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prev.cervical-cancer-screening.v1

Cervical cancer screening (adult)

general_internal_medicinechronicadult
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Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm cervical-screening scope: asymptomatic person WITH A CERVIX, age 21-65. Excludes <21 (Grade D — transient HPV/regressive CIN, overdiagnosis dominates), >65 with adequate prior negatives (Grade D), post-total-hysterectomy for benign indication with no CIN2+ history (Grade D — no pretest target), and any visible lesion/abnormal bleeding (→ diagnostic work-up, not screening) (USPSTF 2018 PMID 30140884)

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Advance rule
Set
Advance when

Asymptomatic, has cervix, age 21-65, not in a Grade-D stop category

Patient inputs (14)

Age band IS the modality decision and sets the pre-test prevalence prior: <21 none (Grade D), 21-29 cytology q3y, 30-65 hrHPV/co-test/cytology, >65 stop if adequate-negative (USPSTF 2018 PMID 30140884)

Prior cytology/hrHPV/genotype dates + results set the CONDITIONAL post-test prior — a prior negative hrHPV greatly lowers current-abnormality CIN3+ risk (Egemen KPNC tables PMID 32243308)

Total hysterectomy (cervix removed) for benign indication with no CIN2+ history = STOP screening (Grade D); supracervical/subtotal hysterectomy retains the cervix → continue (USPSTF 2018 PMID 30140884)

Person must have a cervix — post-total-hysterectomy with cervix removed for benign indication and no CIN2+ history = no pretest target (USPSTF 2018 Grade D PMID 30140884)

HIV/immunocompromise = higher prior + faster CIN progression → start within 1 yr of sexual activity, screen more frequently, continue past 65 (special-population branch — not average-risk interval)

Cytology sens for CIN2/3 ~55.4% single-test (Mayrand NEJM 2007 PMID 17942871); NILM/ASC-US/LSIL/ASC-H/HSIL category is a likelihood input to the ASCCP risk table

Primary hrHPV sens ~94.6% > cytology (Mayrand PMID 17942871); negative-hrHPV 10-y CIN3+ risk ≈ negative-cytology 3-y (Gilham ARTISTIC PMID 31219027) — drives the q5y interval

HPV-16/18 partial genotyping is a high-LR+ stratifier → immediate colposcopy; other-hrHPV → reflex cytology triage (ASCCP 2019 PMID 32243307)

Quadrivalent HPV vaccination lowers the prevalence prior substantially (IRR 0.37; 0.12 if <17 y — Lei NEJM 2020 PMID 32997908) but per USPSTF 2018 / ACS 2020 the screening protocol is unchanged (transitional)

Pregnancy: continue age-appropriate screening but defer colposcopy/biopsy work-up of low-grade abnormalities per ASCCP — special-population branch

FDA-approved 2024 self-collection: PCR-based self vs clinician hrHPV sens ratio 0.99 (Arbyn BMJ 2018 PMID 30518635); pooled absolute CIN2+ sens 0.86 / spec 0.81 (USPSTF 2024 draft) — equity tool for under-screened

A visible cervical lesion or abnormal/post-coital bleeding is a DIAGNOSTIC indication (exit to diagnostic work-up), NOT average-risk screening (USPSTF 2018 scope)

Prior CIN2/3 treatment carries a ~25-year elevated CIN3+ risk tail — HPV-based surveillance, do NOT return to routine interval (ASCCP 2019 PMID 32243307)

In-utero diethylstilbestrol exposure raises clear-cell adenocarcinoma prior → off-interval intensified screening (special-population branch)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (10)

