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Who Should Get Screened for Cervical Cancer?

01 February 2023

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Cervical cancer awareness has become a priority in the United States with more women are making preventative screenings a priority. Still, a 2022 report from the American Cancer Society found 23 percent of women were overdue for cervical screenings, a number that nearly doubled from 14 percent in 2005. Who needs to be screened and how often screenings should occur plays a role in these figures.

In the past, some women were accustomed to yearly testing that became both time consuming and costly. This blog will share the latest cervical cancer screening recommendations and guidelines and explore what your test results mean.

The role of your cervix

The cervix is often overshadowed by the vagina or ovaries, but it remains an important role in the reproductive system. Located in the lower part of the uterus, the cervix connects the uterus and vagina together.

Every day, the cervix helps keep unwanted things from entering your body. After sexual intercourse, the cervix opens to allow sperm to reach the uterus to fertilize an egg. For women who become pregnant, the cervix then seals off the womb so the embryo has a secure place to grow and develop.

As important as the cervix is, it’s also prone to abnormal growths and infection, most notably human papillomavirus (HPV). Nearly all sexually active women will contract HPV at some point during their life  – it can be as common as a cold – although the immune system usually controls these infections. However, some high-risk HPV infections can lead to cervical cancer, which furthers the importance of screenings.

The cervix is made up of two types of cells – glandular and squamous – where these growths can occur. 

Glandular cells are found in the inner part of the cervix called the endocervix, while squamous cells line outside of the cervix and vagina in an area called the ectocervix. The endocervix and ectocervix meet to form what is called the transformation zone. Most cases of cervical cancer originate in squamous cells in this area.

Updated cervical cancer screening guidelines

Currently, there are three sets of guidelines from three groups – American College of Obstetricians and Gynecologists (ACOG), American Cancer Society (ACS) and United States Preventive Services Task Force (USPSTF). Both ACOG and USPSTF share identical recommendations. Additionally, the Society of Gynecologic Oncology (SGO) and American Society for Clinical Pathology (ASCCP) both endorse recommendations from ACOG and USPSTF.

The latest recommendations from the American Cancer Society were established in 2020. Two main changes were noted: pushing back the starting age of screening from 21 to 25 and recommending the high-risk human papillomavirus (hrHPV) test every five years. Previously, a pap smear every 3 years was the gold standard cervical cancer screening.

There have been no adjustments made for testing among older women – low-risk patients over the age of 65 don’t require screening as long as they’ve had negative results for the past 10 years. Women over the age of 65 who have had abnormal results of a history of precancerous cells can still be screened.

American College of Obstetricians and Gynecologists

  • Women under 21: No screening
  • Women ages 21-29: Pap smear every 3 years
  • Women ages 30-65: Pap smear every 3 years or primary high-risk human papillomavirus (hrHPV) test every 5 years
  • Women older than 65: No screening required with previous negative result

American Cancer Society

  • Women under 25: No screening
  • Women ages 25-29: hrHPV test every 5 years (preferred); or HPV/Pap cotest every 5 years; or pap smear every 3 years
  • Women ages 30-65: HPV test every 5 years (preferred); or HPV/Pap cotest every 5 years; or pap smear every 3 years
  • Women older than 65: No screening required with previous negative result

United States Preventive Services Task Force

  • Women under 21: No screening
  • Women ages 21-29: Pap smear every 3 years
  • Women ages 30-65: Pap smear every 3 years; or every 5 years with hrHPV alone; or HPV/Pap cotest every 5 years
  • Women older than 65: No screening required with previous negative result

Regardless of screening type, being proactive with your cervical health can have a direct impact on your future health. Each year, about 14,000 women are diagnosed with cervical cancer, according to the American Cancer Society. Further, the ACS estimates more than 4,00 women will die from cervical cancer in 2023, a number that used to be much higher before screenings were widely available.

For context, when detected through routine screenings, early-stage cervical cancer has a 5-year survival rate of 92 percent. By comparison, a late-stage diagnosis that has spread to distant organs has just a 5-year survival rate of 17 percent.

What are the differences in testing?

Both a pap smear and a HPV test involve using an instrument called a speculum to hold the vaginal walls open so a small cone-shaped brush has room to scrape cells from the opening of the cervix. Once collected, the cells are then sent to a lab for examination to check precancerous or cancerous cells.

The difference is what the tests screen for. With a pap smear, the collected cells are examined to see if they look normal. Any abnormal cells detected are called cervical precancer, indicating they may develop into cancer in the future. 

By comparison, a HPV test screens for human papillomavirus, a common virus that can lead to many types of cancer, including cervical, anal, penile, vaginal, vulvar and throat. There are hundreds of types of HPV, although only about 14 are considered high risk. Most often, HPV type 16 and HPV type 18 can lead to cervical cancer. Chronic HPV infections are responsible for nearly all cervical cancers, according to the National Cancer Institute.

Why did the guidelines change?

In 2018, the USPSTF updated its guidelines to include HPV testing – instead of a pap smear – as an option for cervical cancer screening. The American Cancer Society then recommended HPV tests in 2020 as the primary option to screen for cervical cancer, along with beginning screenings at 25 instead of 21. 

Simply put, HPV tests are more accurate, require less effort and reduce screening costs, according to the American Cancer Society. 

