A cross-sectional study of more than 5000 cytology tests among women older than 50 years found that identification of vaginal intraepithelial neoplasia and cancer was rare in this age group after hysterectomy. 63 In a second study of more than 10,000 Pap tests performed over 2 years in 6265 women who had a hysterectomy with removal of the cervix, screening yielded 104 abnormal Pap test results and no cases of cervical cancer; in addition, 6 cases of high-grade vaginal lesions were detected, but it is not known whether detection of these cases improved clinical outcomes. 64
Harms of Screening
Screening with cervical cytology and hrHPV testing can lead to harms, including more frequent follow-up testing and invasive diagnostic procedures (eg, colposcopy and cervical biopsy), as well as unnecessary treatment in women with false-positive results. Evidence from RCTs and observational studies indicate that harms from diagnostic procedures include vaginal bleeding, pain, infection, and failure to diagnose (due to inadequate sampling). Abnormal screening test results are also associated with psychological harms. In particular, women who received positive hrHPV results reported greater distress and lower satisfaction with past and current sexual partners than women who received abnormal cytology results.
The USPSTF found adequate evidence that the harms of hrHPV testing alone in women aged 21 to 29 years are moderate. Primary hrHPV testing has been found to result in high rates of positive tests in this age group, in which HPV infections are likely to resolve spontaneously. The high frequency of transient HPV infection among women younger than 30 years can lead to unnecessary follow-up diagnostic and treatment interventions with potential for harm.
The USPSTF found adequate evidence that the harms of screening for cervical cancer (with cytology alone, hrHPV testing alone, or cotesting with both) in women aged 30 to 65 years are moderate. Screening strategies that include hrHPV testing are slightly more sensitive than those that include cytology alone but also yield more false-positive results. Cotesting is also slightly more sensitive than cytology alone but leads to the highest false-positive rates.
The USPSTF found adequate evidence that the harms of screening for cervical cancer in women older than 65 years who have had adequate prior screening and are not otherwise at high risk are at least small. The USPSTF also found adequate evidence that the harms of screening for cervical cancer in women younger than 21 years are moderate.
The USPSTF found adequate evidence that screening for cervical cancer in women who have had a hysterectomy with removal of the cervix and do not have a history of a high-grade precancerous lesion or cervical cancer is associated with harms.
Harms of Treatment
The harms of treatment include risks from the treatment procedure and the potential subsequent consequences of treatment. Evidence from observational studies indicates that certain treatments for precancerous lesions (eg, cold-knife conization and loop excision) are associated with subsequent adverse pregnancy outcomes, such as preterm delivery and related complications. 2 The USPSTF found convincing evidence that many precancerous cervical lesions will regress and that other lesions are indolent, slow growing, and will not become clinically important over a woman’s lifetime; identification and treatment of these lesions constitute overdiagnosis. Estimating the precise magnitude of overdiagnosis associated with any screening or treatment strategy is difficult, but it is of concern because it confers no benefit and leads to unnecessary surveillance, diagnostic tests, and treatments, with associated harms.
Estimate of Magnitude of Net Benefit
There is convincing evidence that screening with cervical cytology alone, primary hrHPV testing alone, or cotesting can detect high-grade precancerous cervical lesions and cervical cancer. The USPSTF found convincing evidence that screening women aged 21 to 65 years substantially reduces cervical cancer incidence and mortality. The USPSTF found adequate evidence that the harms of screening for cervical cancer (with cytology alone, hrHPV testing alone, or cotesting with both) in women aged 30 to 65 years are moderate. The USPSTF concludes with high certainty that the benefits of screening every 3 years with cytology alone in women aged 21 to 29 years substantially outweigh the harms. The USPSTF concludes with high certainty that the benefits of screening every 3 years with cytology alone, french dating sites every 5 years with hrHPV testing alone, or every 5 years with both in combination in women aged 30 to 65 years outweigh the harms.
