Human Papillomavirus (HPV) Testing - Cervical Cancer Screening

Human papillomavirus (HPV) is the most common sexually transmitted viral infection and is the etiologic agent for most cases of cervical cancer. High-risk HPV genotypes are also associated with an increased risk of developing vulvar, vaginal, anal, penile, and oropharyngeal cancer. Most cases of HPV clear within 1-2 years.  The American Cancer Society (ACS), American Society for Colposcopy and Cervical Pathology (ASCCP), and the American Society for Clinical Pathology (ASCP) jointly recommend an age-based approach to cervical cancer screening; the ACS issued its own recommendations in 2020.  Testing options vary depending on the individual’s age but include cytology, cotesting, and primary HPV testing. There is no routinely recommended screening test for other HPV-related cancers.

Quick Answers for Clinicians

At what age should individuals with a cervix begin to have screening for cervical cancer? At what age should screening end?

Cervical cytologic abnormalities are common in individuals younger than 21 years, yet clinically important cervical lesions are rare. To minimize the need for subsequent follow-up by colposcopy and biopsy, the American Society for Colposcopy and Cervical Pathology (ASCCP) recommends screening beginning at 21 years,    whereas updated American Cancer Society guidelines  recommend screening beginning at 25 years for average-risk individuals. In the United States, guideline-issuing organizations recommend screening be discontinued in individuals 65 years and older with a cervix if they are up to date on testing and have normal results.    , 

How often should individuals with a cervix be screened for cervical cancer?

Recommended screening intervals are based on age and clinical history, as set forth by the joint American Cancer Society (ACS)/American Society for Colposcopy and Cervical Pathology (ASCCP)/American Society for Clinical Pathology (ASCP) guideline and the updated ACS guideline released in 2020. -  The 2020 ACS guideline states that primary human papillomavirus (HPV) testing is appropriate every 5 years for individuals 25-65 years of age with a cervix and at average risk; more frequent testing is recommended if an alternative test is used.  Other acceptable screening options include cotesting every 5 years or cytology alone every 3 years.

Is it appropriate to screen for cervical cancer with human papillomavirus testing alone?

In January 2015, the Society of Gynecologic Oncology (SGO) and the American Society for Colposcopy and Cervical Pathology (ASCCP), motivated by the U.S. Food and Drug Administration (FDA) approval of the Roche cobas human papillomavirus (HPV) test as a primary test for cervical cancer screening, issued interim clinical guidance suggesting that FDA-approved primary HPV testing can be considered as an alternative to cytology-based cancer screening methods in individuals 25 years and older with a cervix. The drafting of the interim guidance was informed by 11 other expert representatives from organizations such as the American Cancer Society (ACS), and the guidance was endorsed by the American College of Obstetricians and Gynecologists (ACOG) and the U.S. Preventive Services Task Force (USPSTF).     In July 2020, the ACS updated its guidelines to state that FDA-approved primary HPV testing is the preferred screening test in individuals 25-65 years of age with a cervix. 

What is the difference between a primary human papillomavirus test and the human papillomavirus tests used in cotesting?

Primary human papillomavirus (HPV) tests are intended to detect high-risk HPV genotypes (including types 16 and 18) in cervical samples. Primary HPV tests are FDA approved for HPV screening. The HPV tests used in cotesting are meant to be used in conjunction with cytology and do not detect as many HPV genotypes as primary HPV tests. As of July 2020, there are two FDA-approved primary HPV tests for cervical cancer screening.  There are also five HPV tests that are FDA approved for cotesting. 

When is human papillomavirus testing appropriate in individuals without a cervix?

Currently, there is no human papillomavirus (HPV) test recommended for individuals born without a cervix (eg, individuals assigned male at birth), although high-risk HPVs are known to cause cancers of the penis or anus. These cancers are uncommon and only a subset are related to HPV. However, some experts recommend yearly anal cancer screening by cytology ("anal Pap") for men who have sex with men (MSM) and HIV-positive individuals because anal cancer is more common in these populations.  Screening tests are not available for penile cancer. 

What are the clinical implications of a positive result for genotype 18 on a human papillomavirus test that does not distinguish between genotypes 18 and 45?

Human papillomavirus (HPV) types 16 and 18 are the most prevalent and carcinogenic HPV genotypes and account for 55-60% and 10-15% of all cervical cancers, respectively.  Other high-risk genotypes, including 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, and 68, account for a smaller percentage of cervical cancers. Some of these genotypes are difficult to distinguish; for example, genotypes 18 and 45 are very similar (as are genotypes 16 and 31) and are therefore not distinguished by many tests. Because genotype 18 is much more common than type 45, and because of the risks associated with both types 18 and 45, a positive test that cannot distinguish between types 18 and 45 should be treated as a positive for type 18. 

Which societies provide clinical guidance for cervical cancer screening?

Several organizations provide guidelines for the frequency of cervical cancer screening and any required follow-up testing based on the results of that screening. Notably, guidelines are provided by the American Cancer Society (ACS),  the U.S. Preventative Services Task Force (USPSTF),  the American Society for Colposcopy and Cervical Pathology (ASCCP),  and the American College of Obstetricians and Gynecologists (ACOG). 

