1. Cervical Cancer Screening Recommendations, 2012
Slide :1
This presentation on Cervical Cancer Screening was developed by the American Society for Colposcopy and Cervical Pathology (ASCCP) to assist all clinicians caring for women in understanding the current primary recommendations for cervical cancer screening published by the ACS/ASCCP and ASCP and the basis for the recommendations. The discussion will also focus on the new option of co-testing of women with cervical cytology and HPV DNA tests, as it is the least understood of the screening options.
Herschel W. Lawson, MD, FACOG
Chief Medical Officer, ASCCP

2. Disclosures I have no relevant disclosures to make.
I am active in the American Society for Colposcopy and Cervical Pathology and serve as Chief Medical Officer.

3. Objectives of Screening
Prevent morbidity and mortality from cervical cancer
Prevent overzealous management of precursor lesions that most likely will regress or disappear and for which the risks of management outweigh the benefits
Slide 6: The main objectives of cervical cancer screening are to prevent morbidity and mortality associated with cervical cancer and to prevent overzealous management of screening changes and precursor lesions that are likely to regress or disappear naturally for which the risks of management outweigh the benefits.

4. Natural History of Cervical Cancer
CIN 1
Avg mo
Avg yrs
HPV infection
CIN 2,3
Invasive CA
Avg mo.
Slide :8
Within 6 to 12 months of detecting HPV by sensitive molecular testing the majority of women will become HPV negative, indicating immune suppression of HPV. (Bullet 1) It is likely that most, if not all, women infected with HPV have some viral vaginal or cervical cell expression prior to immune suppression, but are not aware that they have it. When low-grade CIN (1) is detected, spontaneous regression can be expected in about 70% within 6 to 24 months. (Bullet 2) About 10% of women diagnosed with CIN 1 following referral for colposcopy to evaluate LSIL Paps will eventually develop CIN 2,3, not as direct progression from CIN 1, but rather as a separate monoclonal high-grade cellular change. (Bullet 3) And some women will develop CIN 2,3 directly from HPV infection without a pre-existing low-grade lesion. (Bullet 4) Approximately 40% of diagnosed CIN 2 resolves spontaneously, (Bullet 5) but most CIN 3 persists, and over a median of 10 to 13 years may progress to invasive cervical cancer as spontaneous mutations accumulate eventually making the cell immortal. It is this long period of time usually required for the HPV-infected cell to become a cancer that has made screening for, and management of cervical pre-cancer, so successful in preventing invasive cervical cancer.
HPV disappearance

5. The strengths and limitations of cervical cancer screening
Slide 9:
Dr. Leopold Koss, a pioneer in cervical cytology, wrote an Editorial in 1989 on the triumph and tragedy of screening for cervical cancer with the Pap test. The triumph is that many lives have been saved with cervical cancer screening. The tragedy is that many lives are still lost despite the fact that this is theoretically a preventable cancer. In this section we will discuss the strengths and limitations of cervical cancer screening. 5

6. Cervical Cancer Prevention
Widespread introduction of the Pap begins
Slide 10
Widespread introduction of the Pap in the US did not begin until about 1949, but in the following 6 decades contributed greatly to reducing the cervical cancer burden from 2nd in incidence and mortality for cancers in women to its present rank of 11th in incidence and 13th in mortality among all cancers in women.
Conventional Pap smear
1949
2000’s

7. Cervical Cancer Incidence (SEER) and U.S. Death Rates,* 1975-2005
Slide 11:
The Surveillance, Epidemiology, and End-Results Program (SEER) of the National Cancer Institute has been an authoritative source of information on cancer incidence and survival, in the United States, since SEER statistics for incidence and the Centers for Disease Control and Prevention (CDC) mortality figures for the years demonstrate the decline in cervical cancer incidence and mortality that accelerated in the 1970s, but has leveled off over the last two decades, due in large part to the women who remain either unscreened or rarely screened, and, to a lesser extent, to the limits of present screening methods particularly for women less screened.
Incidence source: SEER 9 areas (San Francisco, Connecticut, Detroit, Hawaii, Iowa, New Mexico, Seattle, Utah, and Atlanta). Mortality source: US Mortality Files, National Center for Health Statistics, CDC.
*Rates are per 100,000 and are age-adjusted to the 2000 US Std Population (19 age groups - Census P ).

8. Being rarely or never screened is the major contributing factor to most cervical cancer deaths today.
Slide 12
Many sources emphasize that being rarely or never screened is the major contributing factor to most cervical cancer deaths today.

