Updated clinical guideline for human papillomavirus vaccine: the Korean Society of Gynecologic Oncology guidelines / 부인종양

Since the human papillomavirus (HPV) vaccine guidelines were developed by the Korean Society of Gynecologic Oncology (KSGO) in 2011, 2016, and 2019, several recent studies on the efficacy and safety of HPV vaccines in middle-aged women and men have been reported. Furthermore, there has been an ongoing debate regarding the efficacy of the HPV vaccine in women with prior HPV infection or who have undergone conization for cervical intraepithelial neoplasia (CIN). We searched and reviewed studies on the efficacy and safety of the HPV vaccine in middle-aged women and men and the efficacy of the HPV vaccine in patients infected with HPV and those who underwent conization for CIN. The KSGO updated their guidelines based on the results of the studies included in this review.

Discrepancy between Cytology and Histology in Cervical Cancer Screening:a Multicenter Retrospective Study (KGOG 1040)

Background@#Cervical cancer is the fourth common cancer in women worldwide. The Papanicolau test is the primary screening procedure to detect abnormal cervical cells.Colposcopy is the main procedure for discriminating high-grade cervical lesions. The study aimed at clarifying the discrepancy between cervical cytology and colposcopic biopsy histology as well as confounding factors. @*Methods@#Eligible patients visited thirteen tertiary hospitals for colposcopic biopsy following cervical cytology and human papillomavirus (HPV) genotypes between January and December 2018. Baseline characteristics including age, body mass index (BMI), and parity were collected. @*Results@#In our study, 3,798 eligible patients were included. Mean age of patients was 42.7(19–88) years and mean BMI was 22.5 (16.9–34.1) kg/m2 . The referred cervical cytologic findings consisted of 495 normal, 1,390 atypical squamous cells of undetermined significance, 380 atypical squamous cells cannot exclude high-grade squamous intraepithelial lesion, 792 low-grade squamous intraepithelial lesion, 593 high-grade squamous intraepithelial lesion, 79 atypical glandular cells, 46 squamous cell carcinoma, and 23 adenocarcinoma. HPV-positive findings were found in 3,008 (79.2%) patients and were not detected in 914 (24.1%) cases. The risk of unexpected low-grade lesions from histology was higher in patients > 45 years (odds ratio [OR], 2.137; 95% confidence intervals [CIs], 1.475–3.096). In contrast, the risk of unexpected high-grade lesions from colposcopic biopsy was lower in patients ≥ 45 years (OR, 0.530; 95% CI, 0.367–0.747) and HPV 16/18 infection was higher than other HPV (OR, 1.848; 95% CI, 1.385–2.469). @*Conclusion@#Age and HPV genotypes were responsible for the discrepancies between cytology and histology. Precautions should be taken for women over the age of 45 in triage for colposcopy in order to avoid unnecessary testing.

Performance and Diagnostic Accuracy of Human Papillomavirus Testing on Self-Collected Urine and Vaginal Samples in a Referral Population / Journal of the Korean Cancer Association, 대한암학회지

Purpose@#The study aimed to evaluate the diagnostic accuracy of polymerase chain reaction ‒based high-risk human papillomavirus (HPV) assays on self-collected vaginal and urine samples for detection of precancerous cervical lesions in referral population. @*Materials and Methods@#Women referred for colposcopy following abnormal cytology, were included this study. A total of 314 matched urine, vaginal, and cervical samples were collected. All samples were tested for HPV DNA using the RealTime HR-S HPV and Anyplex II HPV 28 assays. Primary endpoints were sensitivity for cervical intraepithelial neoplasia (CIN) 2+/CIN3+ and specificity for

Discrepancy between Cytology and Histology in Cervical Cancer Screening:a Multicenter Retrospective Study (KGOG 1040)

