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{{Cervical cancer}}
{{Cervical cancer}}
{{CMG}}; ''Assistant Editor-in-Chief:''' [[User:Sarthak|Sarthak Sachdeva]]
{{CMG}}; '''Assistant Editor-in-Chief:''' {{Nnasiri}}{{MD}}


==Overview==
==Overview==
According to the [[American Cancer Society]] (ACS) (the American Society for Colposcopy and Cervical Pathology (ASCCP), and American Society for Clinical Pathology participated in the 2021 update<ref name="pmid22422631">{{cite journal| author=Saslow D, Solomon D, Lawson HW, Killackey M, Kulasingam SL, Cain J | display-authors=etal| title=American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer. | journal=CA Cancer J Clin | year= 2012 | volume= 62 | issue= 3 | pages= 147-72 | pmid=22422631 | doi=10.3322/caac.21139 | pmc=3801360 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22422631  }} </ref> but did not participate in this update):
"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).."<ref name="pmid32729638">{{cite journal| author=Fontham ETH, Wolf AMD, Church TR, Etzioni R, Flowers CR, Herzig A | display-authors=etal| title=Cervical cancer screening for individuals at average risk: 2020 guideline update from the American Cancer Society. | journal=CA Cancer J Clin | year= 2020 | volume= 70 | issue= 5 | pages= 321-346 | pmid=32729638 | doi=10.3322/caac.21628 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32729638  }} </ref>
Importantly, self-sampling HPV testing is not yet approved by the FDA although this is a priority of the "Last Mile" initiative of the National Cancer Institute<ref>https://prevention.cancer.gov/major-programs/nci-cervical-cancer-last-mile-initiative</ref>
==Screening==
==Screening==
You should start getting regular Pap tests at age 21, or within three years of the first time you have sex—which ever happens first. The Pap test is one of the most reliable and effective cancer screening tests available. It also can find other conditions that might need treatment, such as infection or inflammation. In addition to the Pap test—the main test for cervical cancer—the HPV test may be used for screening women aged 30 years and older, or women of any age who have unclear Pap test results. If you are 30 or older, and your screening tests are normal, your chance of getting cervical cancer in the next few years is very low. For that reason, your doctor may tell you that you will not need another screening test for up to three years. But you should still go to the doctor regularly for a check-up that may include a pelvic exam. It also is important for you to continue getting a Pap test regularly—even if you think you are too old to have a child, or are not having sex anymore.
The Pap test screening detects and prevents the progression of HPV-induced [[cervical cancer]] and other abnormalities in the female [[genital]] tract by sampling [[cell (biology)|cells]] from the outer opening of the [[cervix]] of the [[uterus]] and the endocervix.
It is generally recommended that sexually active females seek [[pap smear]] testing annually, although guidelines may vary from country to country. <ref>{{cite journal|journal=ecancermedicalscience|issn=17546605|doi=10.3332/ecancer.2012.258}}</ref><ref name="CurryKrist2018">{{cite journal|last1=Curry|first1=Susan J.|last2=Krist|first2=Alex H.|last3=Owens|first3=Douglas K.|last4=Barry|first4=Michael J.|last5=Caughey|first5=Aaron B.|last6=Davidson|first6=Karina W.|last7=Doubeni|first7=Chyke A.|last8=Epling|first8=John W.|last9=Kemper|first9=Alex R.|last10=Kubik|first10=Martha|last11=Landefeld|first11=C. Seth|last12=Mangione|first12=Carol M.|last13=Phipps|first13=Maureen G.|last14=Silverstein|first14=Michael|last15=Simon|first15=Melissa A.|last16=Tseng|first16=Chien-Wen|last17=Wong|first17=John B.|title=Screening for Cervical Cancer|journal=JAMA|volume=320|issue=7|year=2018|pages=674|issn=0098-7484|doi=10.1001/jama.2018.10897}}</ref><ref>{{cite journal|doi=10.1097/AOG.0000000000001708.}}</ref><ref name="HuhAult2015">{{cite journal|last1=Huh|first1=Warner K.|last2=Ault|first2=Kevin A.|last3=Chelmow|first3=David|last4=Davey|first4=Diane D.|last5=Goulart|first5=Robert A.|last6=Garcia|first6=Francisco A. R.|last7=Kinney|first7=Walter K.|last8=Massad|first8=L. Stewart|last9=Mayeaux|first9=Edward J.|last10=Saslow|first10=Debbie|last11=Schiffman|first11=Mark|last12=Wentzensen|first12=Nicolas|last13=Lawson|first13=Herschel W.|last14=Einstein|first14=Mark H.|title=Use of Primary High-Risk Human Papillomavirus Testing for Cervical Cancer Screening|journal=Obstetrics & Gynecology|volume=125|issue=2|year=2015|pages=330–337|issn=0029-7844|doi=10.1097/AOG.0000000000000669}}</ref><ref name="urlFinal Recommendation Statement: Cervical Cancer: Screening - US Preventive Services Task Force">{{cite web |url=https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/cervical-cancer-screening2 |title=Final Recommendation Statement: Cervical Cancer: Screening - US Preventive Services Task Force |format= |work= |accessdate=}}</ref><ref name="urlPractice Advisory: Cervical Cancer Screening (Update) - ACOG">{{cite web |url=https://www.acog.org/Clinical-Guidance-and-Publications/Practice-Advisories/Practice-Advisory-Cervical-Cancer-Screening-Update |title=Practice Advisory: Cervical Cancer Screening (Update) - ACOG |format= |work= |accessdate=}}</ref>
*