9. Who are the Rarely and Never Screened?
Descriptions
Minorities
Low SES*
Foreign born
Living in the US < 10 years
No usual source of health care
Where are the data?
US Census
NCHS§ Cervical cancer mortality
BRFSSµ
NHIS**
Slide 13:
Based on data from a variety of reputable U.S. national resources, this slide describes the groups most likely to be unscreened or less screened.
* Socio-economic status
§ National Center for Health Statistics, CDC
µ Behavioral Risk Factor Surveillance System, CDC
** National Health Interview Survey, CDC

10. System Failures Leading to Cervical Cancer Diagnosis
Health care providers
do not screen women
at visits
Patient does not get
appropriate therapy
Women do not
come in for
screening
Slide 14:
There are multiple system failures that can occur that lead to a diagnosis of cervical cancer. (bullet 1) The primary reason, as noted earlier, is that women do not present for screening at all or are only rarely screened at irregular intervals. (Bullet 2) The second reason is that health care providers do not screen women during routine office visits. (bullet 3) Another reason is that no, or inadequate follow up is delivered to women with abnormal screening results, and finally (bullet 4) there are those women who either refuse appropriate therapy, delay it or are lost to follow up for one of several reasons. (bullet 5) The end result is the occurrence of invasive cervical cancer.
Colposcopy for
abnormal screen
not done
Patient gets cervical cancer
Courtesy of Connie Trimble, MD, Johns Hopkins University School of Medicine, Baltimore, MD

11. Failure to screen No Pap 464 (56%)
Retrospective Study of Cervical Cancers Diagnosed at Kaiser Northern California
Pap results 3-36 months prior to diagnosis
N=833
Failure to screen No Pap (56%)
Failure in detection st Pap WNL 263 (32%)
Failure to follow-up st Pap abnormal (13%)
No visit 19%
Slide 15:
These failings are demonstrated by the results of a retrospective study conducted by researchers at Kaiser Northern California. Leyden, et al. evaluated the histories of the 833 women in the Kaiser Health Care System diagnosed with cervical cancer in a recent time period. (Bullet 1) More than half the women diagnosed never had a Pap test despite the routine availability of this service to members without additional charge. Eighty percent visited the clinic at least once but were not scheduled for a Pap. (Bullet 2) About one third of the women developing cancer had one or more false negative Pap tests prior to the diagnosis, most of which were satisfactory for evaluation. (Bullet 3) Another 13% had an abnormal Pap but failed to receive adequate follow-up for the abnormal result, either as a result of failure of notification or failure of the patient to follow through when appropriately advised. The clinical implications of this analysis are applicable to nearly all medical settings and include 1). That provision of a service does not guarantee that it will be utilized even if cost is not an issue and the patient attends the clinic for other reasons. 2). False negative Pap tests do occur even when the Pap is satisfactory, and 3). Abnormal Pap follow-up notification and reminder systems must be as “fail proof” as possible, but even when that is the case, some patients will not receive follow-up as advised.
1-2 visits 18%
>3 visits 63%
Leyden MA, Manos M, Kinney W et al JNCI 2005;97:67583.

12. Proportion of Women Receiving Cervical Cancer Screening, NHIS
Proportion of Women Receiving Cervical Cancer Screening, NHIS*, United States, 2000
Group
% Pap test
past 3 years
All women
82%
Insured
Yes No
85%
62%
Country of birth
US born
Foreign born in U.S. <10 yrs
83%
61%
Slide 16:
The highest risk groups reporting inadequate screening are women who are (Bullet 1) uninsured, and (Bullet 2) recent immigrants, in the US less than 10 yrs. Hence, these groups of women could benefit most from being screened with a test having both high sensitivity and specificity, since they may only be screened rarely. Among some foreign born women, even those with extensive education and economic affluence, there are cultural barriers to seeking screening.
*National Health Interview Survey
Swan J, Breen N, Coates RJ, Rimer BK, Lee NC. Progress in cancer screening practices in the United States: results from the 2000 National Health Interview Survey. Cancer. 2003;97:

13. Prevalence of Pap Tests during last 3 years, by education level, U.S.
Slide 18:
2007 data from CDC demonstrated that screening rates were highest among women 25-44, but that in all age groups, there was a direct correlation between prevalence of screening and education level attained. Women with higher education levels were more likely to be screened than women with less education. Hence it is clear that screening rates are affected by education levels, insurance access, and country of birth. Screening rates in the US have improved considerably during the last two decades, but approximately 18% are not screened at all or not often enough to provide adequate protection.
2007. Health US 2007.CDC, National Center for Health Statistics.

