European guidelines on cervical cancer screening and diagnosis

Should cervical cytology or co-testing vs. HPV detection test be used as the primary screening test for cervical screening in asymptomatic populations with a cervix aged 30–50 years?

The overall justification for recommending HPV detection testing over cervical cytology and co-testing is grounded in the better clinical performance of HPV detection, particularly its high sensitivity for detecting high-grade lesions, which results in earlier diagnosis and treatment of precancer. HPV detection tests are considered more effective in preventing cervical cancer than cytology alone, with negligible differences when compared with co-testing. While cytology results in fewer referrals to colposcopy, this small benefit is outweighed by its lower detection rates and potential for delayed treatment. HPV detection offers higher effectiveness, cost-effectiveness and growing feasibility and acceptability in Europe. In contrast, co-testing provides only trivial additional benefit over HPV detection while increasing resource use and causing more unnecessary follow-up procedures (tests, colposcopies and treatments).

Equity was a key consideration for the WG, who highlighted the potential for HPV detection tests (with the possibility for self-sampling) to improve access and reduce disparities.

For the recommendation (i) comparing cytology with HPV detection, there was high certainty of evidence to support the recommendation. For the recommendation (ii) comparing co-testing with HPV detection tests, the certainty of evidence was low. However, evidence showed low certainty about trivial desirable effects alongside moderate/high undesirable effects, with net undesirable effects, and large costs associated with co-testing making the intervention not cost-effective. Furthermore, the WG considered that co-testing may reduce equity compared with HPV detection alone due to the need to combine it with cervical cytology, which may be less accessible to all individuals.

This recommendation applies to general populations with cervix at average risk. Specific guidance for both higher-risk (immunocompromised) and lower-risk (vaccinated) populations will be detailed in later recommendations. 

The WG agrees that ensuring equity is crucial to the implementation of this recommendation in screening programmes. Additionally, there is a need to expand the definition of equity to include all unscreened individuals with a cervix, not just those belonging to vulnerable or at-risk groups. A future section will explore programmatic questions about invitation strategies, focusing on how different methods can enhance coverage and equity.

The WG highlights that, in the implementation of this recommendation, quality assurance in HPV laboratories needs consideration to ensure the reliability of test results. The European Quality Assurance Scheme being developed as part of EC-CvC will address many of the issues related to monitoring the implementation of this recommendation.

The WG highlights the importance of closely monitoring the downstream impact of HPV-based screening programmes – including triage, colposcopy referrals and treatments – especially as they transition from cytology-based screening. The European Quality Assurance Scheme, currently being developed under EC-CvC, will play a central role in supporting countries to monitor the implementation of this recommendation, ensuring that changes are evidence-based and do not lead to unintended consequences – for example, emergence of new inequalities in access or outcomes.

The WG considered research on ensuring equitable access to cervical screening in this age group a research priority.