Indications for Testing

According to the ACS, asymptomatic individuals with a cervix who are 25-65 years of age and at average risk should be routinely screened for cervical cancer, regardless of history or HPV vaccination status. The ASCCP recommends screening beginning at age 21. These recommendations do not apply to individuals who are at increased risk for cervical cancer (eg, individuals with a solid organ or stem cell transplantation, HIV-infected individuals, immunosuppressed individuals, or individuals who were exposed to diethylstilbestrol in utero), who may require earlier or more frequent testing. 

There is no recommendation for routine HPV screening in individuals born without a cervix. 

Laboratory Testing

HPV Testing in Individuals With a Cervix: Cervical Cancer Screening

Screening with cervical cytology and/or testing for multiple oncogenic HPV types can lead to the detection of high-grade precancerous cervical lesions and cervical cancer.   High-risk HPV genotypes are necessary for the development of cervical cancer. HPV types 16 and 18 are the most prevalent and carcinogenic genotypes and account for 55-60% and 10-15% of all cervical cancers, respectively.  There are several additional high-risk HPV genotypes, including 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, and 68. Low-risk HPV types are unrelated to cervical cancer and have no clinical role in cervical cancer screening or the evaluation of individuals with abnormal cytology.

Cotesting is more sensitive than cytology alone for detecting cervical abnormalities and has the potential to improve disease detection and lengthen screening intervals. 

Screening Guidelines by Population

Individuals 21-<25 Years With a Cervix

The ASCCP recommends screening in individuals with a cervix who are 21-<25 years of age and at average risk, although the ACS no longer recommends screening in this population.  Management of individuals who have been tested by cytology depends on results. - 

Individuals 21-<25 Years With a Cervix
Testing Method Results Follow-Up
Cytology Normal cytology Return to routine screening
ASC-US cytology Repeat cytology in 1 yr (preferred) OR reflex to HPV testing
LSIL cytology Repeat cytology in 1 yr (preferred) OR reflex to HPV testing
ASC-US, atypical squamous cells of undetermined significance; LSIL, low-grade squamous intraepithelial lesion
Individuals 25-<30 Years With a Cervix

Interim guidance from the Society of Gynecologic Oncology (SGO)/ASCCP suggests that primary HPV screening can be considered as an alternative to cytology beginning at 25 years of age.  This method of screening should be repeated no more than every 3 years in the event of a normal result.  The U.S. Preventive Services Task Force (USPSTF) and American College of Obstetricians and Gynecologists (ACOG) endorse the recommendation.   In alignment with the recommendation, the ACS 2020 guideline update recommends screening via primary HPV testing every 5 years beginning at age 25 in individuals with a cervix who have average risk.  Cotesting every 5 years or cytology alone every 3 years are acceptable alternatives if primary HPV testing is unavailable. 

Individuals 25-<30 Years With a Cervix
Testing Method Results Follow-Up
Cytology (with or without reflex) Normal cytology Repeat cytology in 3 yrs
ASC-US cytology Repeat cytology in 1 yr OR perform HPV testing (preferred)
  • HPV negative: repeat cotesting at 3 yrs
  • HPV positive: colposcopy; refer to ASCCP algorithms 
LSIL cytology Refer to ASCCP algorithms 
Primary hrHPV testing with genotyping

(ONLY for women ≥25 years)

HPV type 16/18 positive Colposcopy
Positive for any other high-risk HPV genotype Cytology
  • ASC-US: colposcopy
  • NILM: repeat cytology in 1 yr
HPV negative Return to routine screening
NILM, negative for intraepithelial lesion or malignancy
Individuals 30-65 Years With a Cervix

The ASCCP endorses cotesting, as an alternative to cytology alone, in individuals 30-65 years with a cervix . -  The ACS 2020 guideline update endorses screening with FDA-approved primary HPV testing every 5 years in individuals age 25-65 with a cervix.  Cytology alone every 3 years is also an acceptable testing strategy if FDA-approved primary HPV testing is unavailable. 

Individuals 30-65 Years With a Cervix
Testing Method Results Follow-Up
Cotesting Normal cytology and HPV negative Repeat screening of choice at 5 yrs (cytology alone every 3 yrs is acceptable)
ASC-US cytology and HPV negative Repeat cotesting at 3 yrs
Normal cytology and HPV positive

OPTION 1: repeat cotesting in 1 yr

  • HPV negative: repeat cotesting in 3 yrs
  • ASC-US or HPV positive: colposcopy

OPTION 2: HPV DNA typing

  • HPV type 16/18 positive: colposcopy
  • HPV type 16/18 negative: repeat cotesting in 1 yr
ASC-US cytology and HPV positive Colposcopy
LSIL cytology Refer to ASCCP algorithms 
Primary hrHPV testing with genotyping HPV type 16/18 positive Colposcopy
Positive for any other high-risk HPV genotype Cytology
  • ASC-US: colposcopy
  • NILM: repeat cytology in 1 yr
HPV negative Return to routine screening
Cytology (with or without reflex) Normal cytology Repeat cytology in 3 yrs
ASC-US cytology Repeat cytology in 1 yr OR perform HPV testing (preferred)
  • HPV negative: repeat cotesting at 3 yrs
  • HPV positive: colposcopy; refer to ASCCP algorithms 
LSIL cytology Refer to ASCCP algorithms 
Individuals >65 Years With a Cervix