===Biopsy===
==Screening Guidelines==
While the pap smear is an effective [[screening test]], confirmation of the diagnosis of cervical cancer or pre-cancer requires a biopsy of the cervix. This is often done through [[colposcopy]], a magnified visual inspection of the cervix aided by using an [[acetic acid]] (e.g. [[vinegar]]) solution to highlight abnormal cells on the surface of the cervix.
{| style="border: 0px; font-size: 90%; margin: 3px;" align="center"
|-
! colspan="2" style="padding: 5px 5px; background: #4479BA; color:#FFF; width: 10%;" |
! style="padding: 5px 5px; background: #4479BA; color:#FFF; width: 30%;" |'''American Cancer Society (ACS), American Society for Colposcopy and Cervical Pathology (ASCCP), and American Society for Clinical Pathology '''
2012 version (has since been updated in 2020
! style="padding: 5px 5px; background: #4479BA; color:#FFF; width: 30%;" |'''U.S. Preventive Services Task Force (USPSTF)'''
2018 guidelines
! style="padding: 5px 5px; background: #4479BA; color:#FFF; width: 30%;" |'''American College of Obstetricians and Gynecologists (ACOG)'''
|-
! colspan="2" style="padding: 5px 5px; background: #DCDCDC;" | When to start screening
| style="padding: 5px 5px; background: #F5F5F5;" | Age 21. Women aged <21 years should not be screened regardless of the age of sexual initiation or other risk factors
| style="padding: 5px 5px; background: #F5F5F5;" | Age 21. (A recommendation) Recommend against screening women aged <21 years (D recommendation)
| style="padding: 5px 5px; background: #F5F5F5;" | Age 21 regardless of the age of onset of sexual activity. Women aged <21 years should not be screened regardless of age at sexual initiation and other behavior-related risk factors (Level A evidence)
|-
! colspan="2" style="padding: 5px 5px; background: #DCDCDC;" | Statement about annual screening
| style="padding: 5px 5px; background: #F5F5F5;" | Women of any age should not be screened annually by any screening method
| style="padding: 5px 5px; background: #F5F5F5;" | Individuals and clinicians can use the annual [[Pap test]] screening visit as an opportunity to discuss other health problems and preventive measures. Individuals, clinicians, and health systems should seek effective ways to facilitate the receipt of recommended preventive services at intervals that are beneficial to the patient. Efforts also should be made to ensure that individuals are able to seek care for additional health concerns as they present
| style="padding: 5px 5px; background: #F5F5F5;" | In women aged 30–65 years, annual cervical cancer screening should not be performed. (Level A evidence) Patients should be counseled that annual well-woman visits are recommended even if cervical cancer screening is not performed at each visit
|-
! colspan="2" style="padding: 5px 5px; background: #DCDCDC;" | Screening method and intervals
| colspan="3" style="padding: 5px 5px; background: #F5F5F5;" |
|-
! rowspan="2" style="padding: 5px 5px; background: #DCDCDC;" | [[Cytology]] (conventional or liquid based)
! style="padding: 5px 5px; background: #DCDCDC;" | 21–29 years
| style="padding: 5px 5px; background: #F5F5F5;" | Every 3 years
| style="padding: 5px 5px; background: #F5F5F5;" | Every 3 years (A recommendation)
| style="padding: 5px 5px; background: #F5F5F5;" | Every 3 years (Level A evidence)
|-
! style="padding: 5px 5px; background: #DCDCDC;" | 30–65 years
| style="padding: 5px 5px; background: #F5F5F5;" | Every 3 years
| style="padding: 5px 5px; background: #F5F5F5;" | Every 3 years (A recommendation)
| style="padding: 5px 5px; background: #F5F5F5;" | Every 3 years (Level A evidence)
|-
! rowspan="2" style="padding: 5px 5px; background: #DCDCDC;" | HPV co-test (cytology + [[HPV test]] administered together)
! style="padding: 5px 5px; background: #DCDCDC;" | 21–29 years
| style="padding: 5px 5px; background: #F5F5F5;" | HPV co-testing should not be used for women aged <30 years
| style="padding: 5px 5px; background: #F5F5F5;" | Recommend against [[HPV]] co-testing in women aged <30 years (D recommendation)
| style="padding: 5px 5px; background: #F5F5F5;" | [[HPV]] co-testing should not be performed in women aged <30 years. (Level A evidence )
|-
! style="padding: 5px 5px; background: #DCDCDC;" | 30–65 years
| style="padding: 5px 5px; background: #F5F5F5;" | Every 5 years; this is the preferred method.
| style="padding: 5px 5px; background: #F5F5F5;" | For women who want to extend their screening interval, HPV co-testing every 5 years is an option (A recommendation)
| style="padding: 5px 5px; background: #F5F5F5;" | Every 5 years; this is the preferred method (Level A evidence)
|-
! colspan="2" style="padding: 5px 5px; background: #DCDCDC;" | Primary hrHPV f testing (as an alternative to cotesting or g cytology alone)