Background@#Cervical cancer is the fourth common cancer in women worldwide. The Papanicolau test is the primary screening procedure to detect abnormal cervical cells.Colposcopy is the main procedure for discriminating high-grade cervical lesions. The study aimed at clarifying the discrepancy between cervical cytology and colposcopic biopsy histology as well as confounding factors. @*Methods@#Eligible patients visited thirteen tertiary hospitals for colposcopic biopsy following cervical cytology and human papillomavirus (HPV) genotypes between January and December 2018. Baseline characteristics including age, body mass index (BMI), and parity were collected. @*Results@#In our study, 3,798 eligible patients were included. Mean age of patients was 42.7(19–88) years and mean BMI was 22.5 (16.9–34.1) kg/m2 . The referred cervical cytologic findings consisted of 495 normal, 1,390 atypical squamous cells of undetermined significance, 380 atypical squamous cells cannot exclude high-grade squamous intraepithelial lesion, 792 low-grade squamous intraepithelial lesion, 593 high-grade squamous intraepithelial lesion, 79 atypical glandular cells, 46 squamous cell carcinoma, and 23 adenocarcinoma. HPV-positive findings were found in 3,008 (79.2%) patients and were not detected in 914 (24.1%) cases. The risk of unexpected low-grade lesions from histology was higher in patients > 45 years (odds ratio [OR], 2.137; 95% confidence intervals [CIs], 1.475–3.096). In contrast, the risk of unexpected high-grade lesions from colposcopic biopsy was lower in patients ≥ 45 years (OR, 0.530; 95% CI, 0.367–0.747) and HPV 16/18 infection was higher than other HPV (OR, 1.848; 95% CI, 1.385–2.469). @*Conclusion@#Age and HPV genotypes were responsible for the discrepancies between cytology and histology. Precautions should be taken for women over the age of 45 in triage for colposcopy in order to avoid unnecessary testing.

Performance and Diagnostic Accuracy of Human Papillomavirus Testing on Self-Collected Urine and Vaginal Samples in a Referral Population / Journal of the Korean Cancer Association, 대한암학회지

Purpose@#The study aimed to evaluate the diagnostic accuracy of polymerase chain reaction ‒based high-risk human papillomavirus (HPV) assays on self-collected vaginal and urine samples for detection of precancerous cervical lesions in referral population. @*Materials and Methods@#Women referred for colposcopy following abnormal cytology, were included this study. A total of 314 matched urine, vaginal, and cervical samples were collected. All samples were tested for HPV DNA using the RealTime HR-S HPV and Anyplex II HPV 28 assays. Primary endpoints were sensitivity for cervical intraepithelial neoplasia (CIN) 2+/CIN3+ and specificity for

Stage II endometrial cancer requires stratification according to uterine risk factor and sentinel lymph node sampling / 부인종양

No abstract available.

Risk factors for type-specific persistence of high-risk human papillomavirus and residual/recurrent cervical intraepithelial neoplasia after surgical treatment

Objective@#This study aimed to investigate the clinicopathologic risk factors for type-specific persistence of high-risk human papillomavirus (hrHPV) and residual/recurrent cervical intraepithelial neoplasia (CIN) after surgical treatment. @*Methods@#Patients with CIN-2/3 who underwent conization or loop electrosurgical excision procedure (LEEP) at Korea University Hospital were enrolled. All patients underwent hrHPV testing and genotyping before conization or LEEP followed by both hrHPV genotyping and cytology. The significance of associations between patient characteristics and persistence of infection were assessed by multivariate logistic regression analyses. @*Results@#Among 398 women with pathologically confirmed CIN-2/3, 154 (38.7%) patients showed hrHPV persistence after surgical treatment. In multivariate analysis, high preoperative hrHPV load (P<0.05; odds ratio [OR], 2.063), presence of CIN-2 at treatment (P<0.01; OR, 2.732), and multiple hrHPV infections (P<0.001; OR, 4.752) were associated with hrHPV persistence. HPV 53 was the most likely to persist after treatment (24/43, 55.8%). The risk of residual/recurrent CIN-2/3 was higher in persistent infection with HPV 16 than other types (P<0.05). Menopause (P<0.001; OR, 3.969), preoperative and postoperative hrHPV load (P<0.05; OR, 2.430; P<0.05; OR, 5.351), and infection with multiple hrHPV types (P<0.05; OR, 2.345) were significantly related to residual/recurrent CIN following surgical treatment. @*Conclusion@#HPV load before treatment and infection with multiple hrHPV types were predictors of postoperative hrHPV persistence. HPV 53 was the type most likely to persist, but HPV 16 was the type that was most closely associated with residual/recurrent CIN-2/3.

