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 Table of Contents  
REVIEW ARTICLE
Year : 2020  |  Volume : 33  |  Issue : 1  |  Page : 1-4

Evidence base for cervical cancer screening and prevention among average-risk women in family practice


1 Department of Family Medicine, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Family Medicine at Ministry of Health, Barheem Health Unit, Menoufia, Egypt

Date of Submission18-Oct-2015
Date of Decision27-Oct-2015
Date of Acceptance02-Nov-2015
Date of Web Publication25-Mar-2020

Correspondence Address:
Samah M. A El Galil Ebied
Menouf City, Elmonfiya Governorate
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_418_15

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  Abstract 

Objective
The aim was to perform a systematic review to identify and summarize evidence base for cervical cancer screening in asymptomatic women who were aged 21 years or older attending family practice.
Materials and methods
Medline, articles in Medscape, American Academy of Family Physicians, and PubMed were searched. Data were collected from April 1, 2015 till August 1, 2015. The initial search presented 150 articles. The researches which met the inclusion criteria were 24 articles. The articles included screening modalities for cervical cancer in asymptomatic women who were aged 21 years or older attending family practice. If the studies did not fulfill the inclusion criteria, they were excluded. Study quality assessment included whether ethical approval was gained, eligibility criteria specified, appropriate controls, adequate information, and assessment measures defined. Comparisons were made by a structured review with the results tabulated.
Recent findings
Total 24 potentially relevant publications were included. All relevant studies stated that screening should start at 21 years, mean age (±3) till 65 years (grade A recommendation). Regarding the screening test, all studies recommended cervical cytology (pap test) with a 3-year screening interval (grade A recommendation). All studies recommended screening with a combination of cytology and human papillomavirus (HPV)(co-testing) every 5 years for women in the age group of 30–65 years who want to lengthen the screening interval (grade A recommendation). All studies recommended against using HPV testing as a primary screening method or under 30 years. Regarding vaccination two studies suggest HPV vaccine for cervical cancer prevention.
Conclusion
Screening for cervical cancer is recommended from 21 to 65 years old with cytology (Pap) test with a 3-year screening interval. Women 30 years and older who want to lengthen the screening interval are screened by cytology plus HPV (co-testing) every 5 years.

Keywords: cervical cancer, evidence base, prevention, screening


How to cite this article:
Shaheen HM, El Galil Ebied SM. Evidence base for cervical cancer screening and prevention among average-risk women in family practice. Menoufia Med J 2020;33:1-4

How to cite this URL:
Shaheen HM, El Galil Ebied SM. Evidence base for cervical cancer screening and prevention among average-risk women in family practice. Menoufia Med J [serial online] 2020 [cited 2020 Jul 15];33:1-4. Available from: http://www.mmj.eg.net/text.asp?2020/33/1/1/281306




  Introduction Top


Cervical cancer is still the third most common cancer among women worldwide[1]. The frequency varies considerably between developed and developing countries. Cervical cancer is the second most common cancer in developing countries, only the tenth most common in developed countries. Similarly, cervical cancer is the second most common cause of cancer-related deaths in women in developing countries but is not even among the top 10 causes in developed countries[2]. Cytological examination of exfoliated cells from the cervix (the Papanicolaou or Pap test) is still the most widely used test primarily focused on identifying very early neoplastic changes[3]. The discovery that infection with high-risk human papillomavirus (HPV) is the primary cause of cervical cancer[4] has been one of the great breakthroughs in cancer research for which Harald Zur Hausen won the Nobel Prize in 2008. It led to the development of vaccines to prevent HPV infection which may ultimately reduce the need for frequent screening and may even eradicate the disease[5]. The recommended age range for and frequency of cervical screening vary internationally but screening usually begins between the ages of 20 and 30 years and is repeated every 3–5 years until the age of 60–65 years[6].


  Materials and Methods Top


The guideline for conducting this review is according to guidance developed by the center for review and dissemination. It is not based on a formal systematic review but instead seeks to assess and collect the screening recommendations based on the best available evidence. This includes systematic reviews and recent guidelines. It focuses on primary screening applied to average-risk women. Average-risk women are defined as those with no history of a precancerous lesion or cervical cancer; those who are not immunocompromised (including being HIV-infected); and those without in-utero exposure to diethylstilbestrol.

