Cervical Cancer—Clinician Summary
POPULATION
Asymptomatic women who are or who have been sexually active. These guidelines do not apply to women with symptoms of cervical cancer (e.g. abnormal vaginal bleeding), previous abnormal screening results (until they have been cleared to resume normal screening), to women who do not have a cervix (due to hysterectomy), or to women who are immunosuppressed.
BURDEN OF ILLNESS
In 2011, the estimated incidence of cervical cancer in Canada was approximately 1,300 new cases while approximately 350 women die each year in Canada from cervical cancer. The incidence of cervical cancer increases significantly after the age of 25 years and peaks during the fifth decade, thus affecting women in their reproductive and productive years.
INTERVENTION: SCREENING FOR CERVICAL CANCER WITH CERVICAL CYTOLOGY
| Recommendation | Strength of recommendation | Basis of recommendation |
|---|---|---|
| For women under age 20 we recommend not routinely screening for cervical cancer | Strong recommendation; high quality evidence | There is very low incidence and no mortality from cervical cancer in this age group, no evidence of the effectiveness of screening and evidence of harms. |
| For women aged 20 to 24 we recommend not routinely screening for cervical cancer | Weak recommendation; moderate quality evidence | There is uncertain benefit of screening in this age group, as well as low incidence of cervical cancer and mortality, combined with higher false positive rates among women under 30 years of age, with consequent harms and unnecessary treatments. |
| For women aged 25 to 29 we recommend routine cytology screening for cervical cancer every 3 years | Weak recommendation; moderate quality evidence | A relatively low value is placed on the small benefit of screening. There is concern about the higher rate of false positives in women under 30, and the estimated harms of over treatment. This recommendation reflects concern for the increasing incidence and mortality of cervical cancer in this group. |
| For women aged 30 to 69 we recommend routine cytology screening for cervical cancer every 3 years | Strong recommendation; high quality evidence | A high value is placed on the evidence for the effectiveness of screening, increased cervical cancer incidence and mortality in this age group, and on the lower rates of potential harms estimated for this age group compared with younger women. |
| For women aged 70 and over who have been adequately screened, we recommend that routine screening may cease | Weak recommendation; low quality evidence | A relatively high value is placed on the limited evidence for screening effectiveness, and on the potential to detect and treat persisting high rates of cervical cancer in this age group. |
| For women aged 70 or over who have not been adequately screened (i.e. 3 successive negative Pap tests in last 10 years) we recommend continued screening every 3 years until this is achieved | Weak recommendation; low quality evidence | A relatively high value is placed on the limited evidence for screening effectiveness, and on the potential to detect and treat persisting high rates of cervical cancer in this age group. |
DETAILS OF RECOMMENDED SERVICE
For women aged 25 and over, we recommend triennial screening with a Pap test by a primary care practitioner. Although some evidence suggests that HPV—DNA testing may be appropriate for reducing incidence and mortality from cervical cancer, recommendations on HPV screening will be made when more research is available.
CONSIDERATIONS FOR IMPLEMENTATION
Consider using an electronic health record to flag a screening reminder for women aged 25 or 30 and over.
SPECIAL CONSIDERATION
Screening rates in Aboriginal women are increasing. New immigrants may be less likely to be screened. Women from certain ethnic and sociocultural groups may prefer to be screened by a female health care practitioner. Attention needs to be paid to increasing screening rates of these under screened populations.