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Guideline Summary
Guideline Title
Screening for cervical cancer.
Bibliographic Source(s)
American College of Obstetricians and Gynecologists (ACOG). Screening for cervical cancer. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2012 Nov. 17 p. (ACOG practice bulletin; no. 131).  [111 references] PubMed External Web Site Policy
Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: American College of Obstetricians and Gynecologists (ACOG). Cervical cytology screening. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2009 Dec. 12 p. (ACOG practice bulletin; no. 109). [96 references]

Scope

Disease/Condition(s)

Cervical cancer

Guideline Category
Screening
Clinical Specialty
Family Practice
Internal Medicine
Obstetrics and Gynecology
Oncology
Pathology
Intended Users
Physicians
Guideline Objective(s)
  • To aid practitioners in making decisions about appropriate obstetric and gynecologic care
  • To provide a review of the best available evidence on screening for cervical cancer
Target Population

Women ages 21 to 65 years with different risk-benefit considerations

Interventions and Practices Considered
  1. Cervical cancer screening
    • Cervical cytology (liquid-based or conventional methods of collection)
    • Human papillomavirus (HPV) testing
  2. Timing of initial screening based on age regardless of sexual initiation or other risk factors
  3. Co-testing with cytology and HPV testing
  4. Optimal frequency of screening based on age and prior screening results
  5. Special populations:
    • History of cervical cancer
    • Human immunodeficiency virus (HIV) infection
    • Immunocompromised
    • Exposed to diethylstilbestrol in utero
    • Women with HPV vaccination
  6. Discontinuation of screening by any modality:
    • In women who have undergone hysterectomy and removal of cervix with no history of cervical intraepithelial neoplasia (CIN) 2 or higher
    • Based on age and prior screening results
  7. Follow-up screening procedures
Major Outcomes Considered
  • Sensitivity and specificity of screening
  • Incidence of cervical cancer
  • Incidence of human papillomavirus (HPV) infections

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

The MEDLINE database, the Cochrane Library, and the American College of Obstetricians and Gynecologists' own internal resources and documents were used to conduct a literature search to locate relevant articles published between January 1990 and March 2012. The search was restricted to articles published in the English language. Priority was given to articles reporting results of original research, although review articles and commentaries also were consulted. Abstracts of research presented at symposia and scientific conferences were not considered adequate for inclusion in this document. Guidelines published by organizations or institutions such as the National Institutes of Health and the American College of Obstetricians and Gynecologists were reviewed, and additional studies were located by reviewing bibliographies of identified articles. When reliable research was not available, expert opinions from obstetrician–gynecologists were used.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Studies were reviewed and evaluated for quality according to the method outlined by the U.S. Preventive Services Task Force:

I: Evidence obtained from at least one properly designed randomized controlled trial.

II-1: Evidence obtained from well-designed controlled trials without randomization.

II-2: Evidence obtained from well-designed cohort or case–control analytic studies, preferably from more than one center or research group.

II-3: Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments also could be regarded as this type of evidence.

III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review
Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

Analysis of available evidence was given priority in formulating recommendations. When reliable research was not available, expert opinions from obstetrician-gynecologists were used. See also the "Rating Scheme for the Strength of Recommendations" field regarding Grade C recommendations.

Rating Scheme for the Strength of the Recommendations

Based on the highest level of evidence found in the data, recommendations are provided and graded according to the following categories:

Level A - Recommendations are based on good and consistent scientific evidence.

Level B - Recommendations are based on limited or inconsistent scientific evidence.

Level C - Recommendations are based primarily on consensus and expert opinion.

