Recommendations are identified as either "evidence-based (A-D, I)" or "consensus-based." For definitions of the levels of recommendations see the end of the "Major Recommendations" field.
Recommendations 1A-D: Effectiveness of Cervical Cancer Primary Screening Tests in Asymptomatic, Average-Risk Women
1A: Routine cervical cancer screening is recommended for all asymptomatic, average-risk women. (Evidence-based: B)
1B: Either of the following tests are options for cervical cancer screening in asymptomatic, average-risk women under age 30.
- Conventional cytology (Evidence-based: B)
- Liquid-based cytology (Consensus-based)
1C: All of the following tests are acceptable options for cervical cancer screening in asymptomatic, average-risk women age 30 and older.
- Conventional cytology (Evidence-based: B)
- Conventional cytology and human papillomavirus (HPV) testing*‡** cytology (Consensus-based)
- Liquid-based cytology (Consensus-based)
- Liquid-based cytology and HPV testing*‡** cytology (Consensus-based)
*HPV testing has not been Food and Drug Administration (FDA) approved as a stand alone test for primary screening.
‡ Combined cytology and HPV testing provides useful risk-stratification
** Hybrid Capture 2 (HC2) Testing Device.
1D: No recommendation for or against routine use of computer-assisted slide evaluation or automated rescreening of cytology slides. (Evidence-based: I)
Recommendations 2A-B: Cervical Cancer Screening Intervals in Asymptomatic, Average-risk Women
2A: The following screening intervals are recommended:
- Cytology alone: every 3 years* (Consensus-based)
- Cytology + HPV (age 30 and older): every 3 years*‡ (Consensus-based)
*Screen if more than 30 months has elapsed.
‡ Hybrid Capture 2 (HC2) Testing Device.
2B: No recommendation for or against routinely providing annual screening tests prior to beginning a triennial screening program. (Evidence-based: I)
Recommendations 3A-B: Optimal Age to Begin and End Screening in Asymptomatic, Average-risk Women
3A: Initiation of cervical cancer screening is recommended approximately 3 years after first sexual intercourse or by the age of 21, whichever comes first.*‡ (Consensus-based)
3B: Routine screening for cervical cancer for women older than age 65 is not recommended if they have had adequate recent screening** with normal results on their last cytology (and HPV test if applicable). (Evidence-based: D)
*The Guideline Development Team (GDT) recognizes that the age to begin screening may not adequately reflect the current The Health Plan Employer Data and Information Set (HEDIS) measures. Some regions may choose to offer screening at a younger age. The HEDIS® cervical cancer screening rate estimates the percentage of women aged 21 to 64 that were enrolled in the health plan and who had one cytology test during measurement year or the two years prior.
‡Routine cervical cancer screening continues to be recommended for women who have received the HPV vaccine.
**The Guideline Development Team defined adequate recent screening as older women who have had three or more documented, consecutive, technically satisfactory normal/negative cervical cytology tests, and who have had no abnormal/positive cytology tests within the last 10 years.
Recommendations 4A-B: Triage for Atypical Squamous Cells of Undetermined Significance (ASC-US) Results Using HPV Testing in Asymptomatic, Average-risk Women
4A: HPV testing is recommended in women of all ages for triage of cytology results indicating atypical squamous cells of undetermined significance. (Evidence-based: B)
4B: No recommendation for or against the use of HPV testing to triage women with cytologic results higher than ASC-US. (Evidence-based: I)
Recommendations 5A-5B: Optimal Cervical Cancer Screening Strategy for Women Who Have Had a Total Hysterectomy for a Benign Condition
5A: Routine cytology screening is not recommended for women who have had a total hysterectomy for a benign condition unless there was a history of cervical intraepithelial neoplasia grade 2/3 (CIN2/3). (Evidence-based: D)
5B: Three consecutive negative cytology results with or without HPV testing are recommended prior to discontinuation of screening in women who have a history of cervical intraepithelial neoplasia grade 2/3 and a subsequent hysterectomy for a benign condition. (Consensus-based)
Recommendations 6A-C: Screening in Women at Increased Risk of Cervical Cancer
6A: Cytology and HPV testing are recommended at 6 months following treatment for CIN2/3, and again at 24 months, with colposcopy for any positive result. Routine screening every 3 years can then be resumed indefinitely. (Consensus-based)
6B: If HPV testing is not done, two cytology tests at 6 and 12 months after treatment are recommended, with colposcopy for a positive result, then annual cytologic screening indefinitely. (Consensus-based)
6C: At least annual cytology with or without HPV testing is recommended for women who are immunosuppressed or human immunodeficiency virus (HIV)-positive. (Consensus-based)
Recommendation 7A: Optimal Initial Management of Concurrent HPV-Positive and Cytology-Negative Cervical Screening Results
7A: HPV and cytology retesting is recommended in 12 months, rather than immediate colposcopy, for management of women with initial concurrent HPV-positive and cytology-negative screening results. (Consensus-based)
Definitions:
Recommendations are classified as either "evidence-based (A-D, I)" or "consensus-based."