Search strategy

Search was performed in several databases. It included Medline, articles in Medscape, American Academy of Family Physicians (AAFP) and PubMed. Data for this search were collected in from April 1, 2015 till August 1, 2015.

Study selection

All researches were independently assessed for inclusion. They were included if they fulfilled the following inclusion criteria:

  1. Focused on screening average risk women
  2. Focused on different modalities for screening and prevention
  3. Published in peer-reviewed journals.


Data extraction

If studies did not fulfill the above criteria they were excluded such as studies focused on precancerous lesions or cervical malignancy and reports without peer-review. Significant data were collected and results were reported on each outcome of interest. Conclusion and comments were made, and the results were tabulated. The analyzed publications were evaluated according to the strength of evidence of the US Preventive Services Task Force (USPSTF) and the AAFP.

US Preventive Services Task Force

The USPSTF grades its recommendations according to one of the five classifications (A, B, C, D, and I), reflecting the strength of evidence and magnitude of net benefit (benefits minus harms):

  1. Grade A: USPSTF recommends the service. There is high certainty that the net benefit is substantial (offer or provide this service)
  2. Grade B: USPSTF recommends the service. There is high certainty that the net benefit is moderate, or there is moderate certainty that the net benefit is moderate to substantial (offer or provide this service)
  3. Grade C: USPSTF recommends against routinely providing the service. There may be considerations that support providing the service in an individual patient, there is at least moderate certainty that the net benefit is small. Offer or provide this service only if other considerations support offering or providing the service in an individual patient.
  4. Grade D: USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits, discourage the use of this service
  5. Grade I: USPSTF statement concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting and the balance of benefits and harms cannot be determined. If the service is offered patients should understand the uncertainty about the balance of benefits and harms.


Quality assessment

The quality of all studies was assessed. Important factors included were study design, ethical approval, evidence of power calculation eligibility criteria, adequate information, and specified assessment measures.

Data synthesis

A structured systematic review was performed with the result tabulated.


  Results Top


Study selection and characteristics

In total, 150 potentially relevant publications were identified; 126 articles were excluded as they did not meet the inclusion criteria [Figure 1]. A total of 24 publications were included in the review as they were deemed eligible by fulfilling the inclusion criteria. The majority of the publications discussed screening recommendations for cervical cancer in average-risk woman with their grading according to the strength of evidence of the USPSTF and the AAFP. Some studies have discussed vaccination against HPV.
Figure 1: Flowchart of study selection.

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Recommendations for cervical cancer screening

The recommended age for screening

Nine relevant studies in this review[7],[8],[9],[10],[11],[12],[13],[14],[15] recommend screening average-risk women from 21 to 65 years (grade A recommendation) [Table 1].
Table 1: Current cervical cancer screening recommendations for average-risk women

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Two another studies differ from the above mentioned; one of them recommends screening from 25 to 69 years[16]; the other one recommends starting screening from 18 to 20 years or 1–2 years after having sex whichever is later and end screening at age 69 years[17].

The screening test and screening intervals

Nine relevant studies in this review[7],[8],[9],[10],[11],[12],[13],[14],[15] recommend screening average-risk women from 21 to 65 years by cervical cytology (Pap) test as a primary screening test every 3 years (grade A recommendation). The same studies[7],[8],[9],[10],[11],[12],[13],[14],[15] recommend screening average-risk women by cervical cytology (Pap) test plus HPV testing in women 30 or older every 5 years to women who want to lengthen the screening intervals (grade A recommendation). These studies also recommend against HPV testing under 30 years either as primary or co-testing (grade: D recommendation). In two studies[16],[17] there is no recommendations about HPV testing. In one study[17] the screening interval for cytology (Pap) testing is 2 years. Two studies[18],[19] support primary HPV testing as a reasonable screening method and consider adopting HPV testing as the primary screening test for women 30 years of age and older.

Recommendations against screening

All relevant publications in this review recommend against screening women older than age 65 years, who had adequate prior screening (have had two consecutive negative cytology results or two consecutive negative cytology plus HPV test results within 10 years with the most recent test performed within 5 years) and are not otherwise at high risk for cervical cancer, women who have had a hysterectomy with removal of the cervix and who do not have a history of a high-grade precancerous lesion [cervical intraepithelial neoplasia (CIN) grade 2 or 3] or cervical cancer (grade D recommendation).

