Cervical cancer was once a leading cause of cancer death for women in the United States, but over the past three decades, mortality rates have declined by more than 50% due to the increased use of Pap test screening.1 There are two major types of cervical cancer: squamous cell carcinoma and adenocarcinoma.
Squamous cell carcinoma arises in the squamous epithelial cells that line the cervix. About 66% of all cervical cancers are of this type.
Adenocarcinoma develops from mucus-producing glandular cells in the endocervix. It accounts for about 28% of all cervical cancers.
Other rarer types comprise the remaining 6%.2
In 2017, an estimated 12,820 new cases of invasive
cervical cancer will be diagnosed in U.S. women.3
In 2017, an estimated 4,210 U.S. women will die from cervical cancer.3
Based on 2010-2012 data, an estimated 250,000 women in the U.S. are living with cervical cancer.4
Most invasive cervical cancers are
found in women who have
not been routinely screened.5
In 2012, an estimated 11.4% of women in the United States had not been screened for cervical cancer in the past five years. This estimate is higher for women with no health insurance (23.1%) and for those without a regular health care provider (25.5%).6
From 2006-2012, the median age of cervical cancer diagnosis was 49.4 However, older
women remain at risk. More than 15% of new cases are
in women over 65.
women younger than age 20 is rare.1
In the U.S., Hispanic women have the highest rate of cervical cancer, followed by African- Americans, Caucasians, American Indian/Alaska Natives, and Asian American/Pacific Islanders. Mortality rates are highest for African American women.7
detected at its earliest stage, cervical cancer
has a 5-year relative survival rate of approximately 92%.
For regional disease, it is approximately 57%. If cancer has spread to distant organs, 5-year survival drops to approximately 17%.4
Virtually all (99.7%) cervical cancers are caused by persistent infection with one of the approximately 15 types of high-risk, mucosal human papillomavirus (HPV).8,9
Two types of HPV are responsible for about 70% of all cervical cancers: HPV16 and HPV18.10,11
In the U.S., 24%-29% of women aged 14-59 are infected with a high-risk strain of HPV.12 However, most high-risk HPV infections do not lead to cervical cancer. For cervical cancer to develop, a high-risk infection must also be persistent.13
Nearly all HPV infections clear within two years, and the median duration of a high-risk HPV infection is less than one year.14 - 16
Low-risk types of HPV, such as HPV6 and HPV11, may cause anogenital warts but are not associated with cervical cancer.1
Three different groups have published guidelines for cervical cancer screening: a multidisciplinary partnership among the American Cancer Society/American Society for Colposcopy and Cervical Pathology/American Society for Clinical Pathology (ACS/ASCCP/ASCP), The United States Preventive Services Task Force (USPSTF), and the American College of Obstetricians and Gynecologists (ACOG). As shown in the table, there is consensus among the groups about nearly all aspects of cervical cancer screening.17-19
Comparison of ACS/ASCCP/ASCP, USPSTF, and ACOG Screening Guidelines
Recommendations apply to both conventional and liquid-based cytology.
When to Start
Cytology alone every 3 years
HPV and cytology cotesting every 5 years is preferred
Cytology alone every 3 years is acceptable
Ages 21-29 years:
Cytology alone every 3 years
HPV and cytology cotesting every 5 years for women who want to extend their screening interval
Cytology alone every 3 years
Cytology alone every 3 years
HPV and cytology cotesting every 5 years is preferred
Cytology alone every 3 years is acceptable
When to Stop
Women older than age 65 following adequate negative prior screening and no history of CIN2 or higher within the last 20 years
Women older than age 65 who have had adequate negative prior screening (as defined below) and who are not otherwise at high risk
(Adequate negative prior screening is defined as 3 consecutive negative cytology results or 2 negative cotests within 10 years before cessation of screening, with the most recent occurring in the past 5 years)
Women older than age 65 with evidence of adequate negative prior screening results and no history of CIN2 or higher
Women who have undergone hysterectomy with removal of the cervix and have no history of CIN2+ should not be screened
Women who have had a total hysterectomy (with removal of the cervix) and no history of a high-grade precancerous lesion (CIN grade 2 or 3) or cervical cancer should not be screened
Women who have had a hysterectomy with removal of the cervix and have never had CIN2 or higher should discontinue routine cytology screening and HPV testing and should not restart for any reason
In addition to Pap and cotesting, for women ages 25-65, ACOG, the Society of Gynecologic Oncology (SGO), and ASCCP have stated that FDA-approved primary HPV screening, no more than every 3 years, can be considered as an alternative screening modality if performed per ASCCP and the SGO guidelines.17,19
Some women are at higher risk than average for cervical cancer and will have special screening protocols. This includes women with:
HIV: Women who are HIV positive should begin screening within one year of sexual debut but no later than 21 years old. Women 21 and older should be screened at the time of HIV diagnosis, and some experts recommend another screening six months after diagnosis. Screening for HIV-infected individuals should continue throughout their lifetime.