14. Cervical cancer prevention: Where have we been and where are we going?
Widespread introduction of the Pap begins
Slide 19:
In recent decades, concerns about the sensitivity of conventional cervical cytology led to the evaluation of alternatives. (Bullet 1) Liquid based cytology (LBC) was first introduced into clinical practice following the 1996 FDA-licensing of a thin layer cytology system. (Bullet 2) An HPV test using hybrid capture technology was FDA-approved for the management of ASC-US Pap results in 1999 and as a co-test with the Pap for women ages 30 and over in A newer signal amplification HPV DNA test and type-specific test for HPV 16 and18 were licensed by the FDA for clinical use in early (Bullet 3) An HPV vaccine became available when the FDA licensed a quadrivalent vaccine in June, This vaccine was approved for use in girls and women 9-26 years of age and included protection against two high risk and two low risk HPV types. A second HPV vaccine became available after the FDA licensed a bi-valent HPV vaccine, for the prevention of two high risk types, in October, 2009, for use in females up to age of 25 (Bullet 4) In the future, other bio-markers for increased risk for cervical cancer, such as mRNA and P16 are expected to be introduced to the market.
Markers
Conventional Pap smear
LBC
HPV testing
Vaccine
1949
1996
2000’s

15. Why isn’t “finding lesions” the objective of screening?
Don’t know which lesions will progress.
Need to place emphasis on:
Persistent HPV infections
CIN 3 (no margin for error)
CIN 2 in older women (no risk to pregnancies)
Persistent CIN 2 and CIN 2/3 in non-adolescent women

16. Consensus Conference Sponsored by
American Society of Colposcopy and Cervical Pathology (ASCCP)
American Cancer Society (ACS)
American Society of Clinical Pathology (ASCP)

17. ACS/ASCCP/ASCP Guidelines Development Process
– A steering committee from the 3 organizations created 6 working groups and a data group to direct the evidence evaluation
Participating organizations:
AHRQ, AAFP, ABOG,ACHA, ACOG, ASHA, ASC, ASCT, CAP, CDC, CMS, FDA, NCI, NCCN, NPWH, PPFA, SCC, SGO, SGOC, AHRQ/USPSTF, VHA

18. Guidelines Development Evidence Review
Used “Grading Recommendations Assessment, Development, and Evaluation” system (GRADE)
Articles retrieved 1995 to mid-2011
WGs reviewed and graded evidence “critical, important, nice to know”
WGs developed recommendations --“strong” or “weak” depending on the quality of the evidence

19. ACS/ASCCP/ASCP Guidelines Development Process
6 topic areas identified:
Optimal screening intervals
Screening women 30+
Managing discordant cytology/HPV results
Exiting women from screening
Impact of HPV vaccination on screening
Potential for primary HPV testing (no Pap)

20. Guidelines Development Process Assumptions
Preventing all cervical cancer is unrealistic
No screening test has 100% sensitivity
Reasonable risk is determined by a strategy of performing cytology alone at 2-3y intervals
Screening strategies with similar outcomes are acceptable
Women at similar risk for cancer should be managed the same

21. Guidelines Development Process Assumptions
Conventional and liquid-based cytology perform similarly
HPV tests should have ≥90% sensitivity for CIN2+ and CIN3+
Comparability of all FDA-approved HPV tests cannot be assumed
Utility of unapproved/laboratory developed tests is unknown, and tests should not be used in screening

22. Guidelines Development Process Assumptions
Benefits of screening
Cancer is the ideal endpoint but unrealistic
CIN3 is a reliable surrogate marker for sensitivity
CIN2 is equivocal (a combination of CIN1 and CIN3)
hard to diagnose—poor inter-rater reliability
often regresses
a threshold for treatment

23. Guidelines Development Process Assumptions
Screening interval
Risk of developing invasive cancer before next screen should be unlikely
Earlier detection of CIN3+ is a benefit
Even studies with less sensitive tests show similar CIN3 detection--no increased cancer risk during later screening rounds

24. Guidelines Development Process Assumptions
Possible harms of screening
Anxiety over a positive test
Stigma of an STI
Pain/bleeding from procedures
Treatment-related pregnancy complications
Number of colposcopies is a marker for harms