Risk factors for type-specific persistence of high-risk human papillomavirus and residual/recurrent cervical intraepithelial neoplasia after surgical treatment

Objective@#This study aimed to investigate the clinicopathologic risk factors for type-specific persistence of high-risk human papillomavirus (hrHPV) and residual/recurrent cervical intraepithelial neoplasia (CIN) after surgical treatment. @*Methods@#Patients with CIN-2/3 who underwent conization or loop electrosurgical excision procedure (LEEP) at Korea University Hospital were enrolled. All patients underwent hrHPV testing and genotyping before conization or LEEP followed by both hrHPV genotyping and cytology. The significance of associations between patient characteristics and persistence of infection were assessed by multivariate logistic regression analyses. @*Results@#Among 398 women with pathologically confirmed CIN-2/3, 154 (38.7%) patients showed hrHPV persistence after surgical treatment. In multivariate analysis, high preoperative hrHPV load (P<0.05; odds ratio [OR], 2.063), presence of CIN-2 at treatment (P<0.01; OR, 2.732), and multiple hrHPV infections (P<0.001; OR, 4.752) were associated with hrHPV persistence. HPV 53 was the most likely to persist after treatment (24/43, 55.8%). The risk of residual/recurrent CIN-2/3 was higher in persistent infection with HPV 16 than other types (P<0.05). Menopause (P<0.001; OR, 3.969), preoperative and postoperative hrHPV load (P<0.05; OR, 2.430; P<0.05; OR, 5.351), and infection with multiple hrHPV types (P<0.05; OR, 2.345) were significantly related to residual/recurrent CIN following surgical treatment. @*Conclusion@#HPV load before treatment and infection with multiple hrHPV types were predictors of postoperative hrHPV persistence. HPV 53 was the type most likely to persist, but HPV 16 was the type that was most closely associated with residual/recurrent CIN-2/3.

Clinical guideline for 9-valent HPV vaccine: Korean Society of Gynecologic Oncology Guideline / 부인종양

In 2016, 9-valent human papillomavirus (HPV) vaccine has been newly introduced in Korea, thus the need to develop recommendations for the vaccine has raised. Until we decide to develop a guideline, no further studies on the bi-valent or quadri-valent HPV vaccine have been announced. We searched and reviewed the literatures focused on the efficacy of 9-valent HPV vaccine, the ideal age of 3-dose schedule vaccination, the efficacy of 9-valent HPV vaccine in middle-aged women, the efficacy of the 2-dose schedule vaccination, the safety of 9-valent HPV vaccine, the possibility of additional 9-valent HPV vaccination, and cross-vaccination of 9-valent HPV vaccine. So, Korean Society of Gynecologic Oncology (KSGO) developed a guideline only for 9-valent HPV vaccine.

Uterocutaneous fistula after pelviscopic myomectomy - successful diagnosis with hystero-salpingo contrast sonography and complete tract resection and medical treatment for fertility preservation in young woman: a case report

A uterocutaneous fistula is rarely reported clinical condition after uterine procedures. Many diagnostic and management strategies are being suggested. In this case report, uterocutaneous fistula after pelviscopic myomectomy was diagnosed simply with hystero-salpingo contrast sonography and managed by surgical tract excision without hysterectomy and uterine wall dehiscence repair combined with medical treatment using gonadotropin-releasing hormone agonist succeeded to preserve fertility in young woman.

The comparison of surgical outcomes and learning curves of radical hysterectomy by laparoscopy and robotic system for cervical cancer: an experience of a single surgeon

OBJECTIVE: The aim of this study was to compare and determine the feasibility, surgical outcomes, learning curves of robotic radical hysterectomy with lymph node dissection (RRHND) to conventional laparoscopic radical hysterectomy with lymph node dissection (LRHND) performed by a single surgeon, in patients with cervical cancer. METHODS: Between April 2009 and March 2013, 22 patients underwent LRHND and 19 patients underwent RRHND. Variables such as age, body mass index, International Federation of Gynecology and Obstetrics stage, histological results, number of dissected lymph nodes, operative time, estimated blood loss, days of hospitalization and complications were reviewed. Learning curves of operation time was obtained using cumulative sum (CUSUM) method. RESULTS: Both groups showed similar patient and tumor characteristics. In surgical outcome analysis, RRHND (51.8±10.4 minutes) showed longer preparing time than LRHND (42.5±14.1 minutes). In the LRHND group, 8 patients experienced postoperative complications (5 void difficulty, 1 postoperative bleeding, 1 right basal ganglia infarction, 1 fever). On the other hand, in the RRHND group, 4 patients experienced a postoperative complication (2 bleeding, 1 peritonitis, 1 dehiscence of trocar site). Using CUSUM method, the learning curves were obtained by plotting the cumulative sequential differences between each data point and the average operation time, and showed two distinct phases in both type of operations. CONCLUSION: RRHND would be appropriate surgical approach in patients with cervical cancer with favorable outcome of less voiding difficulty. A minimum of 13 cases of robotic radical hysterectomies are required to achieve surgical improvement in the treatment of cervical cancer.

