie Markman, MD

HemOnc Today Editorial Board member