USPSTF Updated Recommendations for Cervical Cancer Screening

Roxanne Nelson, BSN, RN

August 21, 2018

The US Preventive Services Task Force (USPSTF) has updated its recommendation on screening for cervical cancer. The final article was published online August 21 in JAMA.

There is a small difference between the final recommendations and the draft guidelines that were released last year. The difference relates to the recommendation on cotesting (details below).

Screening with cytology alone every 3 years for women aged 21 to 65 years (grade A recommendation) continues to be recommended, but for the first time, the USPSTF now recommends a stand-alone test for high-risk types of human papillomavirus (hrHPV) in women aged 30 to 65 years (grade A recommendation).

Of note, in contrast to the task force's position in their earlier draft, the final update continues to recommend cytology plus hrHPV cotesting every 5 years for women aged 30 to 65 years (grade A recommendation).

However, cotesting is considered an "alternative" strategy as opposed to the "preferred" use of cytology or hrHPV testing alone. The USPTF notes that although cotesting has been demonstrated to be similar in effectiveness to cytology or hrHPV testing, its use may result in more tests and procedures as compared with either cytology or hrHPV testing alone.

"I commend the USPSTF for listening to women and their healthcare providers and giving an A recommendation for the broadest number of cervical cancer screening options, including cytology, HPV primary screening, and especially cotesting, also known as Pap+HPV," said Mark Spitzer MD, medical director of the Center for Colposcopy, New Hyde Park, New York.

Spitzer told Medscape Medical News that multiple large US studies have shown that cotesting identifies more cases of cervical precancer and cancer than either test alone and that cotesting is the gold standard recommended by US medical societies. "In discussing the issue with my patients, they place the greatest value on the incremental benefit cotesting offers over either test alone," he said. "I also explain that the experience with all screening options are the same and involve just one swab.

"We have made significant progress over time in the fight against cervical cancer, and the most important part of the equation is for women to visit their healthcare provider to get tested with the best method available," Spitzer added.

Key Recommendations

The final version of the guidelines was based on a review of the evidence on screening, including clinical trials and cohort studies, as well as a decision analysis modeling study that was commissioned by the task force. The key recommendations are as follows:

  • The USPSTF continues to recommend screening for cervical cancer every 3 years with cervical cytology alone in women aged 21 to 29 years; for those aged 30 to 65 years, screening every 3 years is recommended with cervical cytology alone, every 5 years with hrHPV testing alone, or every 5 years with hrHPV testing in combination with cytology (cotesting) (grade A recommendation).

  • Screening in women older than 65 years is not recommended if they have had adequate prior screening and are not at high risk for cervical cancer (grade D recommendation).

  • The USPSTF recommends against screening for cervical cancer in women younger than 21 years (grade D recommendation). It also recommends against screening in women who have undergone a hysterectomy with removal of the cervix and who do not have a history of a high-grade precancerous lesions.

None of these recommendations apply to women who have been diagnosed with a high-grade precancerous cervical lesion or cancer, were exposed to diethylstilbestrol in utero, or have a compromised immune system.

The Modeling Study

A cervical cancer disease simulation model was conducted to accompany the evidence report for new, updated guidelines in order that gaps in the expected benefits and harms of cervical cancer screening strategies in the primary care setting could be better addressed.

This analysis was published online in JAMA along with the final recommendations. It was led by Jane J. Kim, PhD, of the Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts.

The authors preformed a microsimulation model of a hypothetical cohort of women who began screening at 21 years of age.

They assessed various screening strategies, including cytology, hrHPV testing, and cytology and hrHPV cotesting. The age of switching to hrHPV screening was evaluated at ages 25, 27, and 30 years, following cytology-only screening starting at age 21 years. Also assessed was the rescreening interval (3 and 5 years) and triage options for patients whose hrHPV test results were positive.

The primary outcomes and measures were the lifetime number of tests, colposcopies, disease detection, false-positive results, cancer cases, and deaths. The authors also assessed the efficiency ratios expressing the trade-off of harms vs benefits.

As compared with no screening, all strategies were estimated to result in substantial reductions in cancer cases and deaths, as well as gains in life-years. Results showed that the effectiveness of screening across the different strategies was similar, although primary hrHPV-based and alternative cotesting strategies demonstrated slightly higher effectiveness and greater harms than current guidelines-based cytology testing.

As an example, the authors point out, cervical cancer–related mortality ranged from 0.30 to 0.76 deaths per 1000 women with guidelines-based strategies. But with new approaches that involved primary hrHPV testing or cotesting, cervical cancer deaths were fewer, ranging from 0.23/1000 women to 0.29/1000 women.