Prevalence of human papillomavirus genotypes and precancerous cervical lesions in a screening population in the Republic of Korea, 2014–2016 / 부인종양

OBJECTIVE: Knowledge regarding the prevalence and distribution of human papillomavirus (HPV) genotyping in healthy women is important in establishing strategies for cervical cancer screening and HPV vaccination. METHODS: A total of 18,170 women who visited a Korean Medical Institute for health check-ups were recruited retrospectively; they underwent HPV genotyping and conventional cervical cytology. An HPV DNA test was performed using the Anyplex™ II HPV 28 detection system (Seegene) or HPV Liquid Bead Microarray (Osang Healthcare). The distribution of HPV genotypes was assessed according to cervical cytology and age. RESULTS: HPV was detected in 3,037 (16.71%) of the 18,170 women enrolled, and 2,268 (12.48%) were positive for high-risk (HR) HPV. In total, HPV 53 (9.69% of all detected HPV viruses) was the most common type; HPV 58 (7.90%) and 52 (7.81%) were also common. HPV 54 (6.99%) was common in low-risk subjects. Overall and in the normal cytology group, the most common HPV genotype was HPV 53, whereas HPV 58 was more common in women who had atypical squamous cells of undetermined significance or low-grade squamous intraepithelial neoplasia cervical cytology. In addition, HPV 16 was the most common type in cases with high-grade squamous intraepithelial neoplasia (HSIL)/atypical squamous cells-cannot exclude HSIL. Among women with normal cytology, 76 of 231 (32.9%) women under 24 years of age were positive for HR HPV, whereas 84 of 852 (9.9%) women aged 55–59 years were positive. CONCLUSION: HPV 53 was the most prevalent genotype in healthy women. Distribution of HPV genotypes varied with cervical cytology and age. Our study provides important baseline data for the recently implemented national HPV vaccination program.

Non-convulsive seizure related to Cremophor EL™-free, polymeric micelle formulation of paclitaxel: a case report

Paclitaxel is a chemotherapeutic agent that is effective against ovarian, breast, lung, and other cancers. Although peripheral neurotoxicity is among the most common side effects of paclitaxel treatment, central neurotoxicity is rarely reported. When centrally mediated side effects are observed, they are attributed to Cremophor EL™ (CrEL), a surfactant-containing vehicle used for paclitaxel administration. In the present report, we discuss the case of a 72-year-old woman with ovarian carcinoma who experienced a non-convulsive seizure following administration of a CrEL-free, polymeric micelle formulation of paclitaxel. One week after her fourth round of chemotherapy, she experienced a transient episode of aphasia for 45 minutes. Electroencephalography demonstrated epileptiform discharges. To our knowledge, this is the first reported case of seizure associated with a CrEL-free formulation of paclitaxel. Although rare, patients and clinicians should remain aware of the risk of non-convulsive seizure following infusion of this paclitaxel formulation.

Programmed death-1 (PD-1) expression in cervical intraepithelial neoplasia and its relationship with recurrence after conization / 부인종양

