Cutting Through the Confusion About Pap Screening

Marilyn W. Edmunds, PhD, CRNP


August 17, 2010

Primary Screening for Cervical Cancer: Incorporating New Guidelines and Technologies Into Clinical Practice

Lemieux ML
J Nurse Pract. 2010;6:417-424

Article Summary

Cervical cancer screening has grown into a remarkable success story in the United States. Women believe that they should visit their healthcare provider for an annual Papanicolaou (Pap) test, and healthcare reimbursement supports this practice. However, recent evidence suggests that many women do not need this type of yearly screening. The newest guidelines from the American College of Obstetricians and Gynecologists (ACOG), published in December 2009, have raised a furor because they challenge traditional cervical cancer screening modes and intervals with level-A recommendations for starting later and screening low-risk women less frequently.

Lemieux aims to provide an evidence-based approach to incorporating the new cervical cancer screening guidelines into clinical practice. The author reviews the goals of screening, considers the epidemiology of human papillomavirus and cervical cancer, evaluates the costs of overscreening, and considers the rationale for the ACOG recommendations.

Lemieux suggests that cervical cancer screening should no longer be the sole focus of the annual well-woman examination. Incorporating new evidence-based cervical cancer screening guidelines into primary screening for cervical cancer requires a shift in thinking from the annual Pap test to a more comprehensive, evidence-based approach to cervical cancer screening that may or may not include HPV testing, and extended screening intervals.

Until recently, the 3 existing sets of guidelines for cervical cancer screening were relatively consistent. The American Cancer Society (ACS), US Preventive Services Task Force (USPSTF), and ACOG guidelines all agreed that screening of women for cervical cancer should start within 3 years of first vaginal intercourse or no later than age 21 years.

What are the changes?

  1. The 2009 ACOG guidelines now recommend waiting until age 21 years to initiate screening.

  2. For women younger than 30 years, the ACS recommends an annual Pap test if the provider is using conventional cytology and every 2 years for liquid-based cytology.

  3. For women aged 30 years or older, the interval can be extended to every 2 to 3 years if the 3 previous Pap test results are negative.

  4. ACOG has now extended recommendations for the screening intervals for all ages:

    • Cytology every 2 years for women aged 21 to 29 years; and

    • Cytology every 3 years for women aged 30 years or older who have had multiple negative screens.

  5. Primary screening with cytology and human papillomavirus DNA testing for women aged 30 years or older is an option according to ACS and ACOG and is now a level-A recommendation for ACOG.

    • The USPSTF found insufficient evidence for or against adjunctive HPV DNA testing. As a result, the USPSTF recommends cytology testing at least every 3 years for women up to age 65 years.

  6. Cervical cancer screening should cease after hysterectomy with removal of the cervix for benign causes.

  7. Organizations disagree on an upper age limit for screening. The ACS recommends stopping screening at age 70 years for low-risk women, the USPSTF recommends stopping at age 65 years, and ACOG does not recommend an age cutoff for screening.

The article reviews the evidence behind the ACOG changes to help clinicians understand the rationale for the guideline changes.


Screening for disease is one of the major purposes of conducting a well-patient examination. Clinical guidelines and recommendations use available research to help inform clinicians and effect practice. Clinical guidelines are an important way for research findings to diffuse into practice. When guidelines from reputable groups differ, the onus is on practitioners to study the original research and try to determine which guideline they will follow. Individual practice, especially in the face of controversy, should be well justified and consistent in order to provide the best standard of care. Being informed about the different guidelines, understanding how and why they differ, and having a defensible policy will protect the clinician if legal problems should arise as a result of the care provided.

Lemieux does an excellent job of examining the research behind the new ACOG guidelines, and this article will help clinicians clarify their own thoughts about which guidelines they believe they should follow.


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