In all analyses, primary hrHPV testing strategies that were conducted at 5-year intervals were efficient. Five-year primary hrHPV testing that was based on switching from cytology to hrHPV screening at ages 30 years, 27 years, and 25 years yielded ratios per life-year gained of 73, 143, and 195 colposcopies, respectively. Conversely, 3-year hrHPV testing had much higher ratios, ranging from 2188 to 3822 colposcopies per life-year gained. Overall, in most analyses, strategies involving cotesting were not efficient.

The authors write that in their study, "it was estimated that primary hrHPV screening may represent a reasonable balance of harms and benefits when performed every 5 years.

"Switching from cytology to hrHPV testing at age 30 years yielded the most efficient harm to benefit ratio when using colposcopy as a proxy for harms," Kim and colleagues conclude.

Where's the Value?

The new final recommendations from the USPSTF differ from the guidelines issued by other medical bodies, notes George F. Sawaya, MD, University of California, San Francisco, in an editorial published online in JAMA Internal Medicine.

For example, the Society for Gynecologic Oncology (SGO) has issued recommendations that differ from those of the USPTSF in two important ways. The SGO recommends that hrHPV testing begin at age 25, not 30 years, and it also recommends that testing be performed every 5 years and not more frequently.

From 2012 to the present, the American Congress of Obstetricians and Gynecologists (ACOG), the American Cancer Society (ACS), and the USPSTF agreed on the general approach to screening, but "it remains to be seen whether ACOG and the ACS will now adopt the latest Task Force approach," Sawaya writes.

Importantly, he emphasizes that there is a need for determining value. The balance of benefits and harms was assessed in this latest USPSTF guideline, "with the added advantage of being able to look across a variety of health conditions for which it has made similar judgments."

Two perspectives that could be captured fully, Sawaya notes, are the economic implications of each approach, as viewed from the societal perspective, and the preferences of women eligible for screening.

The task force does not take cost of cervical cancer screening into account, and in contrast to its recommendations on breast cancer screening, it also does not consider quality-adjusted life-years. "Although the USPSTF sets the standard for evidence-based recommendations and acknowledges the critical value of high quality evidence in making recommendations, it might reasonably be asked, where is the evidence of value in cervical cancer screening?" he writes.

Value can be considered from various perspectives, and the USPSTF states that women aged 30 to 65 years "should discuss with their health care professional which testing strategy is best for them." But if it is up to individual women to decide for themselves which option provides an appropriate balance of benefits and harms as compared with cytology, Sawaya argues, then "user-friendly educational tools will need to be developed to assure that women are making informed choices reflective of their preferences."

We Have the Tools, Access Needed

In a second editorial, Lee A. Learman, MD, PhD, Florida Atlantic University, Boca Raton, and Francisco A. R. Garcia, MD, MPH, University of Arizona, Tucson, explain why cotesting was added in the final recommendations.

In the draft recommendations, cotesting was not recommended because of evidence that it did not improve either the efficiency or effectiveness of testing, they explain.

However, public comments "raised questions about the strength of evidence supporting the inferiority of co-testing compared with primary hrHPV testing," they point out. They add that the "USPSTF has shown a high degree of responsiveness to the concerns of clinicians and patients about co-testing."

Cotesting is now included in the final version, and the results from the commissioned modeling study were nearly identical for hrHPV testing alone and for cotesting, they point out.

New testing approaches, coupled with prophylactic HPV vaccination and more effective therapeutic approaches to treatment for those with advanced cervical cancer, have given clinicians the necessary tools "to make cervical cancer mortality a memory," the editorialists write.

But tools are only as good as the access to them. "This promise will not be realized unless these tools also can be made available to the populations that bear the greatest disease burden from cervical cancer: poor women, women from communities of color, and other women with compromised access to timely and effective care," they conclude.

The USPSTF is supported by the Agency for Healthcare Research and Quality (AHRQ). The simulation study was funded by the AHRQ under a contract to support the USPSTF. Several of the USPSTF authors have disclosed relevant financial relationships, as noted in the article. Dr Spitzer is a past president of the American Society for Colposcopy and Cervical Pathology (ASCCP). Dr Sawaya is principal investigator of a study funded by the National Cancer Institute to use cost-effectiveness analyses to determine the range of reasonable options for cervical cancer screening and was previously a member of the USPSTF. Dr Garcia has served in various roles with the US Department of Health and Human Services Breast and Cervical Cancer Early Detection, the Control Advisory Committee of the Centers for Disease Control and Prevention, the ACOG's Women's Preventive Services Initiative. He has also served as a member of the USPSTF and as a board member of the ASCCP but has received no compensation for these roles. The authors of the simulation study have disclosed no relevant financial relationships.

JAMA. Published online August 21, 2018. Recommendation statement, Full text; Modeling study, Full text; Editorial

JAMA Intern Med. Published online August 21, 2018. Editorial

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