| style="padding: 5px 5px; background: #F5F5F5;" | For women aged 30–65 years, screening by [[HPV]] testing alone is not recommended in most clinical settings
| style="padding: 5px 5px; background: #F5F5F5;" | Recommend against screening for cervical cancer with HPV testing (alone or in combination with cytology) in women aged <30 years (D recommendation)
| style="padding: 5px 5px; background: #F5F5F5;" | Not addressed
|-
! colspan="2" style="padding: 5px 5px; background: #DCDCDC;" | When to stop screening
| style="padding: 5px 5px; background: #F5F5F5;" | Aged >65 years with adequate negative prior screening and no history of [[CIN]]2 or higher within the last 20 years
| style="padding: 5px 5px; background: #F5F5F5;" | Aged >65 years with adequate screening history and are not otherwise at high risk for cervical [[cancer]] (D recommendation)
| style="padding: 5px 5px; background: #F5F5F5;" | Aged >65 years with adequate negative prior screening* results and no history of CIN 2 or higher (Level A evidence)
|-
! colspan="2" style="padding: 5px 5px; background: #DCDCDC;" | When to screen after age 65 years
| style="padding: 5px 5px; background: #F5F5F5;" | When to screen after age 65 years Aged >65 years with a history of [[CIN]]2 CIN2, CIN3, or [[adenocarcinoma]] in situ, routine screening should continue for at least 20 years
| style="padding: 5px 5px; background: #F5F5F5;" | Women aged >65 years who have never been screened, do not meet the criteria for adequate prior screening, or for whom the adequacy of prior screening cannot be accurately accessed or documented. Routine screening should continue for at least 20 years after spontaneous regression or appropriate management of a high-grade precancerous lesion, even if this extends screening past age 65 years. Certain considerations may support screening in women aged > 65 years who are otherwise considered high risk (such as women with a highgrade precancerous lesion or cervical cancer, women with in utero exposure to diethylstilbestrol, or women who are [[immunocompromised]])
| style="padding: 5px 5px; background: #F5F5F5;" | Women aged >65 years with a history of CIN2, [[CIN]]3, or [[AIS]] should continue routine agebased screeningk for at least 20 years (Level B evidence)
|-
! colspan="2" style="padding: 5px 5px; background: #DCDCDC;" | Screening post-[[hysterectomy]]
| style="padding: 5px 5px; background: #F5F5F5;" | Women who have had a total [[hysterectomy]] (removal of the [[uterus]] and [[cervix]]) should stop screening. Women who have had a supra-cervical [[hysterectomy]] (cervix intact) should continue screening according to guidelines
| style="padding: 5px 5px; background: #F5F5F5;" | Recommend against screening in women who have had a [[hysterectomy]] (removal of the [[cervix]]) (D recommendation)
| style="padding: 5px 5px; background: #F5F5F5;" | Women who have had a [[hysterectomy]] (removal of the [[cervix]]) should stop screening and not restart for any reason, (Level A evidence)
|-
! colspan="2" style="padding: 5px 5px; background: #DCDCDC;" | The need for a bimanual [[pelvic exam]]
| style="padding: 5px 5px; background: #F5F5F5;" | Not addressed in 2012 guidelines but was addressed in 2002 ACS guidelines
| style="padding: 5px 5px; background: #F5F5F5;" | Addressed in USPSTF ovarian cancer screening recommendations.
| style="padding: 5px 5px; background: #F5F5F5;" | Aged <21 years, no evidence supports the routine internal examination of the healthy, asymptomatic patient. An “external-only” genital examination is acceptable. Aged ≥21 years, no evidence supports or refutes the annual [[pelvic]] examination or speculum and bimanual examination. The decision whether or not to perform a complete [[pelvic]] examination should be a shared decision after a discussion between the patient and her health care provider. Annual examination of the external genitalia should continue
|-
! colspan="2" style="padding: 5px 5px; background: #DCDCDC;" | Screening among those immunized against [[HPV]] 16/18
| style="padding: 5px 5px; background: #F5F5F5;" | Women at any age with a history of [[HPV]] vaccination should be screened according to the age specific recommendations for the general population
| style="padding: 5px 5px; background: #F5F5F5;" | The possibility that [[vaccination]] might reduce the need for screening with cytology alone or in combination with [[HPV]] testing is not established. Given these uncertainties, women who have been vaccinated should continue to be screened
| style="padding: 5px 5px; background: #F5F5F5;" | Women who have received the [[HPV]] vaccine should be screened according to the same guidelines as women who have not been vaccinated (Level C evidence)
|}
HPV = human papillomavirus; CIN = cervical intraepithelial neoplasia; AIS=adenocarcinoma in situ; hrHPV = high-risk HPV.