HIV infected women who are 21 to 29 years old should have a Pap test every 12 months. After three normal Pap tests, the testing interval can extend to one Pap test every three years as long as the results are normal. Women who are 30 and older can follow the same protocol or can have cotesting with a Pap and an HPV test at the time of diagnosis and then every three years as long as the results of screening are normal.21
These protocols also apply to women who are immunusuppressed due to other illnesses, such as lupus, or to the use of immunosuppressive medications (e.g., for organ transplants).20
Diethylstilbestrol (DES) exposure in utero: DES
was given to some pregnant women in the United States from 1940-1971. In utero exposure to DES increases the risk of a rare form of cervical
cancer; about 1 in every 1,000 "DES daughters" will be diagnosed with this cancer. Women who were exposed to DES in utero should have annual Pap tests.20, 22, 23
Personal History of CIN2, CIN3, or Cervical Cancer: Women who have been treated for high-grade cervical intraepithelial neoplasia or cervical cancer (CIN2 or higher) should continue to have cervical cancer screening at age-appropriate intervals for at least 20 years after treatment is completed even if this extends screening beyond the age of 65.20
Other factors have been found to increase the risk of developing cervical cancer but do not change routine screening protocols: (1) early onset of sexual activity; (2) multiple sexual partners; (3) first full-term pregnancy at a young age; (4) multiple full-term pregnancies; and (5) past or current chlamydia infection. Smoking is associated with an increased risk for squamous cell carcinoma but not for adenocarcinoma.24-29
In addition, the long-term use (5 or more years) of oral contraceptives is associated with an increased risk of developing cervical cancer. This risk increases with duration of use and declines after use ceases.30 However, oral contraceptives have a variety of health benefits and decrease the risk of endometrial, ovarian, and colorectal cancer. The benefits of fertility management along with these health benefits are thought to generally outweigh the potential risk for most patients.28-31
There are two FDA-approved vaccines available in the Unites States to prevent HPV infection: Gardasil, which protects against four strains of HPV; and Gardasil9, which protects against nine strains of HPV. Please note, Gardasil-9 will soon be the only HPV vaccine available in the United States. Those vaccines target HPV16 and HPV18, the strains of HPV that cause the majority of cervical cancers. Important information about the vaccines:
FDA-approved vaccinations have been proven to be highly effective and may prevent up to 100% of HPV infections and precancerous cervical lesions in women not already exposed to HPV. They also prevent infection in other anatomical sites including the vulva, vagina, penis, anus and perineum.32
The Advisory Committee on Immunization Practices (ACIP) recommends HPV vaccination for females and males at age 11 or 12. The series can start beginning at age 9 years.33,34
For individuals who were not vaccinated at those ages, the vaccine can still be administered. Catch-up vaccines are recommended for females, men who have sex with men, transgender people, and those who are immunocompromised until age 26. For men who have sex only with women, catch up vaccinations are recommended until the age of 21.33,34
HPV vaccines are very safe. Pain in the injection site is the most frequently reported adverse event.32,35
The vaccines are most effective when administered before exposure to HPV, so it is important to give the vaccination before sexual debut. However, HPV-exposed individuals not already immunized should still receive the vaccine as it will provide protection against strains of HPV to which the individual has not been exposed.33
Vaccinated individuals should continue to have routine cervical cancer screening at age appropriate intervals.33
Would you like to learn more about the HPV vaccination
in the US and how to improve uptake?