OBJECTIVE: Impaired local cellular immunity contributes to persistent human papillomavirus (HPV) infection and development of cervical intraepithelial neoplasia (CIN). Programmed death-1 (PD-1) and its ligands PD-ligand-1 (L1) and PD-L2 are negative regulators of T cell activity in various cancers, but few studies exist. The aim of this study was to determine the clinicopathologic and immunologic parameters (PD-1, PD-L1, and PD-L2) related to the persistence/recurrence of CIN after conization. METHODS: Medical records of 652 patients diagnosed with CIN and underwent conization were reviewed. The associations between clinicopathologic parameters (e.g., age, parity, initial HPV load, etc.) and persistence/recurrence of CIN were analyzed. Expression of PD-1, PD-L1, and PD-L2 was assessed on 100 conization specimens by immunohistochemistry (IHC) in women matched for propensity-score (50 with persistence/recurrence and 50 without). RESULTS: Initial HPV load (>1,000 relative light unit) and positive margin were shown to be significantly associated with CIN persistence/recurrence (p=0.012 and p < 0.001, respectively). Multivariate analysis showed that margin status was an independent predictor of persistence/recurrence (hazard ratio=8.86; 95% confidence interval=1.67–16.81; p < 0.001). On IHC analysis, none of the patients expressed PD-L1. PD-1+ T cells were observed in 25 of 100 patients. Also, PD-1+ T cells were significantly correlated with increasing grade of CIN (p=0.031). In addition, patients with persistence/recurrence had increased expression of PD-1 compared with those without (36% vs. 14%, respectively; p=0.020). Although PD-L2 expression did not differ between 2 groups, it was significantly higher in patients with high-grade CIN compared to low-grade (34.7% vs. 12%, respectively; p=0.041). CONCLUSION: Positive surgical margin and expression of PD-1+ T cells were associated with CIN persistence/recurrence after conization.

Comparison of the Accuracy of Syringes Washed with Heparin, Manually and Heparin Coated Product for Arterial Blood Gas Analysis on Electrolytes and Hemoglobin

PURPOSE: The results of arterial blood gas analysis using conventional liquid sodium heparin syringes are inaccurate due to the dilution effect, chelation of heparin and the electrolyte, and interference of the heparin electrolyte measurement. This study compared the accuracy of using heparin with a liquid sodium heparin syringe (LHs) and balanced lithium/zinc heparin syringe (BHs). METHODS: This study evaluated 6,778 cases who underwent an arterial blood gas test, serum electrolytes test, and complete blood count test among patients aged 18 years or older who visited the emergency room from November 1, 2016 to March 3, 2017. Finally, there were 2,383 cases using LHs and 2,584 cases using BHs. The results were compared between the groups using the LHs and BHs for sodium, potassium, and hemoglobin, and the agreement was compared using the Bland-Altman plot. RESULTS: Sodium difference value was the 5.714±5.696 mmol/L in the LHs group, -1.549±3.339 mmol/L in the BHs group. The potassium difference value was -0.650±0.494 mmol/L (LHs group) and -0.257±0.367 mmol/L (BHs group). The hemoglobin difference values were -0.556±1.116 g/dL (LHs group) and -0.170±1.062 g/dL (BHs group). The results showed that the BHs group was improved compared to the LHs group (p<0.001). CONCLUSION: The results of arterial blood gas analysis of sodium, potassium, and hemoglobin were more accurate for the BHs group than the LHs group based on the serum electrolytes and complete blood counts.

Atypical squamous cells of undetermined significance and low-grade squamous intraepithelial lesion triage in Korean women: Revisiting the 2012 American Society of Colposcopy and Cervical Pathology screening guidelines

OBJECTIVE: To determine whether triage for atypical squamous cells of undetermined significance (ASC-US) and low-grade squamous intraepithelial lesion (LSIL) from the updated American Society for Colposcopy and Cervical Pathology cervical cancer screening guidelines is applicable in Korean women. METHODS: We investigated women with ASC-US or LSIL including referred from local hospitals visited for cervical cancer screening at Korea University Guro Hospital from February 2004 to December 2014. Detailed information on the results of Papanicolaou (Pap) smears, human papillomavirus (HPV) DNA tests, and cervical biopsies were collected through chart review. Cervical biopsy results were compared in eligible women according to individual Pap smear findings and HPV DNA status. RESULTS: Of 216,723 possible cases, 3,196 were included. There were 212 (6.6%) women with ASC-US and 500 (15.6%) with LSIL. The risk of ≥cervical intraepithelial neoplasia (CIN) 2 was significantly higher in women who were ASC-US/HPV+ than ASC-US/HPV- and LSIL/HPV+ than LSIL/HPV- (93.3% vs. 6.7% and 96.7% vs. 3.3%, P<0.001 and P<0.001, respectively). The risk of ≥CIN 3 was also significantly higher in women who were ASC-US/HPV+ than ASC-US/HPV- and LSIL/HPV+ than LSIL/HPV- (97.0% vs. 3.0% and 93.0% vs. 7.0%, P<0.001 and P<0.001, respectively). Age-stratified analysis revealed that more CIN 2 or CIN 3 was diagnosed in women aged 30 to 70 with ASC-US or LSIL when HPV DNA was present. CONCLUSION: Observation with Pap and HPV DNA tests rather than immediate colposcopy is a reasonable strategy for ASC-US or LSIL when the HPV DNA test is negative, especially in women aged 30 to 70. Reflection of these results should be considered in future Korean screening guidelines.

