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Cervical Cancer Screening Conundrum

Cervical cancer incidence and mortality have declined markedly in the United States with widespread implementation of cytology-based screening programs, but many women will die from the disease this year — probably because they will not have been appropriately screened, stated George F. Sawaya, MD, University of California, San Francisco, in an editorial published online in JAMA Internal Medicine[1].

In 2018, an estimated 13,240 women will receive a diagnosis of cervical cancer and 4170 will die, he noted.

Dr Sawaya described the US Preventive Services Task Force (USPSTF) position as stated in its 2018 cervical cancer screening recommendation:

  • continues to recommend screening with cytology alone every 3 years for women aged 21 to 65 years (A recommendation).
  • recommends screening with a stand-alone test for high-risk types of human papillomavirus (hrHPV) in women aged 30 to 65 years (A recommendation).
  • continues to recommend cytology plus hrHPV testing (co-testing) every 5 years for women aged 30 to 65 years (A recommendation) but designates co-testing as an “alternative” strategy to the “preferred” strategies of cytology and hrHPV testing alone.
  • because of uncertainty about the overall effect of HPV vaccination on the incidence of cervical cancer and precancerous conditions, recommends no change in the approach to screening for vaccinated women.

Dr Sawaya pointed out that the new USPSTF recommendations differ from an earlier recommendation in 2 ways: (1) begin hrHPV testing at age 30 years, not age 25 years, and (2) perform testing every 5 years, not more frequently.

He noted that whether the American Congress of Obstetricians and Gynecologists and the American Cancer Society will adopt the latest USPSTF approach remains to be seen.

The new USPSTF recommendation statement describes anticipated trade-offs: hrHPV testing alone and co-testing would avert about 1 additional cancer case per 1000 women screened compared with cytology alone, representing a “very small” improvement in life-years gained, but hrHPV testing alone and co-testing would subject women to “more tests and procedures” than cytology alone.

In assessing the balance of benefits and harms, the USPSTF statement does not fully capture the preferences of women eligible for screening and the economic implications of each strategy as viewed from a societal perspective, Dr. Sawaya suggested.

The USPSTF stated that women aged 30 to 65 years “should discuss with their health care professional which testing strategy is best for them.” If decisions on which strategy provides an appropriate balance of benefits and harms is left to them, user-friendly educational tools will need to be developed to ensure that they are making informed choices, he said.

Cost-effectiveness analyses have been proposed as part of the guideline process, Dr. Sawaya concluded. He is leading a study on using cost-effectiveness analyses to determine the range of reasonable options for cervical cancer screening and inform future screening recommendations.

Last updated on 9/14/19.

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