Cervical cancer screening in high-risk patients: Clinical challenges in primary care

Article Figures & Data

TABLE 1

Cervical cancer screening among average-risk patients

Organization	Recommended screening test and frequency
2018 US Preventive Services Task Force¹³	Age < 21 years No screening	Age 21–29 years Cervical cytology (Pap test) every 3 years	Age 30–65 years Choose between Cervical cytology (Pap test) every 3 years, or Primary HPV testing every 5 years, or Cotesting every 5 years

2020 American Cancer Society¹²	Age 25–65 years Primary HPV testing every 5 years preferred
2020 American Cancer Society¹²	Acceptable alternatives (given access to primary HPV testing may be limited): Cotesting every 5 years, or Cervical cytology (Pap test) every 3 years

TABLE 2

When to stop cervical cancer screening in average-risk patients

Age > 65 years, if…	After hysterectomy, if…
Patient is asymptomatic, and	Total hysterectomy (removal of the cervix) was performed,^{^a} and
Has no history of CIN2 or worse in the past 25 years, and	Hysterectomy was performed for benign indication, and
Has undergone adequate prior screening: 3 consecutive negative cytology results in past 10 years with most recent within 3 years, or 2 consecutive negative HPV test results in past 10 years with most recent within 5 years	There is no history of high-grade precancerous lesion (eg, CIN2 or worse) in the past 25 years or history of HPV-related lower genital tract cancer

↵^a Patients who have undergone a hysterectomy and retained the cervix (subtotal or supracervical hysterectomy) should continue screening per guidelines for average- or high-risk screening, as clinically appropriate.
CIN2 = cervical intraepithelial grade 2; HPV = human papillomavirus
Based on information in references 12 and 13.

TABLE 3

Immunosuppressants and immunosuppressive treatments

Calcineurin inhibitors	Cytotoxic agents	mTOR inhibitors	Steroids	Biologics	Monoclonal antibodies
Tacrolimus (Crohn; non-FDA) Cyclosporine (UC; non-FDA)	Mycophenolate Azathioprine (IBD; non-FDA) Leflunomide (Crohn; non-FDA) Chlorambucil Cyclophosphamide Mercaptopurine (IBD; non-FDA) Methotrexate (Crohn; non-FDA) Platinum compounds Fluorouracil Dactinomycin	Sirolimus Everolimus	Prednisone (IBD; FDA) Prednisolone (IBD; FDA) Budesonide (IBD; FDA) Dexamethasone (IBD; FDA)	Abatacept Adalimumab (IBD; FDA) Anakinra Apremilast Certolizumab (Crohn; FDA) Etanercept (Crohn; non-FDA) Golimumab (UC; FDA) Infliximab (IBD; FDA) Ixekizumab Natalizumab (Crohn; FDA; (UC; non-FDA) Rituximab Secukinumab Tocilizumab Ustekinumab (Crohn; FDA) Vedolizumab (IBD; FDA)	Basiliximab Daclizumab Muromonab

FDA = US Food and Drug Administration; IBD = inflammatory bowel disease; mTOR = mammalian target of rapamycin; UC = ulcerative colitis
Reprinted from Moscicki AB, et al. Guidelines for cervical cancer screening in immunosuppressed women without HIV infection. J Low Genit Tract Dis 2019; 23(2):87–101. doi:10.1097/LGT.0000000000000468 with permission from Wolters Kluwer Health.

TABLE 4

Cervical cancer screening and management among individuals with HIV

Screening
Age to start	Age to stop	Recommended test and frequency		Rationale
Screening should begin at time of diagnosis but not before age 21	Screening should continue throughout a patient’s lifetime (considering life expectancy)^{^a}	Age < 30 years Cytology (Pap test) at baseline, then annually If 3 consecutive Pap tests are normal, then cytology every 3 years (until age 30)	Age ≥ 30 years Choose between cytology (Pap test) at baseline, then annually (if not already completed before age 30); if 3 consecutive Pap tests are normal, then cytology every 3 years or cotesting every 3 years	Begin screening at age 21 to provide a 3–5-year window before age 25, when the risk of invasive cervical cancer in patients with HIV exceeds that of the general population²⁰; while historically screening was done before age 21, patients rarely develop cervical cancer before age 21²¹ In patients age < 30, cotesting is not recommended due to a high prevalence of transient HPV in this age group³
Management
Regardless of age, colposcopy is recommended in the following scenarios: HPV-positive ASC-US; if HPV testing is not performed, then repeat cytology in 6–12 months is recommended, with colposcopy referral for ASC-US or worse All cytology results of low-grade squamous intraepithelial lesion or worse (including ASC-H, atypical glandular cells, adenocarcinoma in situ, and high-grade squamous intraepithelial lesion) regardless of HPV test results (if completed)

↵^a If a patient with HIV undergoes a hysterectomy with removal of cervix (total hysterectomy) for benign disease and has no history of cervical intraepithelial neoplasia 2+, then ongoing routine screening for cervical or vaginal cancer is generally not recommended.
ASC-H = atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion; ASC-US = atypical squamous cells of undetermined significance; HIV = human immunodeficiency virus; HPV = human papillomavirus; Pap = Papanicolaou
Data from references 3 and 16.