25. Treatment saves lives, but at what cost?
Women with LEEP more likely to have
Preterm birth (O.R. 1.7)
LBW (O.R. 1.8)
PPROM (O.R. 2.7)
Single studies show association with perinatal death, incompetent cervix
Risk rises with depth and number of LEEPs
Similar findings after conization or laser treatment
Absolute risk increase is small
Kyrgiou M et al. Lancet 2006;367:489-98
Bruinsma et al BJOG 2007;114:70-80

26. Guidelines Development Evidence Review Process
Recommendations posted to ASCCP website for public comment 10/19-11/9/11
Revisions made based on comments as needed
Consensus conference held 11/17-18/2012
Discussion of draft recommendations by attendees
Recommendations approved by at least a 2/3 majority of delegates

27. 2012 ACS/ASCCP/ASCP Cervical Cancer Screening Guidelines
Slide 21:
In 2002, the American Cancer Society published updated cervical cancer screening recommendations that differed considerably from ACS Guidelines first issued in 1980 and updated in The 2002 updates included recommendations for age to begin and end screening, and how often screening should be conducted. The changes were based in part on a more complete understanding of the natural history of HPV and its relationship to cervical carcinogenesis. In March, 2003, following FDA approval of HPV co-testing with the Pap among women 30 and older, ACOG published updated cervical cancer screening guidelines which agreed in part with the ACS recommendations and incorporated a recommendation for the use of the approved hybrid capture HPV DNA test as an optional adjunct to the Pap for women ages 30 and over. In December 2009, ACOG reissued cervical cancer screening recommendations based in large part on the evidence published since the 2003 recommendations. The new recommendations are closely aligned to the 2002 ACS recommendations, including when to begin and end screening, appropriate use of HPV DNA testing and how frequently to screen. In the Spring of 2011, ACS will publish new screening recommendations based on up to date information. For this reason, the information in the next few slides is largely based on the 2009 ACOG recommendations and more specifically are age-based. For a complete list of ACOG and ACS recommendations please see the websites noted on this slide.
Saslow, Solomon, Lawson, et al. JLGTD, March 14, 2012 (online)
Saslow, Solomon, Lawson, et al. CA: A Cancer J for Clinicians, March 14, 2012 (online) 27

28. New ACS/ASCCP/ASCP Guidelines When to begin screening
Cervical cancer screening should begin at age 21.
Women < 21 should not be screened regardless of age of sexual onset
Slide 19
The new 2009, ACOG recommendation is to begin cervical cancer screening at age 21 regardless of timing of onset of sexual activity.
Guidelines do not apply to special populations – hx of cervical cancer, DES exposure, & immune-compromise
Saslow, Solomon, Lawson, et al. JLGTD, March 14, 2012 (online)
Saslow, Solomon, Lawson, et al. CA: A Cancer J for Clinicians, March 14, 2012 (online)

29. Cervical Cancer Incidence
by Age Group, USCS*,
Age
Rate per 100,000
Slide 24:
This new guideline reflects the rarity of invasive cervical cancer prior to age 21 and the observed high rate of HPV DNA detection and subsequent occurrence of equivocal and low grade Pap reports in young women. It also reflects the concern for adverse outcomes associated with the follow-up of adolescents and very young reproductive-aged women with minor cytological abnormalities. The age specific incidence of cervical cancer noted here confirms the recommendation to delay the beginning of screening until age 21. Even though some clinicians may be concerned that delaying screening to age 21 may result in missing cervical cancer, the evidence shows how little risk there is of cervical cancer in an adolescent population. This risk is 1 case per million women per year in the age group 19 and below.
All ages
*United States Cancer Statistics includes data from CDC’s National Program of Cancer Registries and NCI’s Surveillance, Epidemiology and End Results Program.
Saraiya M et al. Obstet Gynecol 2007;109:

30. Adolescent Needs Care for contraception and STI screening/treatment.
No Pap test
No speculum exam for asymptomatic women
STI testing can be done using urine

31. Cytology alone every 3 years
Screening for ages 21-29
Cytology alone every 3 years
HPV testing “should not be used to screen”
Not as a component of cotesting
Not as a primary stand-alone screen

32. Rationale for Longer Pap Screening Intervals
Sensitivity of single Pap test 50-70%
Cancer risk 18mo after 3 neg Paps = 1.5/100,000
Cancer risk 36mo after 3 neg Paps = 4.7/100,000
99,997 women screened unnecessarily to help 3
Risk of HSIL/cancer <3 years after negative Pap not significantly higher than risk after 1year
Longer Pap screening intervals (e.g., 5y) inappropriate for mobile US population
Sawaya GF et al. Acta Cytol 2005;49:391-7

33. Rationale for Longer Pap Screening Intervals-2
Screening harms: lifetime risk of colposcopy
Screening q3y: 760 colpos/1000 women
Screening q2y: 1080 colpos/1000 women
Screening annually: 2000 colpos/1000 women
Stout NK et al. Arch Intern Med 2008;168:181.
Kulasingam S et al AHRQ Publication No EF-1.