10 need judgement
  • informationalseverepositive_screen_asccp_risk_crosses_action_threshold — ASCCP 2019
    ASCCP risk %: immediate CIN3+ risk ≥4% → colposcopy/biopsy; immediate ≥60% (e.g., HPV-16+ HSIL) → expedited treatment; 5-y CIN3+ risk <0.15% → 5-y return to routine; ~0.15-3.9% → 1-3 yr surveillance. The structured risk % is the post-test probability that crosses the workup/treat threshold (Perkins PMID 32243307; Egemen PMID 32243308)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresymptomatic_or_visible_lesion_is_diagnostic_not_screening — USPSTF 2018 scope
    A visible cervical lesion or abnormal/post-coital bleeding is a DIAGNOSTIC indication — exit average-risk screening to diagnostic colposcopy/work-up; symptomatic cervicitis/PID is a gyn look-alike, route to gyn.pelvic-inflammatory-disease.core.v1
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatehrhpv_not_used_under_30_low_ppv_transient_infection — conditional dependency #2
    The SAME positive hrHPV result has a much lower PPV for CIN3+ at 21-29 (transient infection highly prevalent and self-clearing) than at 30-65, and lower still in HPV-vaccinated cohorts (Lei NEJM 2020 IRR 0.37; 0.12 if vaccinated <17 y PMID 32997908). hrHPV PPV is conditional on age band + vaccination cohort — do NOT apply a fixed hrHPV LR across ages
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateasccp_risk_table_conditional_on_screening_history — conditional dependency #1
    A prior negative hrHPV dramatically lowers the post-test CIN3+ risk of a current abnormality (Egemen KPNC 1.5M tables PMID 32243308). The ASCCP 2019 engine conditions on screening history — it does NOT treat each round independently and multiply likelihood ratios serially
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateover_screening_and_overdiagnosis_harm — USPSTF 2018
    Screening <21, annual cytology, screening >65 with adequate negatives, or screening post-benign-hysterectomy — a positive in these low-prior contexts is far more likely transient HPV / reactive cytology / regressive CIN that would never progress; the colposcopy/biopsy/overtreatment harm is the denominator the PPV is weighed against (USPSTF 2018 Grade D PMID 30140884)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateimmunocompromised_hiv_off_interval_more_frequent — special-population
    HIV/immunocompromise = higher CIN3+ prior + faster progression → start screening within 1 yr of sexual activity, screen more frequently (per specialty guidance), and continue beyond age 65 — NOT the average-risk interval
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepost_treatment_cin_25y_elevated_risk_tail — ASCCP 2019
    Prior CIN2/3 treatment carries a ~25-year elevated CIN3+ risk tail — HPV-based surveillance (test at 6 mo then per ASCCP), do NOT return to the routine interval (ASCCP 2019 PMID 32243307)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildpretest_prevalence_below_testing_threshold_do_not_screen — USPSTF 2018
    Age <21, age >65 with adequate prior negatives and no CIN2+ in 25 y, or post-total-hysterectomy for a benign indication with no CIN2+ history — the pre-test prevalence × harm of the colposcopy/biopsy cascade + overdiagnosis of transient HPV / regressive CIN exceeds expected benefit (USPSTF 2018 Grade D PMID 30140884)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildage_band_sets_modality_the_prior_is_the_decision — USPSTF 2018 / ACS 2020
    Age 21-29 → cytology q3y (hrHPV NOT used — transient-infection PPV too low); age 30-65 → hrHPV-primary q5y preferred (sens 94.6% vs cytology 55.4%) OR co-test q5y OR cytology q3y. The age-band IS the Bayesian modality decision (USPSTF 2018 PMID 30140884; ACS 2020 PMID 32729638; Mayrand PMID 17942871)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildhpv_vaccinated_cohort_prevalence_shift_protocol_unchanged — Lei NEJM 2020
    Quadrivalent HPV vaccination lowers invasive cervical-ca incidence substantially (IRR 0.37; 0.12 if vaccinated <17 y — Lei NEJM 2020 PMID 32997908), shifting the pre-test prior, but USPSTF 2018 / ACS 2020 keep the screening protocol unchanged (transitional — interval not yet vaccination-stratified)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Cervical 21-29 — cytology q3y (USPSTF 2018 Grade A PMID 30140884)
axis: screening_modality_cervical_age_21_29
Selected axis "Cervical 21-29 — cytology q3y (USPSTF 2018 Grade A PMID 30140884)" by default fallback (first axis)
  • cervical_cytology_q3yr_age_21_29
    first line
    cytology_screen
    Cytology q3y, age 21-29 • procedure • q3yr
    USPSTF 2018 Grade A (PMID 30140884). Single-test cytology sens for CIN2/3 ~55.4% (Mayrand NEJM 2007 PMID 17942871) but the q3y program substantially reduces incidence + mortality (deaths 2.8→2.3 / 100k women 2000-2015). hrHPV NOT used <30 — transient-infection prevalence makes its PPV too low.
  • acs_start_age_25_cytology_acceptable
    second line
    cytology_screen
    ACS 2020: start age 25 (cytology acceptable & transitional) • procedure • q3yr
    triggers: acs_aligned_program, age_25_to_29
    ACS 2020 (Fontham CA Cancer J Clin 2020 PMID 32729638) starts at 25 vs USPSTF-2018 start 21; cytology acceptable until primary-HPV access universal.