Since HPV tests are more precise, they don’t have to be repeated as often – hence 5 years instead of 3 years. Further, pap smears aren’t as sensitive as HPV tests, meaning there is a greater chance they don’t detect precancerous cells in the cervix.

Instead of HPV tests or the traditional pap smear, some people opt for the HPV/pap smear cotest. Although this type of test is more sensitive than HPV testing, it can detect many small changes that don’t actually increase your chances of getting cervical cancer. Plus, the need for two tests isn’t as cost effective as the single HPV test.

As for the age difference, less than 1 percent of cervical cancers are diagnosed in patients younger than 25 years, so the ACS saw limited benefits in testing women ages 21 to 24. However, the ACOG mentioned that increasing the age of testing could compound the already high rate of young women in their late 20s who don’t receive screenings.

Here’s the bottom line: There isn’t a right or wrong test. Pap smears, hrHPV tests and co-testing are all effective. In other words, the act of getting screened is more important than which test you choose. The difference may come down to personal preference, as pap smears require more frequent visits compared to HPV testing alone. Plus, some women may not have a screening choice because some locations, such as rural communities, don’t have access to primary HPV testing.

What do the results mean?

As with any cancer screening, it’s important to remember the difference between a screening and a diagnosis. Cervical cancer screening, either from a pap smear or a HPV test, can’t diagnose cancer – it only tells your doctor you need further testing to confirm or rule out cancer.

If you receive a negative HPV test, high-risk HPV wasn’t found in your cervix and you won’t have to receive another screening for 5 years. For positive HPV tests, you’re at a higher risk for cervical cancer than others – although it doesn’t mean you’ll develop cancer.

In some cases, women who have tested negative for HPV for years are caught off guard when they receive a positive test result. This is because HPV can remain dormant for years before becoming active again, similar to how chicken pox develops into shingles later in life.

For pap smear tests, you will either receive results that are normal, abnormal or unsatisfactory. A normal result means the test didn’t detect precancerous cells. An abnormal test doesn’t mean you have cancer – or will even develop it in the future – it just signifies some of the cells look different and may eventually cause cervical cancer. For example, hormones, yeast infections and irritation to your cervix can all cause cells to appear abnormal. An unsatisfactory result means there were either not enough cells collected to get an accurate test result or the cells itself didn’t provide a conclusive result.

Abnormal pap smear results

If your test results come back abnormal, here are some specific cellular changes that may have been noticed:

  • Atypical squamous cells of undetermined significance (ASC-US): This result means abnormal cells were noticed, but they did not meet the criteria for a lesion. Usually, your OBGN will request a HPV test to determine if the cell changes are related to an HPV infection – they often are. ASC-US is the most common pap smear result.
  • Low-grade squamous intraepithelial lesions (LSIL): The lesions detected are in the early stages of changing size and shape. In many women, these lesions resolve without the need for treatment, although your doctor may request a colposcopy (a procedure to examine abnormal tissue) to confirm the cellular changes haven’t progressed.
  • High-grade squamous intraepithelial lesions (HSIL): The lesions detected are considered moderate or severe abnormal cellular growth in the cervix. Treatment to remove the cells is needed to prevent a future cancer diagnosis. 
  • Adenocarcinoma in situ (AIS): Advanced lesions are found in the glandular tissue of the cervix and can develop into cancer if left untreated. AIS is often referred to as a precancerous condition because the cells are cancerous but haven’t spread or grown into the cervix.
  • Atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion (ASC-H): This result means some cells may indicate HSIL, but the result is uncertain. In other words, this is a way to flag the potential for high-grade lesions. A follow-up colposcopy can help determine the extent of the tissue growth.
  • Atypical glandular cells (AGC): This result means there were abnormal growths detected in glandular cells, a type of tissue in the uterus and the inner part of the cervix. A colposcopy is usually needed to confirm or rule out the presence of cancerous or precancerous cells.

What happens after you receive your results?

Positive or inconclusive tests will require follow-up testing to find a more conclusive diagnosis. For women with high-grade lesions, your provider can perform different types of procedures to remove the abnormal cells.

Repeat testing is often performed by using what is called reflex testing. If you had an HPV test, the same cells collected will be used for a pap test. Likewise, if you had a pap test, those cells will be used for an HPV test. You can also be specifically tested for HPV type 16 and HPV type 18 – the most common types of HPV to cause cancer – using a HPV typing test.

Your doctor may also choose to conduct a colposcopy, which uses a magnifying device to more closely examine the cervix. If they spot any abnormal cells, they can collect sample tissue for a biopsy.

If treatment is needed following your screening, your doctor may perform an excisional procedure (tissue removal) or an ablative procedure (tissue is destroyed).

A loop electrosurgical excision procedure (LEEP) is the most common type of way to remove tissue. Your doctor will use a wire loop carrying an electric current to remove tissue. Conization can also remove abnormal tissue using a scalpel, a laser knife or a wire loop.

To destroy the tissue, your doctor can use cryotherapy to freeze them so they die off. Laser therapy uses wavelengths of light to kill abnormal lesions.

The bottom line with cervical cancer screening is you should receive it every 3 or 5 years (depending on which test is performed). Talk to your primary care physician or OBGYN if you’re not up to date with your screening. They can discuss which testing option is right for you. Contact us today to schedule your visit.

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