34. Prevalence of HPV by Age, Manchester, U.K.
Low-grade CIN: Cytology/Histology/Colposcopy
Thomas C. Wright, Jr.
Prevalence of HPV by Age, Manchester, U.K.
Percentage HPV (+)
Slide 35:
Prevalence data from Manchester, England clearly demonstrate that women age 30 and over have the lowest rate of HPV detection for all HPV types, and more importantly, for high-risk types.
Age Group
Peto et al Br. J. Cancer (2004:91:942-53)

35. Weighted Prevalence of Low-risk and High-risk HPV Types Among US Women 14–59yo, 2007-2010 (NHANES)
Hariri S et al. J Infect Dis. 2011;204:

36. Rationale for Avoiding HPV Tests Among Women Ages 21-29
Prevalence of carcinogenic HPV approaches 20% in teens and early 20s
Most carcinogenic HPV infections resolve without intervention
Identifying carcinogenic HPV that will resolve leads to repeated call-back, anxiety, and interventions without benefit

37. Screening For Women Ages 30-64
Cytology + HPV testing (Cotesting) every 5 years is preferred
Cytology alone every 3 years is acceptable

38. Rationale for Cotesting, Ages 30-64
Increased detection of prevalent CIN3
Decreased CIN3 in subsequent screening rounds
Achieves risk of CIN3 equal to cytology 1-3year intervals
Enhances detection of adenocarcinoma/AIS
Minimizes the increased number of colposcopies, thus it reduces harms.

39. Why Not Cotesting for All Women 30-64?
Some sites may lack access to HPV testing
Financial
Logistical
Cytology remains effective
Requires more frequent visits
Requires more colposcopy for equivocal results

40. Why Not Annual Cotesting?
High NPV of one cotest means most abnormal screens at 1-3y intervals are transient HPV infection, not precancer
Potential harms are amplified without benefit

41. Rapid clearance of HPV in Women >308% *
61%
Slide 50:
We conclude this section with a summary about the clearance of HPV infections as it pertains to previously screened women. Repeating the Pap and HPV test in 12 months allows for spontaneous resolution of the majority of HPV infections destined to be transient, thereby referring only those women persistently HR HPV positive to colposcopy. In this natural history study of 10,000 women ages 30 and over, by Rodriguez, et al., seen here, (Arrow 1) approximately 60% of those HPV positive turned HPV negative within 12 months while over (Arrow 2) 35% remained positive. However, it is clear that with increasing persistence, the risk for developing pre-cancer and cancer, shown in red, increases.
* Histological progression
Rodriguez AC et al. J Natl Cancer Inst. 2008;100:

42. Managing ASC-US/HPV negative tests
“ Women with ASC-US cytology and negative HPV test results should continue screening per age-specific guidelines.”
CIN3 risk of ASC-US/ HPV neg <2%, below threshold for colposcopy.

43. Managing HPV+/Cytology- Cotests
“Women cotesting HPV positive and cytology negative should be followed with either (1) repeat cotesting in 12 months, or (2) immediate HPV genotype-specific testing for HPV16 alone or HPV 16/18. Direct referral to colposcopy is not indicated”

44. (1) Repeat cotest in 12 months
If either repeat test is positive, refer to colposcopy
If both tests are negative, return to routine screening.

45. (2) Immediate HPV genotyping
If HPV 16 or HPV16/18 positive, refer directly to colposcopy.
If HPV 16 or HPV 16/18 negative, repeat cotest in 12 months and then…
If either repeat test is positive, refer to colposcopy
If both tests are negative, return to routine screening.

46. Managing HPV+/Cytology- Cotests Rationale
Consistent observational data indicate short term risk of CIN3 far below risk threshold of HPV+/ASC-US and LSIL used for colposcopy referral
Evidence from cohort studies shows majority of transient infections clear by 12 months allowing most to return to routine screening without excessive risk.

