In 2020, the American Cancer Society (ACS) issued an updated set of guidelines for cervical cancer screening, emphasizing the shift toward screening with primary human papillomavirus (HPV) testing. While the ACS recommendation accounts for a transition period to implement primary HPV screening, additional factors should be considered to operationalize these guidelines, according to a special white paper in the July issue of the Journal of Lower Genital Tract Disease (JLGTD), official journal of the American Society for Colposcopy and Cervical Pathology (ASCCP). The journal is published in the Lippincott portfolio by Wolters Kluwer.
In the article, the ASCCP Cervical Cancer Screening Task Force voices its support for the ACS’s 2020 cervical cancer screening guidelines, which include “a strong recommendation to screen with primary HPV testing.” Meanwhile, the ASCCP Task Force reserves its full endorsement for the 2018 US Preventive Services Task Force (USPSTF) recommendations, which provide greater flexibility as the US healthcare system shifts to more widespread use of primary HPV screening. Jenna Z. Marcus, MD, of Rutgers New Jersey Medical School and Cancer Institute of New Jersey, Newark, is lead author of the ASCCP Task Force white paper.
Endorsing All Cervical Cancer Screening
Coauthor Patty Cason, MS, FNP-BC notes, “Since HPV causes the vast majority of cervical cancers, testing for HPV as the primary screening test is a more effective approach to screening than cervical cytology (Pap testing).” With this approach, a cervical swab is used to test for the presence of high-risk HPV strains responsible for virtually all cervical cancers. In its 2020 guideline update, the ACS recommends the HPV test alone (primary HPV screening), for people with a cervix, beginning at age 25 and continuing through age 65.
At the current time, many patients receive care at sites where FDA-approved tests for primary HPV screening are not yet available, so this screening approach is not yet accessible to all patients. The ACS states that when FDA-approved tests for primary HPV screening are not available at a given health center, other options – co-testing with both HPV testing and cervical cytology, and cervical cytology alone – are “acceptable” alternative strategies. The ACS also suggests that these methods may be excluded from future guideline updates.
The Task Force acknowledges the benefits of primary HPV screening. “The ASCCP recognizes the need to transition to primary HPV screening and acknowledges that logistical considerations surrounding implementation, the impact of limited HPV vaccination in the United States, and inclusion of populations who may be marginalized are necessary and must be prioritized.”
However, during this transition period, a flexible approach is needed to ensure maximum availability of screening. For that reason, the ASCCP Task Force endorses the 2018 USPSTF cervical cancer screening recommendations, which include “all screening modalities.” The USPSTF statement provides “flexibility that may benefit those who are marginalized, underinsured, or experiencing inequity and health disparities.” Through its endorsement of the 2018 USPSTF guidelines, that document is considered official ASCCP clinical guidance.
ASCCP assesses guidance from other organizations according to its Guidelines Endorsement Policy, which has three levels: endorsement, support, and comment. Endorsement indicates endorsement of a peer organization’s clinical document and denotes that ASCCP fully supports the clinical guidance. Support of a peer organization’s clinical document denotes that ASCCP deems the document to be of educational value to its members, although ASCCP may not agree with every recommendation or statement in the document. Comments to a peer organization’s clinical document denotes that ASCCP does not agree with the recommendation, and feels the need to formally voice that opinion through public comment. In announcing its support for the 2020 ACS guidelines, The ASCCP recognizes the need to transition to primary HPV screening and acknowledges that logistical considerations surrounding implementation, the impact of limited HPV vaccination in the United States, and inclusion of populations who may be marginalized are necessary and must be prioritized.
The Task Force emphasizes the need for “sound and conservative clinical judgment” when applying the guidelines to the individual patient’s situation. The authors conclude: “Most importantly, the ASCCP endorses any cervical cancer screening for secondary prevention of cervical cancer and recommends interventions that improve screening for those who are underscreened or unscreened.”