- Evidence-based: sufficient number of high-quality studies from which to draw a conclusion, and the recommended practice is consistent with the findings of the evidence. A recommendation can also be considered "evidence-based" if there is insufficient evidence and no practice is recommended.
- Consensus-based: insufficient evidence and a practice is recommended based on the consensus or expert opinion of the Guideline Development Team (GDT).
Label and Language of Recommendations*
| Label |
Evidence-Based Recommendations |
| Evidence-based (A) |
Language: a The intervention is strongly recommended for eligible patients.
Evidence: The intervention improves important health outcomes, based on good evidence, and the Guideline Development Team (GDT) concludes that benefits substantially outweigh harms and costs.
Evidence Grade: Good.
|
| Evidence-based (B) |
Language: a The intervention is recommended for eligible patients.
Evidence: The intervention improves important health outcomes, based on 1) good evidence that benefits outweigh harms and costs; or 2) fair evidence that benefits substantially outweigh harms and costs.
Evidence Grade: Good or Fair.
|
| Evidence-based (C) |
Language: a No recommendation for or against routine provision of the intervention. (At the discretion of the GDT, the recommendation may use the language "option," but must list all the equivalent options.)
Evidence: Evidence is sufficient to determine the benefits, harms, and costs of an intervention, and there is at least fair evidence that the intervention improves important health outcomes. But the GDT concludes that the balance of the benefits, harms, and costs is too close to justify a general recommendation.
Evidence Grade: Good or Fair.
|
| Evidence-based (D) |
Language: a Recommendation against routinely providing the intervention to eligible patients.
Evidence: The GDT found at least fair evidence that the intervention is ineffective, or that harms or costs outweigh benefits.
Evidence Grade: Good or Fair.
|
| Evidence-based (I) |
Language: a The evidence is insufficient to recommend for or against routinely providing the intervention. (At the discretion of the GDT, the recommendation may use the language "option," but must list all the equivalent options.)
Evidence: Evidence that the intervention is effective is lacking, of poor quality, or conflicting and the balance of benefits, harms, and costs cannot be determined.
Evidence Grade: Insufficient.
|
| Consensus-based |
Language: a The language of the recommendation is at the discretion of the GDT, subject to approval by the National Guideline Directors.
Evidence: The level of evidence is assumed to be "Insufficient" unless otherwise stated. However, do not use the A, B, C, D, or I labels which are only intended to be used for evidence-based recommendations.
Evidence Grade: Insufficient, unless otherwise stated.
|
| For the rare consensus-based recommendations which have "Good" or "Fair" evidence, the evidence must support a different recommendation, because if the evidence were good or fair, the recommendation would usually be evidence-based. In this kind of consensus-based recommendation, the evidence grade should point this out (e.g., "Evidence Grade: Good, supporting a different recommendation").
|
[a] All statements specify the population for which the recommendation is intended.
*Recommendations should be labeled and given an evidence grade. The evidence grade should appear in the rationale. Evidence is graded with respect to the degree it supports the specific clinical recommendation. For example, there may be good evidence that Drugs 1 and 2 are effective for Condition A, but no evidence that Drug 1 is more effective than Drug 2. If the recommendation is to use either Drug 1 or 2, the evidence is good. If the recommendation is to use Drug 1 in preference to Drug 2, the evidence is insufficient.