Cost Analysis
  • Annual cervical cytology screening for women aged 21–29 years leads to a very small increment in cases of cancer prevented at the cost of a very large excess of procedures and treatments and should not be performed.
  • Because cervical cancer occurs at a median of 15–25 years after human papillomavirus (HPV) infection, screening women in the over 65 age group would prevent very few cases of cancer. Modeling studies suggest that in women screened with cytology every 3 years until age 65 years, continued screening every 3 years until age 90 years in 1,000 women would prevent approximately 1.6 cancer cases and 0.5 cancer deaths. This slight gain would come at significant cost, including an increase in required colposcopy procedures.
Method of Guideline Validation
Internal Peer Review
Description of Method of Guideline Validation

Practice Bulletins are validated by two internal clinical review panels composed of practicing obstetrician-gynecologists generalists and sub-specialists. The final guidelines are also reviewed and approved by the American College of Obstetricians and Gynecologists (ACOG) Executive Board.

Recommendations

Major Recommendations

The grades of evidence (I-III) and levels of recommendation (A-C) are defined at the end of the "Major Recommendations" field.

The following recommendations are based on good and consistent scientific evidence (Level A):

  • Cervical cancer screening should begin at age 21 years. Women younger than age 21 years should not be screened regardless of the age of sexual initiation or the presence of other behavior-related risk factors.
  • Women aged 21–29 years should be tested with cervical cytology alone, and screening should be performed every 3 years. Co-testing should not be performed in women younger than 30 years.
  • For women aged 30–65 years, co-testing with cytology and human papillomavirus (HPV) testing every 5 years is preferred. 
  • In women aged 30–65 years, screening with cytology alone every 3 years is acceptable. Annual screening should not be performed.
  • Women who have a history of cervical cancer, have human immunodeficiency virus (HIV) infection, are immunocompromised, or were exposed to diethylstilbestrol in utero should not follow routine screening guidelines.
  • Both liquid-based and conventional methods of cervical cytology collection are acceptable for screening. 
  • In women who have had a hysterectomy with removal of the cervix (total hysterectomy) and have never had cervical intraepithelial neoplasia (CIN) 2 or higher, routine cytology screening and HPV testing should be discontinued and not restarted for any reason.
  • Screening by any modality should be discontinued after age 65 years in women with evidence of adequate negative prior screening results and no history of CIN 2 or higher. Adequate negative prior screening results are defined as three consecutive negative cytology results or two consecutive negative co-test results within the previous 10 years, with the most recent test performed within the past 5 years.

The following recommendations are based on limited and inconsistent scientific evidence (Level B):

  • Women with atypical squamous cells of undetermined significance (ASC-US) cytology and negative HPV co-testing results have a very low risk of CIN 3 and should continue with routine screening as indicated for their age.
  • Women with a history of CIN 2, CIN 3, or adenocarcinoma in situ should continue to undergo routine age-based screening for 20 years after the initial posttreatment surveillance period, even if it requires that screening continue past age 65 years.
  • Women should continue to be screened if they have had a total hysterectomy and have a history of CIN 2 or higher in the past 20 years or cervical cancer ever. Continued screening for 20 years is recommended in women who still have a cervix and a history of CIN 2 or higher. Therefore, screening with cytology alone every 3 years for 20 years after the initial post treatment surveillance period seems reasonable for women with a hysterectomy.
  • Women with negative cytology and positive HPV co-testing results who are aged 30 years and older should be managed in one of two ways:
    1. Repeat co-testing in 12 months. If the repeat cervical cytology test result is low-grade squamous intraepithelial lesions (LSILs) or higher or the HPV test result is still positive; the patient should be referred for colposcopy. Otherwise, the patient should return to routine screening (see Figure 1 in the original guideline document).
    2. Immediate HPV genotype-specific testing for HPV-16 alone or HPV-16/18 should be performed. Women with positive results from tests for HPV-16 alone or HPV-16/18 should be referred directly for colposcopy. Women with negative results from tests for HPV-16 or HPV-16/18 should be co-tested in 12 months, with management of results as described (see Figure 2 in the original guideline document).

The following recommendations are based primarily on consensus and expert opinion (Level C):

  • Women who have received the HPV vaccine should be screened according to the same guidelines as women who have not been vaccinated.

Definitions:

Grades of Evidence

I: Evidence obtained from at least one properly designed randomized controlled trial.

