January is Cervical Cancer Awareness month, and I love educating women on cervical cancer prevention and screening. Because of my experience caring for cervical cancer patients, I am even more charged to make sure my patients and women in our community are adequately screened. I’ve seen firsthand what cervical cancer looks like, how it effects women, and what treatment entails.
What is cervical cancer?

The cervix is the lower segment of the uterus, and it lives at the top of the vagina. It’s where menstrual blood escapes the uterus and into the vagina and the cervical os which is the opening that dilates for the baby passes through during vaginal deliveries. A women’s health clinician can see the cervix by looking inside the vagina with a speculum, but we can’t necessarily see the uterus. Most cases of cervical cancer, like 99%, caused by human papilloma virus (HPV). There are many types of HPV, but not all types of HPV cause cervical cancer. Low-risk HPV does not cause cervical cancer but can cause genital warts. High-risk HPV can cause cervical dysplasia (pre-cancer) and cervical cancer. The high risk types are 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, and 59. Types 16 and 18 cause over 70% of cervical cancers, so those are thought to be the most significant.
The American Cancer Society estimates that in 2024 about 13,820 new cases of cervical cancer will be identified and about 4,360 women will die from cervical cancer. It is the 4th most common cause of cancer in women worldwide. Cervical cancer is most frequently diagnosed in women between ages 35 and 44, but more than 20% of cervical cancer cases are found in women over age 65. This is likely due to inadequacy of screening as women get older.

Risk factors
According to the World Health Organization, women living with HIV are 6 times more likely to develop cervical cancer compared to women living without HIV. This has to do deficiency in immune response. Smoking is also a risk factor for cervical cancer, and women who smoke are twice as likely to get cervical cancer. Tobacco byproducts have been found in cervical mucous, and this may be the reason for increased cervical cancer rates in smokers. Other risk factors include having a weakened immune system, long term steroid use, chlamydia infection, and increased sexual partners.

Prevention
There are two main ways to prevent cervical cancer outside of reducing risk factors. These ways are through HPV vaccination and Pap tests. I will make a blog post about the HPV vaccine at a later date, so we can focus on Pap tests here. However, I will say, that currently the HPV vaccine is the only vaccine we have available that prevents cancer. How does Pap tests prevent cancer? Will it picks up on precancerous changes, which leads to treatment of those precancerous changes so that an invasive cancer does not develop. I will note here that early stage cervical cancer is very much treatable, and the 5 year survival of the earliest cervical cancer is 99%.
If you’ve had the full HPV vaccination series, you still need Pap tests!

What is a Pap test?
A Pap test, used to be called a Pap smear, is a test that takes a sample of cells from the cervix. Those cells are looked at under a microscope to see if they look normal or abnormal. There’s a grading scale of ASCUS, LSIL, HSL, ASC-H, and AGUS. You don’t need to worry about what all these mean, but these different categories help your clinician determine your risk of cervical cancer and what to do next. This is the type of test we’ve used to screen for cervical cancer for many years!

What is an HPV test?
An HPV test is exactly that – tests for the presence or absence of HPV. We can take it a step further and determine the genotype of HPV, if present, which will be of benefit because then your clinician can more accurately determine your risk for cervical cancer. For example, we know that low risk HPV such as 6 and 11 do not cause cervical cancer and that high risk HPV such as 16 and 18 do cause cervical cancer. Therefore it is important to know which genotype your HPV infection is.
What is a co-test?

A co-test is a Pap test AND an HPV test. Together using what the cells look like AND the presence or absence of HPV.

How do I know which test I need? How often do I need to be screened?
Well, my favorite answer in medicine, it depends. The American Society for Colposcopy and Cervical Pathology (ASCCP) has updated it’s Pap guidelines several times over the last several years – 2006, 2012, and most recently in 2019. Interestingly, the 2019 risk-based guidelines were really put into existence right before the pandemic. Unfortunately, at the beginning of the pandemic a lot of preventative health was put on hold as we navigated this new and uncertain pandemic. In 2019, these guidelines were based on RISK not based on an algorithm, as they were in the past. They said this:

• No Pap tests before age 21.
• Starting at age 21 and until age 29, Pap test only no HPV test every 3 years.
• Starting at age 30 and until age 65, Pap test plus HPV test (co-test) every 1-5 years.
• The frequency of Pap tests is based on risk stratification, and your clinician will be able to tell you whether repeat Pap is needed at 1, 3, or 5 years based on your current and prior Pap test results.

In 2020, the American Cancer Society updated their guidelines and these differ from ASCCP. They say:
• Begin cervical cancer screening at age 25 with HPV test only every 5 years.
• If HPV only testing is not available, it’s okay to follow the above guidelines from ASCCP.

Um, so what does this mean for me?
I agree that Pap test frequency and type is kind of confusing. So much so that I have given many talks to peers and other professional organizations breaking this down so that clinicians feel confident on how and when to order and how to interpret the results. I recommend working with your women’s health clinician every year at minimum. Every woman should have an Annual Physical that includes talking about disease prevention, including cervical cancer as well as addressing any concerns she may have about her health.

What about home cervical cancer tests?
Self-swabbing for HPV was my masters project in PA school! This has been around for many years, and it is used in other countries to help improve access and compliance with cervical cancer screening. While I do see the value in increasing the number of women that can be screened, I do feel it has some downfalls. The HPV tests that we use in the clinic are held to a high standard for sensitivity and specificity, meaning not giving too many false negatives or false positives. Are these direct-to-consumer tests held to the same standard? At this time, I do not know the answer to this question.

Also, when an HPV test or Pap test is collected in the clinic, it is done under direct visualization of the cervix. That serves two purposes. One, we are taking the sample from the cervix directly. Two, we are looking at the cervix and can note any visual abnormalities. Sometimes visual inspection during exam leads to further workup and diagnosis. It makes me a little nervous when we are removing this important part of the clinical evaluation process.

Lastly, if someone has a positive home HPV test, what does the follow up look like? Will she get triaged from the direct-to-consumer company? Will someone be following up to make sure she follows through?

It is my dream that everyone has access to a trusted women’s health clinician, for her to be able to talk about adequate cervical cancer screening, and can form a trusted relationship so that when sexual concerns arise there is a professional they are able to discuss with.

I had a hysterectomy, do I need a Pap test?
Again – it depends! If you had a hysterectomy, you do not need a cervical cancer screening if the following is true for you:
• You had a hysterectomy for any reason other than for
• They removed your cervix at the time of hysterectomy.

If you had a hysterectomy and one of the following applies to you, then you still need cervical cancer screening!
• You had a supra-cervical hysterectomy, meaning they left your cervix in place at the time of your hysterectomy.
• You had a hysterectomy for due to high risk pre-cancerous cells on the cervix. If this is the case, you will need to have cervical cancer screening for 20 years after surgery.

I hope this shed some light and insight on the nuances of cervical cancer screening. It is my hope that every woman has a trusted healthcare provider to partner with to navigate this!

Resources
1. Cervical Cancer, American Cancer Society – https://www.cancer.org/cancer/types/cervical-cancer.html
2. Cervical Cancer, World Health Organization – https://www.who.int/news-room/fact-sheets/detail/cervical-cancer
3. Cervical Cancer Screening, American College of Obstetrics and Gynecology – https://www.acog.org/womens-health/faqs/cervical-cancer-screening