Recommended immunization against human papillomavirus

The following two HPV vaccines are approved by the FDA:

  1. Gardasil (Merck, Whitehouse Station, New Jersey, USA): this quadrivalent vaccine is approved for girls and women 9–26 years of age to prevent cervical cancer (and also genital warts and anal cancer) caused by HPV types 6, 11, 16, and 18; it is also approved for men 9–26 years of age[20]
  2. Cervarix (GlaxoSmithKline, Research Triangle Park, North Carolina, USA): this bivalent vaccine is approved for girls and women 9–25 years of age to prevent cervical cancer caused by HPV types 16 and 18[21].



  Discussion Top


According to Sasieni et al.[7], the purpose of cervical screening is to reduce the risk of cervical cancer through the detection of lesions that have the potential to become invasive cervical cancer. A secondary aim is to reduce the risk of advanced cancer through the detection of asymptomatic or early-stage cancer. Vesco et al.[8] reported that cervical cancer is believed to be the long-delayed consequence of infection with high-risk (or oncogenic) types of HPV. Sawaya et al.[9] added that persistent high-risk HPV infection can lead to cervical precancerous lesions known as CIN which can become invasive. Identification and treatment of CIN lesions through screening lead to reductions in cervical cancer incidence, morbidity, and mortality.

Qaseem et al.[15] stated that cervical cancer screening has traditionally used the Pap smear (conventional or liquid-based cytology). More recently, cytology has been supplemented by HPV testing. Samples for these tests may be taken during a pelvic examination along with visual inspection of the cervix but pelvic examination itself is not part of the screening process for cervical cancer. Munoz et al.[22] have reported that the recognition of the etiologic role of HPV infection in cervical cancer has led to the recommendation of adding HPV testing to the screening regimen in women of 30–65 years of age[22]. The World WHO International Agency for Research on Cancer Monograph Working Group has grouped HPV types of the mucosotropic alpha genus according to the evidence supporting their association with cervical cancer[23]. Although current guidelines advise against performing HPV testing in women younger than 30 years of age and do not recommend HPV testing alone for primary cervical cancer screening, a growing body of evidence calls these recommendations into question. In April 2015, a panel of experts that included representatives from seven relevant organizations issued interim guidance that supports primary HPV testing as a reasonable technique for cervical cancer screening[18]. Organized screening programs in higher resource settings should consider adopting HPV testing as the primary screening test for women 30 or 35 years of age and older[19]. Evidence suggests that HPV vaccines prevent HPV infection[21]. Women who have been vaccinated against HPV should still follow the screening recommendations for their age group[17].


  Conclusion and Recommendation Top


The evidence available in this review is a distillation of relevant publications including systematic reviews used to support current international guidelines. It supports regular and continuous cervical screening to reduce the incidence of invasive cervical cancer and cervical cancer mortality. These recommendations should be added to the National Egyptian Guidelines for family physicians.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
World Health Organization. International Agency for Research on Cancer, GLOBOCAN: estimated cancer incidence, mortality, prevalence and disability adjusted life years (DALYs) worldwide, 2008. Available at: http://globocan.iarc.fr. [Last accessed on 2010 May 01].  Back to cited text no. 1
    
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Jemal A, Bray F, Center MM, Ferlay J, Ward E, Forman D. Global cancer statistics. CA Cancer J Clin 2011; 61:69–90.  Back to cited text no. 2
    
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Jordan J, Martin-Hirsch P, Arbyn M, Schenck U, Baldauf JJ, Da Silva D, Prendiville W. European guidelines for clinical management of abnormal cervical cytology, part 2. Cytopathology 2009; 20:5–16.  Back to cited text no. 3
    
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Walboomers JM, Jacobs MV, Manos MM, Bosch FX, Kummer JA, Shah KV, Muñoz N. Human papillomavirus is a necessary cause of invasive cervical cancer worldwide. J Pathol 1999; 189:12–19.  Back to cited text no. 4
    
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Harper DM, Franco EL, Wheeler CM, Moscicki AB, Romanowski B, Roteli-Martins CM. HPV Vaccine Study Group. Sustained efficacy up to 4.5 years of a bivalent L1 virus-like particle vaccine against human papillomavirus types 16 and 18:Follow-up from a randomised control trial. Lancet 2006; 367:1247–1255.  Back to cited text no. 5
    