The Characteristics of First Suicide Attempt Patients with Self-poisoning: Comparison of Patients with Self-injury

PURPOSE: This study was conducted to compare the characteristics of first suicide attempt patients with self-poisoning with those of self-injured patients. METHODS: In this retrospective data analysis, data were collected from emergency department patients who made a first suicide attempt between October 2013 and January 2017. Data included demographic, socioeconomic, physical and mental health status, method of suicide attempt, and authenticity of suicide intent. Patients were classified into a self-poisoning and self-injury group. RESULTS: Among 2,252 patients, 788 patients were making their first suicide attempt. Of these patients, 443 were self-poisoning patients. Males were less common among the self-poisoning group. Cohabitants (303 [89.4%] vs. 193 [81.4%]; p=0.010), married state (214 [57.4%] vs. 108 [41.2%]; p<0.001), and asking for help after suicide attempt (136 [86.1%] vs. 103 [73.6%]; p=0.009) was more common in the self-poisoning group than the self-injury group. However, planned suicide attempt was more frequent in the self-injury group (26 [16.0%] vs. 9 [4.7%]; p=0.001). Moreover, authenticity of suicide intent was higher in the self-injury group (12 [11.3%] vs. 42 [40.4%]; p<0.001). CONCLUSION: In the self-poisoning group, there was a higher rate of females, married people, existing cohabitants, and tendency to ask for help after suicide attempt. There were also more impulsive suicide attempts in this group. The results presented herein will help prevent self-poisoning suicide attempts among high risk patients.

Preventive vaccination against cervical cancer: Korean Society of Gynecologic Oncology Guideline / 부인종양

After human papillomavirus (HPV) vaccine guidelines published by Korean Society of Gynecologic Oncology (KSGO) in 2011, new studies have been published, leading to additional data regarding efficacy, safety, number of vaccination rounds, and ideal age of vaccine administration. We searched and reviewed the literatures focused on the efficacy of 2-dose schedule vaccination, the efficacy of 3-dose schedule vaccination in middle-aged women, the ideal age of 3-dose schedule vaccination, the safety of HPV preventive vaccine, and the ability of cross-protection of each HPV preventive vaccine. The KSGO has revised the previous guideline based on the results of the above studies.

Delayed retropneumoperitoneum following vaginal laceration in a 7-year-old girl

We describe an unusual case of delayed retropneumoperitoneum caused by a deep vaginal laceration as a result trauma from a water jet in a fountain. A 7-year-old premenarcheal girl presented to the emergency department after experiencing an injury from a water jet at a fountain park. Initially, the patient's vital sign and perineum were within normal range. Because the patient's vital signs became unstable 12 hours after vaginal injury, we carried out abdomino-pelvic computed tomography resulting in retropneumoperitoneum. Arterial bleeding from vaginal lateral wall was founded and controlled by electrocoagulation. No damage to the rectum was laparoscopically confirmed. A diagnostic laparoscopy, not laparotomy, should be considered in cases of retropneumoperitoneum with an ambiguous cause first.

The Korean guideline for cervical cancer screening / 부인종양

The incidence rate of cervical cancer in Korea is still higher than in other developed countries, notwithstanding the national mass-screening program. Furthermore, a new method has been introduced in cervical cancer screening. Therefore, the committee for cervical cancer screening in Korea updated the recommendation statement established in 2002. The new version of the guideline was developed by the committee using evidence-based methods. The committee reviewed the evidence for the benefits and harms of the Papanicolaou test, liquid-based cytology, and human papillomavirus (HPV) testing, and reached conclusions after deliberation. The committee recommends screening for cervical cancer with cytology (Papanicolaou test or liquid-based cytology) every three years in women older than 20 years of age (recommendation A). The cervical cytology combined with HPV test is optionally recommended after taking into consideration individual risk or preference (recommendation C). The current evidence for primary HPV screening is insufficient to assess the benefits and harms of cervical cancer screening (recommendation I). Cervical cancer screening can be terminated at the age of 74 years if more than three consecutive negative cytology reports have been confirmed within 10 years (recommendation D).