Further diagnostic procedures are [[loop electrical excision procedure]] (LEEP) and [[conization]], in which the inner lining of the cervix is removed to be examined pathologically. These are carried out if the biopsy confirms severe [[cervical intraepithelial neoplasia]].
==See also==
[[Colposcopy]]


==References==
==References==
{{reflist|2}}
{{reflist|2}}
{{WH}}
{{WS}}


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Latest revision as of 19:46, 16 September 2023



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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Assistant Editor-in-Chief: Nima Nasiri, M.D.[2]Monalisa Dmello, M.B,B.S., M.D. [3]

Overview

According to the American Cancer Society (ACS) (the American Society for Colposcopy and Cervical Pathology (ASCCP), and American Society for Clinical Pathology participated in the 2021 update[1] but did not participate in this update):

"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).."[2]

Importantly, self-sampling HPV testing is not yet approved by the FDA although this is a priority of the "Last Mile" initiative of the National Cancer Institute[3]

Screening

The Pap test screening detects and prevents the progression of HPV-induced cervical cancer and other abnormalities in the female genital tract by sampling cells from the outer opening of the cervix of the uterus and the endocervix. It is generally recommended that sexually active females seek pap smear testing annually, although guidelines may vary from country to country. [4][5][6][7][8][9]

Screening Guidelines

American Cancer Society (ACS), American Society for Colposcopy and Cervical Pathology (ASCCP), and American Society for Clinical Pathology

2012 version (has since been updated in 2020

U.S. Preventive Services Task Force (USPSTF)

2018 guidelines

American College of Obstetricians and Gynecologists (ACOG)
When to start screening Age 21. Women aged <21 years should not be screened regardless of the age of sexual initiation or other risk factors Age 21. (A recommendation) Recommend against screening women aged <21 years (D recommendation) Age 21 regardless of the age of onset of sexual activity. Women aged <21 years should not be screened regardless of age at sexual initiation and other behavior-related risk factors (Level A evidence)
Statement about annual screening Women of any age should not be screened annually by any screening method Individuals and clinicians can use the annual Pap test screening visit as an opportunity to discuss other health problems and preventive measures. Individuals, clinicians, and health systems should seek effective ways to facilitate the receipt of recommended preventive services at intervals that are beneficial to the patient. Efforts also should be made to ensure that individuals are able to seek care for additional health concerns as they present In women aged 30–65 years, annual cervical cancer screening should not be performed. (Level A evidence) Patients should be counseled that annual well-woman visits are recommended even if cervical cancer screening is not performed at each visit
Screening method and intervals
Cytology (conventional or liquid based) 21–29 years Every 3 years Every 3 years (A recommendation) Every 3 years (Level A evidence)
30–65 years Every 3 years Every 3 years (A recommendation) Every 3 years (Level A evidence)
HPV co-test (cytology + HPV test administered together) 21–29 years HPV co-testing should not be used for women aged <30 years Recommend against HPV co-testing in women aged <30 years (D recommendation) HPV co-testing should not be performed in women aged <30 years. (Level A evidence )
