The U.S. Preventive Services Task Force (USPSTF) grades its recommendations (A, B, C, D, or I) and identifies the levels of certainty regarding net benefit (High, Moderate, and Low). The definitions of these grades can be found at the end of the "Major Recommendations" field.

Summary of Recommendations and Evidence

This recommendation statement applies to women who have a cervix, regardless of sexual history. This recommendation statement does not apply to women who have received a diagnosis of a high-grade precancerous cervical lesion or cervical cancer, women with in utero exposure to diethylstilbestrol, or women who are immunocompromised (such as those who are human immunodeficiency virus [HIV] positive).

The USPSTF recommends screening for cervical cancer in women age 21 to 65 years with cytology (Papsmear) every 3 years or, for women age 30 to 65 years who want to lengthen the screening interval, screening with a combination of cytology and human papillomavirus (HPV) testing every 5 years. See the Clinical Considerations for discussion of cytology method, HPV testing, and screening interval (A recommendation).

The USPSTF recommends against screening for cervical cancer in women younger than age 21 years (D recommendation).

The USPSTF recommends against screening for cervical cancer in women older than age 65 years who have had adequate prior screening and are not otherwise at high risk for cervical cancer. See the Clinical Considerations for discussion of adequacy of prior screening and risk factors (D recommendation).

The USPSTF recommends against screening for cervical cancer in women who have had a hysterectomy with removal of the cervix and who do not have a history of a high-grade precancerous lesion (cervical intraepithelial neoplasia [CIN] grade 2 or 3) or cervical cancer (D recommendation).

The USPSTF recommends against screening for cervical cancer with HPV testing, alone or in combination with cytology, in women younger than age 30 years (D recommendation).

Clinical Considerations

Patient Population Under Consideration

This recommendation statement applies to all women who have a cervix, regardless of sexual history. This recommendation statement does not apply to women who have received a diagnosis of a high-grade precancerous cervical lesion or cervical cancer, women with in utero exposure to diethylstilbestrol, or women who are immunocompromised (such as those who are HIV positive).

Screening Tests

The effectiveness of cervical cancer screening observed in the United States over the past several decades is attributed to the use of conventional cytology. Current evidence indicates that there are no clinically important differences between liquid-based cytology and conventional cytology. The USPSTF realizes that the choice of cytology method may not be under the direct control of the clinician and considers cytology screening in appropriate age groups at appropriate intervals to be of substantial net benefit, regardless of method. HPV testing with Digene Hybrid Capture 2 (HC2) (Qiagen, Germantown, Maryland) is commonly used in the United States, and both HC2 and polymerase chain reaction–based methods have been evaluated in effectiveness trials. Although alternative HPV detection methods are emerging, the clinical comparability and implications of these methods are not completely understood.

Screening Interval

Screening women age 21 to 65 years every 3 years with cytology provides a reasonable balance between benefits and harms. Among women age 30 to 65 years, HPV testing combined with cytology (co-testing) every 5 years offers a comparable balance of benefits and harms and is therefore a reasonable alternative for women in this age group who would prefer to extend the screening interval. Screening with cytology more often than every 3 years confers little additional benefit, with large increases in harms, including additional procedures and assessment and treatment of transient lesions. Treatment of lesions that would otherwise resolve on their own is harmful because it can lead to procedures with unwanted side effects, including the potential for cervical incompetence and preterm labor. Similarly, the frequency of HPV testing with cytology should not be more often than every 5 years in order to maintain a reasonable balance of benefits and harms similar to that seen with cytology alone every 3 years. Maintaining the comparability of the benefits and harms of co-testing and cytology alone demands that patients, clinicians, and health care organizations adhere to currently recommended screening intervals, protocols for repeat testing, cytologic thresholds for further diagnostic testing (that is, colposcopy) and treatments, and extended surveillance as recommended by current American Cancer Society/American Society for Colposcopy and Cervical Pathology/American Society for Clinical Pathology (ACS/ASCCP/ASCP) guidelines.

Women choosing co-testing to increase their screening interval (and potentially decrease testing) should be aware that positive screening results are more likely with HPV-based strategies than with cytology alone and that some women may require prolonged surveillance with additional frequent testing if they have persistently positive HPV results. Because HPV test results may be positive among women who would otherwise be advised to end screening at age 65 years on the basis of previously normal cytology results alone, the likelihood of continued testing may increase with HPV testing. The percentage of U.S. women undergoing co-testing who will have a normal cytology test result and a positive HPV test result (and who will therefore require additional testing) ranges from 11% among women age 30 to 34 years to 2.6% among women age 60 to 65 years.

Timing of Screening

Women Younger Than Age 21 Years

Cervical cancer is rare before age 21 years. The USPSTF found little evidence to determine whether and how sexual history should affect the age at which to begin screening. Although exposure of cervical cells to sexually transmitted HPV during vaginal intercourse may lead to cervical carcinogenesis, the process has multiple steps, involves regression, and is generally not rapid. There is evidence that screening earlier than age 21 years, regardless of sexual history, would lead to more harm than benefit. The harms are greater in this younger age group because abnormal test results are likely to be transient and to resolve on their own; in addition, resulting treatment may have an adverse effect on future child-bearing.

Women Older Than Age 65 Years

Clinicians and patients should base the decision to end screening on whether the patient meets the criteria for adequate prior testing and appropriate follow-up per established guidelines. The ACS/ASCCP/ASCP guidelines define adequate prior screening as 3 consecutive negative cytology results or 2 consecutive negative HPV results within 10 years before cessation of screening, with the most recent test occurring within 5 years. They further state that 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. The ACS further states that screening should not resume after cessation in women older than age 65 years, even if a woman reports having a new sexual partner.

Women Older Than Age 65 Years Who Have Never Been Screened

Screening may be clinically indicated in older women for whom the adequacy of prior screening cannot be accurately accessed or documented. Women with limited access to care, minority women, and women from countries where screening is not available may be less likely to meet the criteria for adequate prior screening. The USPSTF realizes that certain considerations may support screening in women older than age 65 years who are otherwise considered high risk (such as women with a high-grade precancerous lesion or cervical cancer, women with in utero exposure to diethylstilbestrol, or women who are immunocompromised).