This is the current release of the guideline.

Cervical cancer

• Women 21 years of age and older (for cervical cancer screening)
• Sexually active adolescent girls (i.e., younger than age 21 years) (for counseling and testing for sexually transmitted infections)

The MEDLINE database, the Cochrane Library, and the American College of Obstetricians and Gynecologists' (ACOG) own internal resources and documents were used to conduct a literature search to locate relevant articles published between January 1985 and July 2009. The search was restricted to articles published in the English language. Priority was given to articles reporting results of original research, although review articles and commentaries also were consulted. Abstracts of research presented at symposia and scientific conferences were not considered adequate for inclusion in this document. Guidelines published by organizations or institutions such as the National Institutes of Health and the American College of Obstetricians and Gynecologists were reviewed, and additional studies were located by reviewing bibliographies of identified articles.

Not stated

Studies were reviewed and evaluated for quality according to the method outlined by the U.S. Preventive Services Task Force:

I: Evidence obtained from at least one properly designed randomized controlled trial.

II-1: Evidence obtained from well-designed controlled trials without randomization.

II-2: Evidence obtained from well-designed cohort or case–control analytic studies, preferably from more than one center or research group.

II-3: Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments also could be regarded as this type of evidence.

III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

Not stated

Analysis of available evidence was given priority in formulating recommendations. When reliable research was not available, expert opinions from obstetrician-gynecologists were used. See also the "Rating Scheme for the Strength of Recommendations" field regarding Grade C recommendations.

Based on the highest level of evidence found in the data, recommendations are provided and graded according to the following categories:

Level A - Recommendations are based on good and consistent scientific evidence.

Level B - Recommendations are based on limited or inconsistent scientific evidence.

Level C - Recommendations are based primarily on consensus and expert opinion.

Practice Bulletins are validated by two internal clinical review panels composed of practicing obstetrician-gynecologists generalists and sub-specialists. The final guidelines are also reviewed and approved by the American College of Obstetricians and Gynecologists (ACOG) Executive Board.

The grades of evidence (I-III) and levels of recommendation (A-C) are defined at the end of the "Major Recommendations" field.

The following recommendations are based on good and consistent scientific evidence (Level A):

• Cervical cancer screening should begin at age 21 years. Screening before age 21 should be avoided because it may lead to unnecessary and harmful evaluation and treatment in women at very low risk of cancer.
• Cervical cytology screening is recommended every 2 years for women between the ages of 21 years and 29 years.
• Women aged 30 years and older who have had three consecutive negative cervical cytology screening test results and who have no history of cervical intraepithelial neoplasia (CIN) 2 or CIN 3, are not human immunodeficiency virus (HIV) infected, are not immunocompromised, and were not exposed to diethylstilbestrol in utero may extend the interval between cervical cytology examinations to every 3 years.
• Both liquid-based and conventional methods of cervical cytology are acceptable for screening.
• In women who have had a total hysterectomy for benign indications and have no prior history of high grade CIN, routine cytology testing should be discontinued.
• Co-testing using the combination of cytology plus human papillomavirus (HPV) deoxyribonucleic acid (DNA) testing is an appropriate screening test for women older than 30 years. Any low-risk woman aged 30 years or older who receives negative test results on both cervical cytology screening and HPV DNA testing should be rescreened no sooner than 3 years subsequently.

The following recommendations are based on limited and inconsistent scientific evidence (Level B):

• Sexually active adolescents (i.e., females younger than age 21 years) should be counseled and tested for sexually transmitted infections, and should be counseled regarding safe sex and contraception. These measures may be carried out without cervical cytology and, in the asymptomatic patient without introduction of a speculum.
• Because cervical cancer develops slowly and risk factors decrease with age, it is reasonable to discontinue cervical cancer screening between 65 years and 70 years of age in women who have three or more negative cytology test results in a row and no abnormal test results in the past 10 years.
• Women treated in the past for CIN 2, CIN 3, or cancer remain at risk for persistent or recurrent disease for at least 20 years after treatment and after initial post-treatment surveillance, and should continue to have annual screening for at least 20 years.
• Women who have had a hysterectomy with removal of the cervix and have a history of CIN 2 or CIN 3—or in whom a negative history cannot be documented—should continue to be screened even after their period of posttreatment surveillance. Whereas the screening interval may then be extended, there are no good data to support or refute discontinuing screening in this population.

