Updated Cervical Cancer Screening Guidelines | ACOG
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Updated Cervical Cancer Screening Guidelines
Updated Cervical Cancer Screening Guidelines
Practice Advisory
PA
April 2021
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(Replaces Practice Bulletin No. 168, October 2016)
(Reaffirmed April 2025)
ASCCP and the Society of Gynecologic Oncology endorse this Practice Advisory.
The American College of Obstetricians and Gynecologists (ACOG) joins ASCCP and the Society of  Gynecologic Oncology (SGO) in endorsing the U.S. Preventive Services Task Force (USPSTF) cervical cancer screening recommendations
, which replace ACOG Practice Bulletin No. 168,
Cervical Cancer Screening and Prevention
, as well as the 2012 ASCCP cervical cancer screening guidelines
The adoption of the USPSTF guidelines expands the recommended options for cervical cancer screening in average-risk individuals aged 30 years and older to include screening every 5 years with primary high-risk human papillomavirus (hrHPV) testing. Primary hrHPV testing uses high-risk HPV testing alone (no cytology) with a test that is approved by the U.S. Food and Drug Administration (FDA) for stand-alone screening. Consistent with prior guidance, screening should begin at age 21 years, and screening recommendations remain unchanged for average-risk individuals aged 21–29 years and those who are older than 65 years
Table 1
. Management of abnormal cervical cancer screening results should follow current ASCCP guidelines
Screening Options
There are now three recommended options for cervical cancer screening in individuals aged 30–65 years: primary hrHPV testing every 5 years, cervical cytology alone every 3 years, or co-testing with a combination of cytology and hrHPV testing every 5 years
Table 1
. All three screening strategies are effective, and each provides a reasonable balance of benefits (disease detection) and potential harms (more frequent follow-up testing, invasive diagnostic procedures, and unnecessary treatment in patients with false-positive results)
. Data from clinical trial, cohort, and modeling studies demonstrate that among average-risk patients aged 25–65 years, primary hrHPV testing and co-testing detect more cases of high-grade cervical intraepithelial neoplasia than cytology alone, but hrHPV-based tests are associated with an increased risk of colposcopies and false-positive results
Currently, there are two hrHPV tests approved by the FDA for primary screening in individuals aged 25 years and older. Although cytology alone is the recommended screening method for individuals aged 21–29 years, ACOG, ASCCP, and SGO advise that primary hrHPV testing every 5 years can be considered for average-risk patients aged 25–29 years based on its FDA-approved age for use and primary hrHPV testing’s demonstrated efficacy in individuals aged 25 years and older.
Future Directions
Primary Human Papillomavirus Testing
In 2020, the American Cancer Society (ACS) updated its cervical cancer screening guidelines to recommend primary hrHPV testing as the preferred screening option for average-risk individuals aged 25–65 years
. Despite the demonstrated efficacy and efficiency of primary hrHPV testing, uptake of this screening method has been slow because of the limited availability of FDA-approved tests and the significant laboratory infrastructure changes required to switch to this screening platform. Limited access to primary hrHPV testing is of particular concern in rural and under-resourced communities and among communities of color, which have disproportionately high rates of cervical cancer incidence, morbidity, and mortality
10
. Although cytology-based screening options are still included in the ACS guidelines in acknowledgement of these barriers to widespread access and implementation, ACS strongly advocates phasing out cytology-based screening options in the near future
. Until primary hrHPV testing is widely available and accessible, cytology-based screening methods should remain options in cervical cancer screening guidelines. Although HPV self-sampling has the potential to greatly improve access to cervical cancer screening, and there is an increasing body of evidence to support its efficacy and utility, it is still investigational in the United States
11
Age to Initiate Screening
The introduction of vaccines targeting the most common cancer-causing HPV genotypes has advanced the primary prevention of cervical cancer. As vaccination coverage increases and more vaccinated individuals reach the age to initiate cervical cancer screening, HPV prevalence is expected to continue to decline
12
13
. This could prompt future changes to screening guidelines, such as raising the screening initiation age to 25 years, as is recommended in the recently updated ACS guidelines
. Although HPV vaccination rates continue to improve, nationwide HPV vaccination coverage remains below target levels, and there are racial, ethnic, socioeconomic, and geographic disparities in vaccination rates
13
14
15
16
. Cervical cancer screening rates also are below expectations, with the lowest levels reported among individuals younger than 30 years
17
18
. Raising the screening start age to 25 years could increase the already high rate of underscreening among individuals aged 25–29 years and exacerbate existing health inequities in cervical cancer screening, incidence, morbidity, and mortality
10
17
18
19
. Given these significant health equity concerns and the current suboptimal rates of cervical cancer screening and HPV vaccination, ACOG, ASCCP, and SGO continue to recommend initiation of cervical cancer screening at age 21 years.