outpatient playbook — drug actions (0)

No drug actions defined for this setting.

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Routine preventive/wellness visit — age-appropriate cervical screening due (USPSTF 2018 Grade A PMID 30140884); Overdue or never-screened person with a cervix identified at any encounter — equity recall (self-collection option; Arbyn BMJ 2018 PMID 30518635); Follow-up of a prior abnormal cytology/hrHPV/genotype result — apply ASCCP 2019 risk-table reasoning (Perkins PMID 32243307).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Cervical cancer screening (adult)** (prev.cervical-cancer-screening.v1).
Phenotype framing: Average-risk vs special-population (HIV/immunocompromised, post-treatment-CIN, DES, pregnancy), AND true-positive (CIN3+/AIS/invasive) vs false-positive (transient HPV, reactive/inflammatory cytology, regressive CIN overdiagnosis). The false-positive cascade + over-screening overdiagnosis are encoded as harm DATA, not prose; screen-negative returns to interval (USPSTF 2018; ASCCP 2019)
Scope: Confirm cervical-screening scope: asymptomatic person WITH A CERVIX, age 21-65. Excludes <21 (Grade D — transient HPV/regressive CIN, overdiagnosis dominates), >65 with adequate prior negatives (Grade D), post-total-hysterectomy for benign indication with no CIN2+ history (Grade D — no pretest target), and any visible lesion/abnormal bleeding (→ diagnostic work-up, not screening) (USPSTF 2018 PMID 30140884)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Cervical 21-29 — cytology q3y (USPSTF 2018 Grade A PMID 30140884)**.
1. cervical_cytology_q3yr_age_21_29 Cytology q3y, age 21-29 procedure q3yr (cytology_screen, first line) — USPSTF 2018 Grade A (PMID 30140884). Single-test cytology sens for CIN2/3 ~55.4% (Mayrand NEJM 2007 PMID 17942871) but the q3y program substantially reduces incidence + mortality (deaths 2.8→2.3 / 100k women 2000-2015). hrHPV NOT used <30 — transient-infection prevalence makes its PPV too low.
2. acs_start_age_25_cytology_acceptable ACS 2020: start age 25 (cytology acceptable & transitional) procedure q3yr (cytology_screen, second line) — ACS 2020 (Fontham CA Cancer J Clin 2020 PMID 32729638) starts at 25 vs USPSTF-2018 start 21; cytology acceptable until primary-HPV access universal.