30–65 years Every 5 years; this is the preferred method. For women who want to extend their screening interval, HPV co-testing every 5 years is an option (A recommendation) Every 5 years; this is the preferred method (Level A evidence)
Primary hrHPV f testing (as an alternative to cotesting or g cytology alone) For women aged 30–65 years, screening by HPV testing alone is not recommended in most clinical settings Recommend against screening for cervical cancer with HPV testing (alone or in combination with cytology) in women aged <30 years (D recommendation) Not addressed
When to stop screening Aged >65 years with adequate negative prior screening and no history of CIN2 or higher within the last 20 years Aged >65 years with adequate screening history and are not otherwise at high risk for cervical cancer (D recommendation) Aged >65 years with adequate negative prior screening* results and no history of CIN 2 or higher (Level A evidence)
When to screen after age 65 years When to screen after age 65 years Aged >65 years with a history of CIN2 CIN2, CIN3, or adenocarcinoma in situ, routine screening should continue for at least 20 years Women aged >65 years who have never been screened, do not meet the criteria for adequate prior screening, or for whom the adequacy of prior screening cannot be accurately accessed or documented. Routine screening should continue for at least 20 years after spontaneous regression or appropriate management of a high-grade precancerous lesion, even if this extends screening past age 65 years. Certain considerations may support screening in women aged > 65 years who are otherwise considered high risk (such as women with a highgrade precancerous lesion or cervical cancer, women with in utero exposure to diethylstilbestrol, or women who are immunocompromised) Women aged >65 years with a history of CIN2, CIN3, or AIS should continue routine agebased screeningk for at least 20 years (Level B evidence)
Screening post-hysterectomy Women who have had a total hysterectomy (removal of the uterus and cervix) should stop screening. Women who have had a supra-cervical hysterectomy (cervix intact) should continue screening according to guidelines Recommend against screening in women who have had a hysterectomy (removal of the cervix) (D recommendation) Women who have had a hysterectomy (removal of the cervix) should stop screening and not restart for any reason, (Level A evidence)
The need for a bimanual pelvic exam Not addressed in 2012 guidelines but was addressed in 2002 ACS guidelines Addressed in USPSTF ovarian cancer screening recommendations. Aged <21 years, no evidence supports the routine internal examination of the healthy, asymptomatic patient. An “external-only” genital examination is acceptable. Aged ≥21 years, no evidence supports or refutes the annual pelvic examination or speculum and bimanual examination. The decision whether or not to perform a complete pelvic examination should be a shared decision after a discussion between the patient and her health care provider. Annual examination of the external genitalia should continue
Screening among those immunized against HPV 16/18 Women at any age with a history of HPV vaccination should be screened according to the age specific recommendations for the general population The possibility that vaccination might reduce the need for screening with cytology alone or in combination with HPV testing is not established. Given these uncertainties, women who have been vaccinated should continue to be screened Women who have received the HPV vaccine should be screened according to the same guidelines as women who have not been vaccinated (Level C evidence)

