In order to maintain a reasonable balance of benefits, harms, and costs, women seeking cervical cancer screening have 2 options: cytologic testing every 3 years from ages 21 years to 29 years with either continued cytologic testing every 3 years or a switch to a low-cost, high-risk HPV test every 5 years from ages 30 years to 65 years. 

This conclusion comes from the evaluation of 12 strategies for cervical cancer screening in a cost-effectiveness model published recently in JAMA Internal Medicine.

“Both the American College of Obstetricians and Gynecologists and the American Cancer Society consider cotesting the preferred cervical cancer screening strategy, and the US Preventive Services Task Force considers it an alternative strategy,” the researchers wrote. “Our findings challenge these endorsements.”

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The study included 451 English- or Spanish-speaking women aged 21 to 65 years identified at women’s health clinics in San Francisco from September 2014 to June 2016. Preferences were measured for 23 cervical cancer screening-associated health states and were applied to a decision model for type-specific HPV-induced cervical carcinogenesis.

The researchers evaluated cytologic testing:

  • every 3 years for women aged 21 to 65 years with either repeat cytologic testing in 1 year, or immediate high-risk HPV triage for atypical squamous cells of undetermined significance,
  • cytologic testing every 3 years from ages 21 to 29 years followed by cytologic testing plus high-risk HPV testing, or,
  • primary high-risk HPV testing alone for women aged 30 to 65 years.

The model varied screening frequency, abnormal test result management, and the age to switch from cytologic testing to high-risk HPV.

Cytologic testing every 3 years with repeated cytologic testing for atypical squamous cells of undetermined significance yielded the most lifetime quality-adjusted life years (QALYs). This approach yielded more QALYs despite its higher cost ($2,166 per QALY), than the lowest-cost strategy (cytologic testing every 3 years with high-risk HPV triage).

All cotesting and strategies with primary high-risk HPV testing provided fewer QALYs at a higher cost, according to the study.

“Without quality adjustments, conferred life-years varied little among all 12 screening strategies (29.54175- 29.54523 life-years), a finding that underscores the importance of quantifying screening harms and costs unique to each strategy,” the researchers wrote. “Identifying and promoting strategies that maximize quality of life outcomes and minimize costs at all steps throughout the screening process will provide higher-value cervical cancer screening from the perspectives of society, the health care sector, and women.”


Sawaya GF, Sanstead E, Alarid-Escudero F, et al. Estimated quality of life and economic outcomes associated with 12 cervical cancer screening strategies. A cost-effectiveness analysis.[published online May 13, 2019]. JAMA Intern Med. doi: 10.1001/jamainternmed.2019.0299