Non-pharmacologic actions:
- Order cytology q3y if age 21-29 (USPSTF 2018 PMID 30140884)
- Order hrHPV-primary q5y (preferred) or co-test q5y or cytology q3y if age 30-65 (USPSTF 2018; ACS 2020 PMID 32729638)
- Offer PCR-based self-collected hrHPV to under-screened/never-screened (Arbyn BMJ 2018 PMID 30518635 — sens ratio 0.99, participation RR 2.33)
- On hrHPV+: HPV-16/18 genotype → immediate colposcopy; other-hrHPV → reflex cytology (ASCCP 2019 PMID 32243307)
- Compute ASCCP 2019 risk % from current + prior results → 1 of 6 actions (Egemen PMID 32243308)
- Refer to colposcopy when immediate CIN3+ risk ≥4%; expedited treatment if ≥60% (HPV-16+ HSIL)
- Address HPV-vaccination catch-up through 26 (ACIP) — adjacent prevention, interval unchanged
- Patient education: over-screening harms (<21, annual, >65 adequate-negative, post-benign-hysterectomy), false-positive cascade, transient-HPV/regressive-CIN overdiagnosis (USPSTF 2018)

AVOID / contraindication checks:
- No_screening_lt_age_21 (USPSTF 2018 Grade D PMID 30140884 — transient HPV / regressive CIN; overdiagnosis dominates)
- Do_not_use_hrhpv_primary_or_cotest_under_age_30 (low PPV from transient infection)
- No_annual_cytology_q3y_is_the_interval (over screening harm — repeat colposcopy/biopsy of regressive lesions)
- Special_pop:hiv_immunocompromised_more_frequent_off_interval_not_average_risk
- Special_pop:pregnancy_continue_age_appropriate_cytology_defer_low_grade_colposcopy_per_ASCCP

Monitoring

Regimen monitoring:
- cytology q3yr age 21 to 29 (USPSTF 2018 PMID 30140884)
- abnormal result to asccp 2019 risk table action (Perkins PMID 32243307)
- transition to 30 65 modality at age 30

Setting (outpatient) monitoring:
- Cytology q3y 21-29 (USPSTF 2018)
- hrHPV q5y / co-test q5y / cytology q3y 30-65 (USPSTF 2018; ACS 2020 hrHPV-primary preferred)
- 1-yr / 3-yr / 5-yr-return surveillance per ASCCP 2019 risk % (Egemen PMID 32243308)
- Post-treatment-CIN HPV-based surveillance, 25-yr elevated-risk tail (ASCCP 2019)
- Immunocompromised/HIV more frequent and beyond age 65

Follow-up plan: STOP-screening / over-screening-harm logic (the deprescribing-equivalent): discontinue at >65 with adequate prior negatives (≥3 consecutive negative cytology OR ≥2 negative hrHPV/co-test in 10 y, most recent within 5 y) and no CIN2+ in 25 y; discontinue after total hysterectomy for benign indication with no CIN2+ history (USPSTF 2018 Grade D PMID 30140884). Patient education: over-screening harms (colposcopy/biopsy of regressive CIN, overtreatment), the value of NOT screening <21 / >65 / post-benign-hysterectomy, and that HPV vaccination does not change the interval (transitional — ACS 2020)
- Close-out criterion: Stop-screening decision OR continued-interval education delivered and documented

Monitoring phase: Interval + recall by age band AND ASCCP risk tier: cytology q3y 21-29; hrHPV q5y or co-test q5y or cytology q3y 30-65 (hrHPV-primary preferred per ACS 2020 / USPSTF-2024-draft); negative-hrHPV safe ≥5y (10-y CIN3+ risk 0.31% ≈ 3-y post-cytology — Gilham ARTISTIC PMID 31219027); 1-yr/3-yr surveillance per ASCCP risk %; post-treatment-CIN HPV-based surveillance with a 25-yr elevated-risk tail; immunocompromised/HIV more frequent and beyond 65 (USPSTF 2018; ASCCP 2019)

Disposition

Current setting: outpatient — Set the pre-test prevalence prior (age band + HPV-vaccination status + screening history), order the age-band-appropriate screen (hrHPV-primary preferred 30-65; cytology 21-29; self-collection for under-screened), triage positives by HPV-16/18 genotype + cytology, apply the ASCCP 2019 risk table to choose 1 of 6 actions, route ≥4%-immediate-CIN3+-risk to colposcopy, schedule recall by age band + risk tier, and apply STOP-screening logic when over-screening harm exceeds benefit (USPSTF 2018 PMID 30140884; ACS 2020 PMID 32729638; ASCCP 2019 PMID 32243307)