HPV = human papillomavirus; CIN = cervical intraepithelial neoplasia; AIS=adenocarcinoma in situ; hrHPV = high-risk HPV.

See also

Colposcopy

References

  1. Saslow D, Solomon D, Lawson HW, Killackey M, Kulasingam SL, Cain J; et al. (2012). "American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer". CA Cancer J Clin. 62 (3): 147–72. doi:10.3322/caac.21139. PMC 3801360. PMID 22422631.
  2. Fontham ETH, Wolf AMD, Church TR, Etzioni R, Flowers CR, Herzig A; et al. (2020). "Cervical cancer screening for individuals at average risk: 2020 guideline update from the American Cancer Society". CA Cancer J Clin. 70 (5): 321–346. doi:10.3322/caac.21628. PMID 32729638 Check |pmid= value (help).
  3. https://prevention.cancer.gov/major-programs/nci-cervical-cancer-last-mile-initiative
  4. ecancermedicalscience. doi:10.3332/ecancer.2012.258. ISSN 1754-6605. Missing or empty |title= (help)
  5. Curry, Susan J.; Krist, Alex H.; Owens, Douglas K.; Barry, Michael J.; Caughey, Aaron B.; Davidson, Karina W.; Doubeni, Chyke A.; Epling, John W.; Kemper, Alex R.; Kubik, Martha; Landefeld, C. Seth; Mangione, Carol M.; Phipps, Maureen G.; Silverstein, Michael; Simon, Melissa A.; Tseng, Chien-Wen; Wong, John B. (2018). "Screening for Cervical Cancer". JAMA. 320 (7): 674. doi:10.1001/jama.2018.10897. ISSN 0098-7484.
  6. . doi:10.1097/AOG.0000000000001708. Check |doi= value (help). Missing or empty |title= (help)
  7. Huh, Warner K.; Ault, Kevin A.; Chelmow, David; Davey, Diane D.; Goulart, Robert A.; Garcia, Francisco A. R.; Kinney, Walter K.; Massad, L. Stewart; Mayeaux, Edward J.; Saslow, Debbie; Schiffman, Mark; Wentzensen, Nicolas; Lawson, Herschel W.; Einstein, Mark H. (2015). "Use of Primary High-Risk Human Papillomavirus Testing for Cervical Cancer Screening". Obstetrics & Gynecology. 125 (2): 330–337. doi:10.1097/AOG.0000000000000669. ISSN 0029-7844.
  8. "Final Recommendation Statement: Cervical Cancer: Screening - US Preventive Services Task Force".
  9. "Practice Advisory: Cervical Cancer Screening (Update) - ACOG".

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