In the U.S., among girls 13-17 years old, only 54% have received one or more doses of the HPV vaccine, and only 33% have received the whole series.35
If the HPV vaccine was given at the same time as other routine immunizations, the rate of coverage could reach approximately 93%.35
If the rate of coverage increased to 80% among U.S. girls, 53,000 cases of cervical cancer could be prevented over the lifetime of girls now 12 and younger.35
Nearly 25% of parents of girls 13-17 years old report that they do not plan to have their daughters immunized. Reasons include believing that the vaccine is unnecessary; not receiving a recommendation for the vaccine; concerns about safety; lack of knowledge about the vaccine and HPV; and that their child is not sexually active.35
Effective strategies to improve coverage rates include clear and strong recommendations from health care providers; checking on the child's immunization status at each health care visit; recall and reminder systems; and using community-based locations such as schools to administer the vaccines.36
Educational materials are available from the Centers for Disease Control and Prevention (CDC) that may be helpful in addressing concerns about the HPV vaccine.35
In California, the Every Woman Counts (EWC) program assists low income, uninsured, underserved women in obtaining high quality breast and cervical cancer screening and follow-up services. The program is funded through the California Department of Health Care Services (DHCS), from federal grant monies, and State of California funds: The Breast Cancer Control Account (BCCA), Proposition 99, and the General Fund.
Women who would like to find an EWC provider in their area may call the automated 24-hour consumer line at 1-800-511-2300 or use the online provider locator on the DHCS website. The EWC representative for your area may know
of other low-cost screening programs that might be
available to you. These Regional Contractors are also your
link to support groups, advocacy groups and the latest
information on what's happening in your community.
American Cancer Society. Cervical
cancer: detailed guide. http://www.cancer.org/cancer/cervicalcancer/detailedguide. Updated February 26, 2015. Accessed March 31, 2016.
National Cancer Institute. SEER cancer statistics review, 1975-2004. Cervix uteri cancer (invasive).
Percent distribution and counts by histology among histologically confirmed cases, 2001-2004. http://seer.cancer.gov/archive/csr/1975_2004/results_merged/topic_histologic_tabs.pdf. Accessed April 4, 2016.
American Cancer Society. Cancer facts & figures 2017. http://www.cancer.org/research/cancerfactsstatistics/cancerfactsfigures2017.
Published 2017. Accessed January 9, 2017.
SEER cancer statistics fact sheets: cervix uteri cancer. The SEER website. http://seer.cancer.gov/statfacts/html/cervix.html . Accessed April 4, 2016.
American Cancer Society. Cervical cancer prevention and early detection. http://www.cancer.org/cancer/cervicalcancer/moreinformation/cervicalcancerpreventionandearlydetection/
cervical-cancer-prevention-and-early-detection-toc. Updated December 14, 2011. Accessed March 31, 2016.
Benard VB, Thomas CC, King J, Massett G, Doria-Rose P, Saraiya M. Vital signs: cerivcal cancer incidence, mortality, and screening -- United States, 2007-2012. MMWR Weekly. November 5, 2014; 63:1-6. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm63e1105a1.htm. Accessed April 4, 2016.
Cervical cancer rates by race and ethnicity. Centers for Disease Control and Prevention website. http://www.cdc.gov/cancer/cervical/statistics/race.htm. Updated August 20, 2015. Accessed April 4, 2016.
Walboomers JMM, Jacobs MV, Manos MM, et al. Human papillomavirus is a necessary cause of invasive cervical cancer worldwide. J Pathol. 1999;(189):12-19.
Muñoz N, Bosch FX, de Sanjosé S, et al. Epidemiologic classification of human papillomavirus types associated with cervical cancer. N Engl J Med. 2003;384(6):518-527.
Li N, Franceschi S, Howell-Jones R, Snijders PJF, Clifford GM. Human papillomavirus type distribution in 30,848 invasive cervical cancers worldwide: variation by geographical region, histological type and year of publication. Int J Cancer.2011;128:927-935.
de Sanjosé S, Quint WGV, Alemany L,et al. Human papillomavirus genotype attribution in invasive cervical cancer: a retrospective cross-sectional worldwide study. Lancet Oncol. 2010;11:1048-1056.
Hariri S, Unger ER, Sternberg M, et al. Prevalence of genital human papillomavirus among females in the United States, the National Health and Nutrition Examination Survey, 2003-2006. J Infect Dis. 2011;204:566-573.
Denny L. Human papillomavirus infections: epidemiology, clinical aspects and vaccines. The Open Infectious Diseases Journal. 2003;3:135-142.
Trottier H, Franco EL. The epidemiology of genital human papillmoavirus infection. Vaccine. 2006;24 Suppl1 S1-15.
Plummer M, Schiffman M, Castle PE, Maucort-Boulch D, Wheeler CM, for the ALTS (Atypical Squamous Cells of Undetermined Significance/Low-Grade Squamous Intraepithelial Lesions Triage Study) Group. A 2-year prospective study of human papillomavirus persistence among women with a cytological diagnosis of atypical squamous cells of undetermined significance or low-grade squamous intraepithelial lesion. J Infect Dis. 2007;195:1582-1589.