Disposition criteria:
- Continue per age-band + ASCCP-risk-tier interval if results negative and still eligible (USPSTF 2018; ASCCP 2019)
- Refer to colposcopy/gyn-onc for ASCCP ≥4%-immediate-CIN3+-risk results (Perkins PMID 32243307)
- STOP screening at >65 with adequate prior negatives + no CIN2+ in 25 y, OR post-total-hysterectomy for benign indication with no CIN2+ history — the deprescribing-equivalent (USPSTF 2018 Grade D PMID 30140884)

Escalation triggers (move to higher acuity):
- ASCCP immediate CIN3+ risk ≥4% → colposcopy/biopsy referral (Perkins PMID 32243307)
- HPV-16/18+ with HSIL (immediate CIN3+ risk ≥60%) → expedited treatment / gyn-onc (ASCCP 2019)
- CIN3+/AIS/invasive on histology → gynecologic oncology (differential-as-data — no terminal engine on disk)
- Visible lesion / abnormal bleeding → diagnostic work-up, NOT screening (USPSTF 2018 scope)
- Symptomatic cervicitis/PID look-alike → gyn.pelvic-inflammatory-disease.core.v1

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [SEVERE] ASCCP risk %: immediate CIN3+ risk ≥4% → colposcopy/biopsy; immediate ≥60% (e.g., HPV-16+ HSIL) → expedited treatment; 5-y CIN3+ risk <0.15% → 5-y return to routine; ~0.15-3.9% → 1-3 yr surveillance. The structured risk % is the post-test probability that crosses the workup/treat threshold (Perkins PMID 32243307; Egemen PMID 32243308)
- [SEVERE] A visible cervical lesion or abnormal/post-coital bleeding is a DIAGNOSTIC indication — exit average-risk screening to diagnostic colposcopy/work-up; symptomatic cervicitis/PID is a gyn look-alike, route to gyn.pelvic-inflammatory-disease.core.v1
- [MODERATE] The SAME positive hrHPV result has a much lower PPV for CIN3+ at 21-29 (transient infection highly prevalent and self-clearing) than at 30-65, and lower still in HPV-vaccinated cohorts (Lei NEJM 2020 IRR 0.37; 0.12 if vaccinated <17 y PMID 32997908). hrHPV PPV is conditional on age band + vaccination cohort — do NOT apply a fixed hrHPV LR across ages

Citations

- USPSTF 2018 cervical cancer screening (FINAL, binding floor) + ASCCP 2019 risk-based management + ACS 2020 (start-25, hrHPV-primary preferred); USPSTF Dec-2024 DRAFT (primary-HPV-preferred-30 + self-collection) annotated as emerging, NOT yet final [PMID:30140884](https://pubmed.ncbi.nlm.nih.gov/30140884/)
- Cited evidence (PMID 17942871) [PMID:17942871](https://pubmed.ncbi.nlm.nih.gov/17942871/)
- Cited evidence (PMID 24192252) [PMID:24192252](https://pubmed.ncbi.nlm.nih.gov/24192252/)
- Cited evidence (PMID 19540162) [PMID:19540162](https://pubmed.ncbi.nlm.nih.gov/19540162/)
- Cited evidence (PMID 31219027) [PMID:31219027](https://pubmed.ncbi.nlm.nih.gov/31219027/)

Last reconciled with current guidelines: 2026-05-16.
References
  • USPSTF 2018 cervical cancer screening (FINAL, binding floor) + ASCCP 2019 risk-based management + ACS 2020 (start-25, hrHPV-primary preferred); USPSTF Dec-2024 DRAFT (primary-HPV-preferred-30 + self-collection) annotated as emerging, NOT yet final — PMID:30140884
  • Cited evidence (PMID 17942871) — PMID:17942871
  • Cited evidence (PMID 24192252) — PMID:24192252
  • Cited evidence (PMID 19540162) — PMID:19540162
  • Cited evidence (PMID 31219027) — PMID:31219027