II-1: Evidence obtained from well-designed controlled trials without randomization.

II-2: Evidence obtained from well-designed cohort or case–control analytic studies, preferably from more than one center or research group.

II-3: Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments also could be regarded as this type of evidence.

III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

Levels of Recommendations

Level A - Recommendations are based on good and consistent scientific evidence.

Level B - Recommendations are based on limited or inconsistent scientific evidence.

Level C - Recommendations are based primarily on consensus and expert opinion.

Clinical Algorithm(s)

The following algorithms are provided in the original guideline document:

  • Management of cytology negative and human papillomavirus positive co-testing results—option 1
  • Management of cytology negative and human papillomavirus positive testing results—option 2

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

When cervical cytology screening programs have been introduced into communities, marked reductions in cervical cancer incidence have followed.

Potential Harms

Not stated

Qualifying Statements

Qualifying Statements

These guidelines should not be construed as dictating an exclusive course of treatment or procedure. Variations in practice maybe warranted based on the needs of the individual patient, resources, and limitations unique to the institution or type of practice.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools
Audit Criteria/Indicators
Clinical Algorithm
Foreign Language Translations
Patient Resources
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
American College of Obstetricians and Gynecologists (ACOG). Screening for cervical cancer. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2012 Nov. 17 p. (ACOG practice bulletin; no. 131).  [111 references] PubMed External Web Site Policy
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2003 Aug (revised 2012 Nov)
Guideline Developer(s)
American College of Obstetricians and Gynecologists - Medical Specialty Society
Source(s) of Funding

American College of Obstetricians and Gynecologists (ACOG)

Guideline Committee

American College of Obstetricians and Gynecologists (ACOG) Committee on Practice Bulletins-Gynecology

Composition of Group That Authored the Guideline

American College of Obstetricians and Gynecologists (ACOG) committees are created or abolished and their overall function defined by the Executive Board. Appointments are made for one year, with the understanding that such appointment may be continued for a total of three years. The majority of committee members are Fellows, but Junior Fellows also are eligible for appointment. Some committees may have representatives from other organizations when this is particularly appropriate to committee activities. The president elect appoints committee members annually.

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: American College of Obstetricians and Gynecologists (ACOG). Cervical cytology screening. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2009 Dec. 12 p. (ACOG practice bulletin; no. 109). [96 references]

Guideline Availability

Electronic copies: None available

Print copies: Available for purchase from the American College of Obstetricians and Gynecologists (ACOG) Distribution Center, PO Box 933104 Atlanta, GA, 31193-3104; telephone, 800-762-2264, ext. 192; e-mail: sales@acog.org. The ACOG Bookstore is available online at the ACOG Web site External Web Site Policy.

Availability of Companion Documents

A proposed performance measure is included in the original guideline document.

Patient Resources

The following are available:

  • Protect & detect: what women should know about cancer. Atlanta (GA): American College of Obstetricians and Gynecologists (ACOG). Available from the American College of Obstetricians and Gynecologists (ACOG) Web site External Web Site Policy.
  • Frequently asked questions: cancer of the cervix. Atlanta (GA): American College of Obstetricians and Gynecologists (ACOG). Available from the ACOG Web site External Web Site Policy.
  • Cancer of the cervix. Spanish patient education pamphlets. Atlanta (GA): American College of Obstetricians and Gynecologists (ACOG). Available from the ACOG Web site External Web Site Policy.
  • The well woman visit & cervical cancer screening guidelines. Public service announcement. Atlanta (GA): American College of Obstetricians and Gynecologists (ACOG). Available from the ACOG Web site External Web Site Policy.

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC Status

This NGC summary was completed by ECRI Institute on October 12, 2007. The information was verified by the guideline developer on December 3, 2007. This NGC summary was updated by ECRI Institute on January 21, 2010. The information was verified by the guideline developer on February 18, 2010. This NGC summary was updated by ECRI Institute on December 14, 2012.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

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