Conclusion
Although cervical cancer screening options have expanded, cervical cytology, primary hrHPV testing, and co-testing are all effective in detecting cervical precancerous lesions and cancer. The specific strategy selected is less important than consistent adherence to routine screening guidelines. Inadequate cervical cancer screening remains a significant problem in the United States, with persistent health inequities across the entire spectrum of cervical cancer care
10
17
19
. Given these concerns, ACOG, ASCCP, and SGO continue to recommend cervical cancer screening initiation at age 21 years. Human papillomavirus vaccination is another important prevention strategy against cervical cancer, and obstetrician–gynecologists and other health care professionals should continue to strongly recommend HPV vaccination to eligible patients and stress the benefits and safety of the HPV vaccine
20
. Cervical cancer prevention, screening, and treatment are critical components of comprehensive reproductive health care.
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References
Curry SJ, Krist AH, Owens DK, Barry MJ, Caughey AB, Davidson KW, et al. Screening for cervical cancer: U.S. Preventive Services Task Force recommendation statement. U.S. Preventive Services Task Force. JAMA 2018;320:674–86. Available at:
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Saslow D, Solomon D, Lawson HW, Killackey M, Kulasingam SL, Cain J, et al. 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. Am J Clin Pathol 2012;137:516–42. Available at:
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A Practice Advisory is a brief, focused statement issued to communicate a change in ACOG guidance or information on an emergent clinical issue (eg, clinical study, scientific report, draft regulation). A Practice Advisory constitutes ACOG clinical guidance and is issued only on-line for Fellows but may also be used by patients and the media. Practice Advisories are reviewed periodically for reaffirmation, revision, withdrawal or incorporation into other ACOG guidelines.
This information is designed as an educational resource to aid clinicians in providing obstetric and gynecologic care, and use of this information is voluntary. This information should not be considered as inclusive of all proper treatments or methods of care or as a statement of the standard of care. It is not intended to substitute for the independent professional judgment of the treating clinician. Variations in practice may be warranted when, in the reasonable judgment of the treating clinician, such course of action is indicated by the condition of the patient, limitations of available resources, or advances in knowledge or technology. The American College of Obstetricians and Gynecologists reviews its publications regularly; however, its publications may not reflect the most recent evidence. Any updates to this document can be found on
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Topics
Cervical intraepithelial neoplasia
Cervix uteri
Cytological techniques
Early detection of cancer
Human papillomavirus DNA tests
Mass screening
Papanicolaou test
Papillomavirus infections
Uterine cervical neoplasms
Cancer
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Figures & Tables
Figures & Tables
Table 1. USPSTF Recommendations for Routine Cervical Cancer Screening. *These recommendations apply to individuals with a cervix who do not have any signs or symptoms of cervical cancer, regardless of their sexual history or HPV vaccination status. These recommendations do not apply to individuals who are at high risk of the disease, such as those who have previously received a diagnosis of a high-grade precancerous cervical lesion. These recommendations also do not apply to individuals with in utero exposure to diethylstilbestrol or those who have a compromised immune system (eg, individuals with human immunodeficiency virus). †Grade A denotes that “The USPSTF recommends the service. There is high certainty that the net benefit is substantial.” A Grade D definition means that, “The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.” For more information on the USPSTF grades, see https://www.uspreventiveservicestaskforce.org/Page/Name/grade-definitions ‡Primary hrHPV testing is FDA approved for use starting at age 25 years, and ACOG, ASCCP, and SGO advise that primary hrHPV testing every 5 years can be considered as an alternative to cytology-only screening in average-risk patients aged 25–29 years. §Adequate negative prior screening test results are defined as three consecutive negative cytology results, two consecutive negative cotesting results, or two consecutive negative hrHPV test results within 10 years before stopping screening, with the most recent test occurring within the recommended screening interval for the test used (1, 5). Data from Curry SJ, Krist AH, Owens DK, Barry MJ, Caughey AB, Davidson KW, et al. Screening for cervical cancer: U.S. Preventive Services Task Force recommendation statement. U.S. Preventive Services Task Force. JAMA 2018;320:674–86. Available at: https://jamanetwork.com/journals/jama/fullarticle/2697704. Retrieved April 12, 2021.
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