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International Cancer Screening Network. Organization of cervical cancer screening programs in 20 ICSN countries (2008). Available at: http://appliedresearch.cancer.gov/icsn/cervical/screening.html. [Last accessed on 2018 May 01].  Back to cited text no. 6
    
7.
Sasieni P, Castanon A, Cuzick J. What is the right age for cervical cancer screening? Womens Health 2010; 6:1–4.  Back to cited text no. 7
    
8.
Vesco KK, Whitlock EP, Eder M, Burda BU, Senger CA, Holmes RS, et al. Screening for cervical cancer: a systematic evidence review for the US Preventive Services Task Force (2011). Evidence synthesis no. 86. AHRQ Agency for Healthcare Research and Quality  Back to cited text no. 8
    
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Sawaya GF, Kulasingam S, Denberg T, Qaseem A. Cervical cancer screening in average-risk women: best practice advice from the Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med 2015; 162:851–859.  Back to cited text no. 9
    
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American Academy of Family Physicians. Cervical Cancer. 2012. Available at: http://www.aafp.org/online/en/home/clinical/exam/cervicalcancer.html. [Last accessed on 2012 Oct 10].  Back to cited text no. 10
    
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Smith RA, Brooks D, Cokkinides V, Salsow D, Brawley OW. Cancer screening in the United States, 2013: a review of current American Cancer Society guidelines, current issues in cancer screening, and new guidance on cervical cancer screening and lung cancer screening. CA Cancer J Clin 2013; 63:87–105.  Back to cited text no. 11
    
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Saslow D, Solomon D, Lawson HW, Killackey, Kulasingam S, Cain J, et al. ACS-ASCCP-ASCP Cervical Cancer Guideline Committee. American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer. CA Cancer J Clin 2012; 62:147–172.  Back to cited text no. 12
    
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Committee on Practice Bulletins—Gynecology. ACOG Practice Bulletin Number 131: screening for cervical cancer. Obstet Gynecol 2012; 120:1222–1238.  Back to cited text no. 13
    
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Moyer VA. U.S. Preventive Services Task Force. Screening for cervical cancer: US Preventive Services Task Force recommendation statement. Ann Intern Med 2012; 156:880–891.  Back to cited text no. 14
    
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Qaseem A, Humphrey LL, Harris R, Starkey M, Denberg TD. Screening pelvic examination in adult women: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2014; 161:67–72.  Back to cited text no. 15
    
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Dickinson J, Tsakonas E, Conner Gorber S, Lewin G, Shaw E, Singh H, et al. CMAJ, Recommendations on screening for cervical cancer. Canadian Medical Association Journal 2013; 185:35–45. doi: 10.1503/cmaj.121505.   Back to cited text no. 16
    
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Department of Health and Ageing. National cervical screening program. Canberra: Australian Government; 2011.  Back to cited text no. 17
    
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Huh WK, Ault KA, Chelmow D, Davey DD, Goulart RA, Garcia FA, et al. Use of primary high-risk human papillomavirus testing for cervical cancer screening: interim clinical guidance. J Low Genit Tract Dis 2015; 19:91–96.  Back to cited text no. 18
    
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Murphy J, Kennedy EB, Dunn S, McLachlin CM, Kee Fung MF, Gzik D, et al. HPV testing in primary cervical screening: a systematic review and meta-analysis. J Obstet Gynaecol Can 2012; 34:443–452.  Back to cited text no. 19
    
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CDC. FDA licensure of bivalent human papillomavirus vaccine (HPV2, Cervarix) for use in females and updated HPV vaccination recommendations from the Advisory Committee on Immunization Practices (ACIP). Centers for Disease Control and Prevention 1600 Clifton Road Atlanta, GA 30329-4027: USA; 2010; 59:626–629.  Back to cited text no. 21
    
22.
Muñoz N, Kjaer SK, Sigurdsson K, Iversen OE, Hernandez-Avila M, Wheeler CM, et al. Impact of human papillomavirus (HPV)-6/11/16/18 vaccine on all HPV-associated genital diseases in young women. J Natl Cancer Inst 2010; 102:325–339.  Back to cited text no. 22
    
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