The following recommendations are based primarily on consensus and expert opinion (Level C):

• Regardless of the frequency of cervical cytology screening, physicians also should inform their patients that annual gynecologic examinations may still be appropriate even if cervical cytology is not performed at each visit.
• Women who have been immunized against HPV-16 and HPV-18 should be screened by the same regimen as nonimmunized women.

Definitions:

Grades of Evidence

I: Evidence obtained from at least one properly designed randomized controlled trial.

II-1: Evidence obtained from well-designed controlled trials without randomization.

II-2: Evidence obtained from well-designed cohort or case–control analytic studies, preferably from more than one center or research group.

II-3: Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments also could be regarded as this type of evidence.

III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

Levels of Recommendations

Level A - Recommendations are based on good and consistent scientific evidence.

Level B - Recommendations are based on limited or inconsistent scientific evidence.

Level C - Recommendations are based primarily on consensus and expert opinion.

None provided

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

When cervical cytology screening programs have been introduced into communities, marked reductions in cervical cancer incidence have followed.

These guidelines should not be construed as dictating an exclusive course of treatment or procedure. Variations in practice may be warranted based on the needs of the individual patient, resources, and limitations unique to the institution or type of practice.

An implementation strategy was not provided.

Not applicable: The guideline was not adapted from another source.

American College of Obstetricians and Gynecologists (ACOG)

American College of Obstetricians and Gynecologists (ACOG) Committee on Practice Bulletins-Gynecology

American College of Obstetricians and Gynecologists (ACOG) committees are created or abolished and their overall function defined by the Executive Board. Appointments are made for one year, with the understanding that such appointment may be continued for a total of three years. The majority of committee members are Fellows, but Junior Fellows also are eligible for appointment. Some committees may have representatives from other organizations when this is particularly appropriate to committee activities. The president elect appoints committee members annually.

Not stated

This is the current release of the guideline.

Electronic copies: None available

Print copies: Available for purchase from the American College of Obstetricians and Gynecologists (ACOG) Distribution Center, PO Box 933104 Atlanta, GA, 31193-3104; telephone, 800-762-2264, ext. 192; e-mail: sales@acog.org. The ACOG Bookstore is available online at the ACOG Web site .

A proposed performance measure is provided in the original guideline document.

The following are available:

• Cancer of the cervix. Atlanta (GA): American College of Obstetricians and Gynecologists (ACOG); 2004. Electronic copies: Available from the American College of Obstetricians and Gynecologists (ACOG) Web site . Copies are also available in Spanish .
• Understanding abnormal Pap test results. Atlanta (GA): American College of Obstetricians and Gynecologists (ACOG); 2009. Electronic copies: Available from the American College of Obstetricians and Gynecologists (ACOG) Web site . Copies are also available in Spanish .
• Human papillomavirus infection. Atlanta (GA): American College of Obstetricians and Gynecologists (ACOG); 2006. Electronic copies: Available from the American College of Obstetricians and Gynecologists (ACOG) Web site . Copies are also available in Spanish .

Print copies: Available for purchase from the American College of Obstetricians and Gynecologists (ACOG) Distribution Center, PO Box 933104 Atlanta, GA, 31193-3104; telephone, 800-762-2264, ext. 192; e-mail: sales@acog.org. The ACOG Bookstore is available online at the ACOG Web site .

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

This NGC summary was completed by ECRI Institute on October 12, 2007. The information was verified by the guideline developer on December 3, 2007. This NGC summary was updated by ECRI Institute on January 21, 2010. The information was verified by the guideline developer on February 18, 2010.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.