Rositch AF, Koshiol J, Hudgens MG, et al. Patterns of persistent genital human papillomavirus infection among women worldwide: a literature review and meta-analysis. Int J Cancer. 2013;133:1271-1285.
Saslow D, Solomon D, Herschel W, et al. 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(3):147-172.
Moyer MA on behalf of the U. S. Preventive Services Task Force (USPSTF). Screening for cervical cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012;156:880-891.
American College of Obstetricians and Gynecologists. Practice bulletin No. 157: cervical cancer screening and prevention. Obstet Gynecol. 2016;127(1):e1-e20
Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents. Guidelines for the prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infections Diseases Society of America.https://aidsinfo.nih.gov/contentfiles/lvguidelines/adult_oi.pdf. Updated February 3, 2016. Accessed April 6, 2016.
Hoover RN, Hyer M, Pfeiffer RM, et al. Adverse health outcomes in women exposed in utero to diethylstilbestrol. N Engl J Med. 2011;365:1304-1314.
DES daughters. DES Action website. http://www.desaction.org/des-daughters/. Accessed April 7, 2016.
International Collaboration of Epidemiological Studies of Cervical Cancer. Comparison of risk factors for invasive squamous cell carcinoma and adenocarcinoma of the cervix: Collaborative reanalysis of individual data on 8,097 women with squamous cell carcinoma and 1,374 women with adenocarcinoma from 12 epidemiological studies. Int J Cancer. 2006;120:885-891.
International Collaboration of Epidemiological Studies of Cervical Cancer. Cervical carcinoma and reproductive factors: Collaborative reanalysis of individual data on 16,563 women with cervical carcinoma and 33,542 women without cervical carcinoma from 25 epidemiological studies. Int J Cancer. 2006;119:1108-1124.
International Collaboration of Epidemiological Studies of Cervical Cancer. Cervical carcinoma and sexual behavior: Collaborative reanalysis of individual data on 15,461 women with cervical carcinoma and 29,164 women without cervical carcinoma from 21 epidemiological studies. Cancer Epidemiol Biomarkers Prev. 2009;18(4):1060-1069.
Anttila T, Saikku P, Koskela P, et al. Serotypes of chlamydia trachomatis and risk of development of cervical squamous cell carcinoma. JAMA. 2001;285:47-51.
International Collaboration of Epidemiological Studies of Cervical Cancer. Carcinoma of the cervix and tobacco smoking: Collaborative reanalysis of individual data on 13,541 women with carcinoma of the cervix and 23,017 women without carcinoma of the cervix from 23 epidemiological studies. Int J Cancer. 2006;118:1481-1495.
International Collaboration of Epidemiological Studies of Cervical Cancer. Cervical cancer and hormonal contraceptives: collaborative reanalysis of individual data for 16 573 women with cervical cancer and 35 509 women without cervical cancer from 24 epidemiological studies. Lancet. 2007;370:1609-1621.
American College of Obstetricians and Gynecologists. Practice bulletin No. 110: noncontraceptive uses of hormonal contraceptives. Obstet Gynecol. 2010;110(1):206-218.
Jensen JT, Speroff L. Health benefits of oral contraceptives. Obstet Gynecol Clin North Am. 2000;27(4):705-721.
Bertram CC. Evidence for practice: oral contraception and risk of cervical cancer. J Am Acad Nurse Pract. 2004;16(10):455-461.
Markowitz LE, Dunne
EF, Saraiya M, et al. Human papillomavirus vaccination: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. 2014;63(RR05):1-30.
Petrosky E, Bocchini, Jr. JA, Hariri S, et al. Use of 9-valent human papillomavirus (HPV) vaccine: Updated HPV vaccination recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. 2015;64(11):300-304.
Angioli R, Lopez S, Aloisi A, et al. Ten years of HPV vaccines: State of the art and controversies. Crit Rev Oncol/Hematol. 2016. In press. doi:10.1016/j.critrevonc.2016.03.020.
Centers for Disease Control and Prevention. Human papillomavirus vaccination coverage among adolescent girls, 2007-2012, and postlicensure vaccine safety monitoring, 2006-2012 - United States. MMWR. 2013;62(29):591-595.
Niccolai LM, Hansen, CE. Practice- and community-based interventions to increase human papillomavirus vaccine coverage. A systematic review. JAMA Pediatr. 2015;169(7):686-692.