Cervical cancer screening guidelines from the American Academy of Family Practice recommend the following: - For women ages 21-29, cytology (Pap test) alone every 3 years. - For women ages 30-65, co-testing with cytology and HPV testing every 5 years or cytology alone every 3 years. - Nearly all cervical cancers are caused by persistent infection with high-risk HPV genotypes like HPV-16 and HPV-18. Screening aims to detect precancerous lesions that may develop due to prolonged HPV infection so they can be treated before developing into invasive cancer.

1. Cervical Cancer Screening Guidelines
American Academy of Family Practice, 2018
MSL Candidate
Brenda Roberts, M.D.

2. OUTLINE
• Background
• Risk Factors for Cervical Cancer
• Clinically Important Human Papilloma Virus (HPV) Genotypes
• Pathogenesis of HPV infections
• Cervical Cancer Screening Recommendations
• Management of Abnormal Test Results

3. Background
• Nearly 13,000 cases of cervical cancer are diagnosed each year, with more
than 4,000 deaths
• This number has decreased nearly 50% since 1975, primarily because of
the widespread use of cytology (Papanicolaou [Pap] test)
• Of women diagnosed with cervical cancer, 50% did not receive any
screening prior to their diagnosis
• 10% of those diagnosed, had not been screened in the previous 5 years
Rerucha CM, Carnall, CR. Cervical Cancer Screening. AFP. 2018;97(7):441-448.

4. Risk Factors
Risk Factors For Cervical Cancer:
Multiple sex partners
Age at first intercourse <18 years
Multiple full term pregnancies
History of sexually transmitted diseases
Smoking
Oral contraceptives for 5 years or more
Family History (genetic susceptibility)
Immunosuppression
Black or Hispanic race
Low socioeconomic status
Wipperman J, Neil T, Williams T. Cervical Cancer: Evaluation and Management. AFP. 2018;97(7):449-454.

5. High Risk Human Papilloma Virus (HPV)
Genotypes
• HPV infections cause 99.7% of cervical cancers
• Most cervical HPV infections are transient and clear within 6-24
months
• HPV 16 & 18 cause over 70% of all cervical cancers
• The progression from persistent HPV infection to invasive cervical
disease takes 10-20 years
Rerucha CM, Carnall, CR. Cervical Cancer Screening. AFP. 2018;97(7):441-448.

6. Clinically Important HPV Genotypes
Genotype Pathogenesis
High Risk (oncogenic):
Type 16 Causes 50% of cervical cancers
Type 18 Causes 20% of cervical cancers
Other High Risk HPV types:
31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, 68 All types combined cause 25% of cervical cancers
Low risk HPV types (wart causing):
Types 6 and 11 Cause 90-95% of anogenital warts
HPV = Human Papilloma Virus
Rerucha CM, Carnall, CR. Cervical Cancer Screening. AFP. 2018;97(7):441-448.

7. Pathogenesis
Wipperman J, Neil T, Williams T. Cervical Cancer: Evaluation and Management. AFP. 2018;97(7):449-454.
CIN = Cervical Intraepithelial Neoplasia. CIN1 involves 1/3 of cell wall. CIN2 involves 2/3 of cell wall. CIN3 involves entire cell
• >50% of adults 20-24 years of age are currently infected with HPV
• 50% will clear the HPV infection within 6 months
• 90% will clear the HPV infection within 2 years
• HPV Infections that persist can lead to dysplastic changes – Cervical
Intraepithelial Neoplasia (CIN):
• CIN1 low-grade dysplasia (usually regresses)
• CIN2-CIN3 high-grade dysplasia (20% progress to invasive cervical cancer within 5
years if untreated)

8. Cervical Cancer Screening Recommendations
Patient Age/Population Recommendations
<21 yrs Screening is not recommended
21– 29 yrs Cytology (pap test) alone every 3 yrs
30 – 65 yrs Cytology (pap test) + HPV testing every 5 yrs (preferred)
or cytology alone every 3 yrs
>65 yrs Screening not recommended if low risk - no history of
CIN2 or higher within the past 20 yrs and no risk factors
Hysterectomy for benign reasons Screening not recommended
Women who have received HPV
vaccine
Routine screening
HPV = Human Papilloma Virus. CIN2 = Cervical Intra-epithelial Neoplasia 2 (involves 2/3 of the cell wall)
Rerucha CM, Carnall, CR. Cervical Cancer Screening. AFP. 2018;97(7):441-448.

9. Management of Abnormal Cytology (Pap test)
and/or Positive HPV
Cytology (Pap Test) Results HPV Results Management
Normal Negative HPV Routine screening
Normal Positive HPV, low risk*
Positive HPV, high risk**
Routine screeing
Co-test in 1 year
Cervical Intraepithelial Neoplasia 1,
CIN1
Negative HPV
Positive HPV, low risk*
Positive HPV, high risk**
Co-test in 1 year
Co-test in 1 year
Refer for colposcopy
CIN2/CIN3 Positive HPV, low* or high risk** Refer for colposcopy
Fontaine P, Saslow D, King V. ACS/ASCCP/ASCP Guidelines for the Early Detection of Cervical Cancer. AFP. 2012;86(6):501-508.
Rerucha CM, Carnall, CR. Cervical Cancer Screening. AFP. 2018;97(7):441-448. HPV = Human Papilloma Virus