Individuals older than 65 years with a cervix need not be screened following an adequate and negative screen; if previous screening was inadequate, cotesting (preferred) or cytology (acceptable) should be performed until the definition of adequate screening has been fulfilled.    Adequate screening is considered two consecutive negative primary HPV tests, three consecutive negative cytology results, or two consecutive negative cotesting results within the last 10 years; the most recent of either test must be within the recommended interval for that test.    Individuals with a cervix who have a history of cervical intraepithelial neoplasia grade 2 or a more severe diagnosis should continue routine screening for at least 20 years after the CIN2-positive histology.  

Individuals >65 Yearsa With a Cervix
Testing Method Results Follow-Up
Cotesting Normal cytology and HPV negative Screen as per individuals 30-65 yrs until adequate screening definition is fulfilled
ASC-US cytology and HPV negative Perform additional surveillance with repeat screening in 1 yr (cotesting is preferred, but cytology is acceptable)
Normal cytology and HPV positive

OPTION 1: repeat cotesting in 1 yr

  • HPV negative: repeat cotesting in 3 years
  • ASC-US or HPV positive: colposcopy; refer to ASCCP algorithms 

OPTION 2: HPV DNA typing

  • HPV type 16/18 positive: colposcopy
  • HPV negative or positive for any other high-risk HPV genotype: repeat cotesting in 1 yr
ASC-US cytology and HPV positive Refer to ASCCP algorithms 
LSIL cytology Refer to ASCCP algorithms 
History of ≥CIN2 Perform screening based on schedule for individuals 30-65 yrs of age and screen for at least 20 yrs after CIN2-positive test
Cytology (with or without reflex) Normal cytology Screen as per women 30-65 yrs until adequate screening definition fulfilled
ASC-US cytology Refer to ASCCP algorithms 
LSIL cytology Refer to ASCCP algorithms 
aIf previous screening was adequate and negative, no further screening is needed. If previous screening was inadequate, proceed with cotesting or cytology. Adequate screening is considered 3 consecutive negative cytology results, 2 consecutive negative cotesting results, or 2 consecutive negative primary HPV test results within the last 10 years; the most recent of either test must be within the recommended testing interval (3 or 5 years) for the test used.
Posthysterectomy

Screening should not be performed at any age in individuals who have undergone hysterectomy with removal of the cervix and have no history of a CIN2-positive or more serious result.  

Post-HPV Vaccination

Screening practices should not change after HPV vaccination; age-based screening recommendations should be followed.  

HPV Testing in Anal Carcinoma

High-risk HPVs are known to cause cancers of the anus, particularly in immunosuppressed individuals (eg, HIV-positive individuals, immunocompromised individuals with a cervix who have a history of HPV or cervical abnormalities). These cancers are uncommon, and only a subset are related to HPV. Screening for anal cancer is not routinely recommended; however, some experts recommend yearly anal cancer screening by cytology ("anal Pap") in populations with an increased rate of anal carcinoma. 

ARUP Laboratory Tests

HPV Testing for Cervical Cancer

FDA-approved test for routine cervical cancer screening in combination with cervical cytology (Pap smear) in individuals ≥30 yrs with a cervix

Follow-up test for abnormal cytology results in individuals ≥21 yrs with a cervix

FDA-approved test and platform for primary HPV screening in individuals ≥25 yrs with a cervix

FDA-approved test for routine cervical cancer screening in combination with cervical cytology (Pap smear) in individuals ≥30 yrs with a cervix

Follow-up test for abnormal cytology results in individuals ≥21 yrs with a cervix

Cotesting (Cytology with HPV Testing) for Cervical Cancer

FDA-approved test for 5-yr interval testing (cotesting) in individuals 30-65 yrs with a cervix

Cytology with Reflex to HPV Testing for Cervical Cancer

FDA-approved test for routine cervical cancer screening in all individuals ≥21 yrs with a cervix

Optional to use for cervical cancer screening at 3-yr intervals in individuals 25-65 yrs with a cervix

FDA-approved test for routine cervical cancer screening at 3-yr intervals in all individuals ≥21 yrs with a cervix

Optional to use for cervical cancer screening at 3-yr intervals in individuals 25-65 yrs with a cervix

Cytology Testing for Cervical Cancer

FDA-approved test for routine cervical cancer screening at 3-yr intervals in all individuals ≥21 yrs with a cervix

For 5-yr interval testing (cotesting) in individuals 30-65 yrs with a cervix, order with HPV testing

Cytology Testing for Anal Cancer

Use to screen individuals at increased risk of developing anal cancer

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