47. Predicted Impact of Pap Screening on Cancer Incidence
Slide 30:
Here we see the results of more recent mathematical modeling based on newer evidence and updated outcome assumptions. Annual screening would lower the risk of cervical cancer to nearly zero if management of women with abnormal cervical cytology is expertly done and follow-up is reliable. However, in most cost effectiveness analyses, annual screening in age groups beyond age 29 is not cost effective. Increasingly longer screening intervals increase risk somewhat, as demonstrated in the white, violet and green lines at 2, 3 and 5 year intervals. The predicted cancer incidence by age group in unscreened women is demonstrated by the red line. Not shown here is the impact of irregular screening, particularly among women seen regularly during their reproductive years, but who do not receive screening for several years after the birth of their youngest child or after menopause. The reduction in protection with this scenario is likely to be similar or greater than that seen with regular but longer screening intervals.
Myers E 2006 ASCCP Biennial Meeting Las Vegas, NV

48. 3 consecutive negative Paps or 2 consecutive negative HPV tests
When to Stop Screening
Stop at age 65 for women with adequate negative prior screening, no CIN2+ within the last 20y.
Definition of adequate negative screening:
3 consecutive negative Paps or
2 consecutive negative HPV tests
(Tests within 10 years of stopping; most recent within 5 years.)

49. Stop screening at age 65
Screening “should not resume for any reason, even if a woman reports having a new sexual partner.”

50. Rationale for stopping at 65 years
CIN2+ is rare after age 65
Most abnormal screens, even HPV+, are false + and do not reflect precancer
HPV risk remains 5-10%
Colposcopy/biopsy/treatment more difficult
Harms are magnified
Incident HPV infection unlikely to lead to cancer within remaining lifetime
Chen HC et al. JNCI 2011;103: ;
Rodrigues AC et al. JNCI 2009;101:721-8

51. When to stop screening - 2
Stop after hysterectomy with removal of cervix and no history of CIN2+
“Evidence of adequate negative prior screening is not required”

52. Rationale for stopping after Hysterectomy
Vag cancer rate is 7/million/year
663 vag cuff Paps needed to find one VAIN
2,066 women followed after hyst. for average 89 months
3% had VAIN, 0 had cancer
Risk of Pap abnormality after hyst = 1%.
Compare risk of breast cancer in men for which screening is not recommended.
Pearce KF et al. NEJM 1996;335: ;
Piscitelli JT et al. AJOG 1995;173:424-30

53. When NOT to stop at age 65 years
If history of CIN2, CIN3, or AIS
Continue “routine screening” for at least 20 years, “even if this extends screening past age 65.”

54. Screening a Vaccinated Cohort
“ Recommended screening practices should not change on the basis of HPV vaccination.”
Vaccination against HPV 16/18
Reduces CIN3+ by 17-33%
Reduces colposcopy by 10%
Reduces treatment by 25%
But who is vaccinated?
Recall? Completed series? HPV naïve?
Paavonen J et al. Lancet 2009;374:301-14

55. HPV as a Primary Screening Test
Strong NPV of HPV test suggests it might replace cotesting, but test specificity lacking
Follow-up to HPV+ test remains unclear
Pap? Repeat HPV in 1y? Genotyping? Colpo?
Knowing HPV status biases cytology reports to abnormal
Harms undefined
No US prospective trials
“In most clinical settings, women ages should not be screened with HPV testing alone.”

56. 2012 Standards USPSTF ACS/ASCCP/ASCP When to start? 21yo How often?
Q3y Paps
Cotesting > 30 years q 5 yrs to lengthen the screening interval
Q3y Paps ages 21-29
Q5y cotesting ages 30-65
Q3y Paps remain an option
When to stop?
65 if adequate prior screens
Age 65 if 3 neg Paps or neg HPV
After hysterectomy for benign disease

57. Conclusion
“The biggest gain in reducing cervical cancer incidence and mortality would be achieved by increasing screening rates among women rarely or never screened. . .
Clinicians, hospitals, health plans, and public health officials should seek to identify and screen these women.”
ACS, 20002

58. Caveats
Clinicians, patients, third-party payers, institutional review committees, other stakeholders, or the courts should never view recommendations as dictates. Even strong recommendations based on high-quality evidence will not apply to all circumstances and all patients.
Users of guidelines may reasonably conclude that following some strong recommendations based on high quality evidence will be a mistake for some patients. No clinical practice guideline or recommendation can take into account all of the often compelling unique features of individual patients and clinical circumstances. Thus, nobody charged with evaluating clinician’s actions, should attempt to apply recommendations in rote or blanket fashion.