In 2012, the US Preventive Services Task Force (USPSTF), one of the leading organizations providing practice guidelines and recommendations for cervical cancer screening, issued HR-HPV recommendations that did not suggest or endorse testing using HPV alone.
However, in August 2018, the guidelines and practice recommendations for cervical cancer screening using HPV testing were updated to include HPV testing alone as the primary screening option. The USPSTF concluded that there was a high degree of certainty that the benefits of screening every three years with cytology alone, every five years with HR-HPV testing alone, or in combination in women aged 30 to 65 outweigh the harm. Although HPV testing has been used for many years to help in cervical cancer screening, this was the first time a national guideline has recommended the sole use of HPV tests for women ages 30 to 65.
The USPSTF stressed that current evidence indicates no clinically significant differences between liquid-based and conventional cytology for cervical cancer screening. Evidence from RCTs has suggested that screening with cytology alone is slightly less sensitive for detecting CIN2 and CIN3 than screening with HR-HPV testing alone. The guidelines recommend screening with cytology alone, HR-HPV alone, and both in combination offer a reasonable balance between benefits and harm for women aged 30 to 65. Women in this age group should discuss with their healthcare professional which testing strategy is best for them.
As of 2024, the USPSTF guidelines have remained essentially the same as presented in 2018. However, the topic is being updated and new guidelines may be published in the near future. It is essential to note the following when discussing the updated guidelines for cervical cancer screening:
- When the 2018 USPSTF guidelines draft was released in late 2017, they did not initially include co-testing as a recommended screening method. However, some clinicians expressed concern about the need for a transition period before HPV is adopted as a primary screening method. Hence, the final 2018 recommendations do include co-testing as an option.
- The updated guidelines are based on findings from recent studies that demonstrated that testing for high-risk strains of HPV detected a higher rate of precancerous lesions in the cervix as compared with the Pap test alone.
- Although evidence from RCTs indicates that HR-HPV testing and co-testing can detect more cases of CIN 2 and CIN 3, they also have higher false-positive rates compared with cytology alone. Co-testing has the highest false-positive rate. False-positive rates are also higher among women younger than 30 years than among older women because of the higher incidence of transient HPV infection in younger women, even though cervical cancer incidence is lower in this age group.
- These recommendations are meant for asymptomatic women regardless of sexual history or HPV vaccination status. As in the previous guideline, the USPSTF recommends against screening for average-risk women younger than 21 years, older than 65 years who have had adequate prior screening, or women who have had a hysterectomy with removal of the cervix and do not have a history of high-grade precancerous lesions
Conclusions on HPV test as a first-line primary cervical cancer screen:
There is accumulating clinical evidence that screening with HR-HPV alone as the primary cervical cancer screen or using a combination of HR-HPV and cytology may offer a reasonable balance between benefits and harms for women aged 30 to 65. With the recent USPSTF guideline recommendations, we can expect to see an increased use of the HR-HPV test as the first-line primary screening for cervical cancer. (We should also expect women in the recommended age group to discuss with their healthcare professional which testing strategy is best for them).
For now, the HR-HPV test used alone as the primary cervical cancer screen is an option for most women aged 30 to 65.
For more details, please consult the following reference links:
U.S Preventive Services Task Force. (2019). Screening for cervical cancer: Recommendation statement.
Am Fam Physician. 99(4): available at
https://www.aafp.org/afp/2019/0215/od1.html
