Cervical cancer: Screening and prevention

In Germany, women aged 20 and over can regularly have screening tests for cervical cancer (paid for by their statutory health insurer). These tests include:

• a smear test (Pap test) to look for abnormal cells, and
• an HPV test to look for certain types of human papillomavirus (HPV) that are considered to be the main cause of cervical cancer.

Smear tests have been used to screen for cervical cancer over many decades. HPV tests have been used for a few years now too. Research has shown that they are also suitable for cervical cancer screening.

Women between the ages of 20 and 34 can have a free smear test once a year. From the age of 35, women are offered a combined test that includes a smear test and an HPV test every three years.

You can download more information on the screening tests offered to women between the ages of 20 and 34 and those offered to women aged 35 and over from the German Federal Joint Committee’s website.

In Pap tests, the doctor inserts an instrument (speculum) into the vagina and scrapes off mucous membrane cells using a small spatula or brush. The cells are taken from the part of the cervix that sticks out into the vagina, as well as from the opening of the cervix. This takes a few seconds and usually doesn’t hurt.

The samples of cells are sent to a lab, where they are examined under a microscope to find out whether there are any abnormal cells and – if so – how much they have changed. The results usually come back within a week.

Most women’s Pap test results are normal. All they have to do is go back and have another Pap test a year later at the earliest. And most “abnormal” cells turn out to be harmless or easy to treat – and not cancer. The following table describes what the different Pap test results mean.

If abnormal cells are found, the treatment options will depend on how much the cells have changed. Mild and moderate cell changes (dyplasia) are usually just monitored. Cells that have changed a lot often develop into cancer, so doctors recommend surgery to remove them.

The HPV test is used to find out whether the cervix is infected with human papillomaviruses (HPV) that can cause cervical cancer. But it can’t predict whether the infection will clear up on its own or become a long-term infection. The test can determine what type of HPV virus a woman has.

• Certain types of HPV are associated with a higher risk of cervical cancer.
• If the test doesn’t find any HPV viruses (a negative HPV test), and the Pap test results are normal, the woman didn’t have a higher risk of getting cervical cancer at the time the test was done.
• The test may also find more harmless HPV viruses that only cause genital warts.

Just like the Pap test, the HPV test involves taking a sample of cells from the part of the cervix that sticks out into the vagina, as well as from the opening of the cervix.

All statutory health insurers in Germany cover the costs of an HPV test if a woman’s Pap test results are abnormal. HPV tests are also a normal part of the screening program for women aged 35 and over. The statutory health insurers usually cover the costs of an HPV test if it is done to check how successful surgery was.

Some gynecologists also ask women under the age of 35 whether they would like to have an HPV test to screen for cervical cancer. It is then an individual health care service (in German: Individuelle Gesundheitsleistung, or IGeL for short), which people have to pay for themselves.

The main advantage of cervical screening is that abnormal cells that might turn into cancer can be discovered and removed in time. Regular screening greatly reduces the risk of developing cervical cancer. Unpleasant and difficult treatments such as surgery, radiotherapy and chemotherapy can be avoided. And discovering cervical cancer early on may improve the chances of successful treatment.

The following tables show projections of how many women develop cervical cancer or die of it if they go for screening and if they don’t go for screening. The numbers in the column “with screening” refer to women who start going for cervical screening between the ages of 20 and 30, and who continue to go regularly for the rest of their life. Because the HPV vaccine greatly reduces the risk of cervical cancer, the projections for women who have, and haven’t, had the vaccine are shown in two separate tables.

Although Pap tests and HPV tests are the best ways to detect abnormal cells early on, they do have their limits. Women who regularly have these tests will probably have “abnormal results” that turn out to be nothing serious at least once in their life.

The tests also lead to the discovery of abnormal cells that would never have turned into cancer. Once discovered, these harmless cells are often removed through a surgical procedure known as conization or a cone biopsy. Unnecessary treatments like this can hardly be avoided when people go for screening. This is because it's not possible to predict which abnormal cells will develop into cancer, and which won’t. But the risk of unnecessary treatment can be reduced if you wait and monitor the development of cells that have only minor or moderate changes, rather than operating straight away.

According to estimates, surgery (conization) will be carried out in

• about 110 to 120 out of 1,000 women who haven’t had an HPV vaccine, and
• about 40 out of 1,000 women who have had an HPV vaccine.

As above, these numbers refer to women who start going for cervical screening between the ages of 20 and 30, and who continue to go regularly for the rest of their life.

Screening offers the most effective protection from cervical cancer if you go regularly. Generally speaking, though, only having a Pap test every two or three years is just as effective as having one every year. And women then face fewer abnormal results and worry less. This reduces the risk of unnecessary treatment too.

Women can decide for themselves – or together with their doctor – when to start going for screening, and how regularly they would like to go. In most countries, cervical screening starts being offered between the ages of 20 and 30.

A lot of doctors offer women extra screening tests which they have to pay for themselves. In Germany, these are known as individual health care services (Individuelle Gesundheitsleistungen, or IGeL for short). All of the necessary screening tests for cervical cancer are paid for by statutory health insurers. Extra tests don’t offer any advantages. Instead, they increase the risk of unnecessary worrying and unnecessary treatments due to abnormal findings that turn out to be nothing serious.

Regular screening helps to discover most abnormal cell changes early enough. One Pap test alone isn’t reliable enough, though: About half of all major cell changes aren’t discovered in this way. But those that aren’t discovered one year will usually be discovered in time through screening in the years after that. Still, there’s no guarantee that all potentially dangerous cell changes will be discovered and that cancer will always be prevented.

So it’s important to see your doctor if you notice changes such as unusual bleeding or unusual discharge.