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Description: The purpose of this best practice advice article is to describe the indications for screening for cervical cancer in asymptomatic, average-risk women aged 21 years or older., Methods: The evidence reviewed in this work is a distillation of relevant publications (including systematic reviews) used to support current guidelines., Best Practice Advice 1: Clinicians should not screen average-risk women younger than 21 years for cervical cancer., Best Practice Advice 2: Clinicians should start screening average-risk women for cervical cancer at age 21 years once every 3 years with cytology (cytologic tests without human papillomavirus [HPV] tests)., Best Practice Advice 3: Clinicians should not screen average-risk women for cervical cancer with cytology more often than once every 3 years., Best Practice Advice 4: Clinicians may use a combination of cytology and HPV testing once every 5 years in average-risk women aged 30 years or older who prefer screening less often than every 3 years., Best Practice Advice 5: Clinicians should not perform HPV testing in average-risk women younger than 30 years., Best Practice Advice 6: Clinicians should stop screening average-risk women older than 65 years for cervical cancer if they have had 3 consecutive negative cytology results or 2 consecutive negative cytology plus HPV test results within 10 years, with the most recent test performed within 5 years., Best Practice Advice 7: Clinicians should not screen average-risk women of any age for cervical cancer if they have had a hysterectomy with removal of the cervix.

The U.S. Preventive Services Task Force (USPSTF) seeks to provide reliable and accurate evidence-based recommendations to primary care clinicians. However, clinicians indicate frustration with the lack of guidance provided by the USPSTF when the evidence is insufficient to make a recommendation. This article describes a new USPSTF plan to commission its Evidence-based Practice Centers to collect information in 4 domains pertinent to clinical decisions about prevention and to report this information routinely. The 4 domains are potential preventable burden, potential harm of the intervention, costs (both monetary and opportunity), and current practice. The process and rationale used to select these domains are presented, along with examples of how clinicians might use the information to guide clinical decision making when evidence is insufficient.

The major goal of the U.S. Preventive Services Task Force (USPSTF) is to provide a reliable and accurate source of evidence-based recommendations on a wide range of preventive services. In this article, the USPSTF updates and reviews the process by which it evaluates evidence, determines the certainty and magnitude of net benefit, and gives a final letter grade to recommendations. Because direct evidence about prevention is often unavailable, the Task Force usually considers indirect evidence. To guide its selection of indirect evidence, a "chain of evidence" is constructed within an analytic framework. The Task Force examines evidence of various research designs that addresses the key questions within the framework. New terms have been added to describe the USPSTF's judgment about the evidence for each key question: "convincing," "adequate," or "inadequate." For increased clarity, the USPSTF has changed its description of overall evidence of net benefit for the preventive service from "good," "fair," or "poor" quality to "high," "moderate," or "low" certainty. This rating considers the extent to which an uninterrupted chain of evidence exists across the analytic framework. Individual studies will continue to be judged as being of "good," "fair," or "poor" quality. Using outcomes tables, the USPSTF estimates the magnitude of benefits and the magnitude of harms, and synthesizes them into an estimate of the magnitude of net benefit. Although some judgment is required at all steps, the USPSTF strives to make the process as explicit and transparent as possible. The USPSTF anticipates that its methods for making evidence-based recommendations will continue to evolve.

Background: The benefits and risks of performing annual cervical smears on postmenopausal women are not well defined. The independent effect of hormone replacement therapy on development of cytologic abnormalities is unknown., Objective: To determine the positive predictive value of cervical smears in previously screened postmenopausal women and to determine the effect of oral estrogen plus progestin on incident cervical cytologic abnormalities., Design: Prospective cohort study (incidence) and randomized, double-blind, placebo-controlled trial (hormone therapy)., Setting: 20 U.S. outpatient and community clinical centers., Participants: 2561 women with a uterus and normal cytologic characteristics at baseline., Interventions: Annual smears; oral conjugated equine estrogens, 0. 625 mg/d, plus medroxyprogesterone acetate, 2.5 mg/d, or identical placebo., Measurements: Incident cytologic abnormalities (atypical squamous cells of undetermined significance, atypical glandular cells of undetermined significance, low-grade squamous epithelial lesion, and high-grade squamous epithelial lesion) and final histologic diagnoses., Results: The incidence of new cytologic abnormalities in the 2 years following a normal smear was 110 per 4895 person-years (23 per 1000 person-years [95% CI, 18 to 27 per 1000 person-years]). Among the 103 women with known histologic diagnoses, one had mild to moderate dysplasia. The positive predictive value of any smear abnormality identified 1 year after a normal smear, therefore, was 0% (CI, 0% to 5.0%) (0 of 78 women); the positive predictive value of abnormalities found within 2 years was 0.9% (CI, 0.0% to 3.0%) (1 of 110 women). In hormone-treated compared with non-hormone-treated women, the incidence of cytologic abnormalities was nonsignificantly higher (relative hazard, 1.36 [CI, 0.93 to 1.99]), largely because of a nonsignificant 58% greater incidence of atypical squamous cells of undetermined significance (relative hazard, 1.58 [CI, 0.99 to 2.52])., Conclusions: Because of a poor positive predictive value, cervical smears should not be performed within 2 years of normal cytologic results in postmenopausal women. Therapy with oral estrogen plus progestin does not significantly affect the incidence of cytologic abnormalities.