Pap and HPV screening tests for early detection of cervical cancer

In Germany, women aged 20 and over can regularly have screening tests for cervical cancer (paid for by their statutory health insurer). Gynecologists offer this kind of screening.

These tests are available:

• Pap test (Pap smear): A smear sample of the mucous membrane is taken and tested for changes in the cells.
• HPV test: A smear sample of the mucous membrane is tested for certain human papillomaviruses (HPV) that are considered to be the main cause of cervical cancer.

The Pap test has been used for decades to screen for cervical cancer. The HPV test is now used in addition. Research has shown that HPV tests are also suitable for cervical cancer screening.

Women between the ages of 20 and 34 can have a free Pap test once a year. Women aged 35 and over are eligible for a combination of the Pap test and the HPV test every three years.

This screening policy can reliably detect the early stages of cervical cancer and then help to have them treated in time. Scientific studies have shown this. More frequent screening – like getting a Pap test once per year after the age of 35 – is not necessary.

You can download more information (in German) 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 protrudes 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. That means that the test hasn't found any changes in the tissue. All they have to do is go back and have another Pap test a year later.

And most “abnormal” results turn out to be caused by something that is harmless or easy to treat – not by cancer. The following table describes what the different Pap test results mean:

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

The sample is then tested for HPV, which can cause cervical cancer. The test can also be used to find out what type of virus was causing the infection.

The following test results are possible:

• The test does not find any human papillomaviruses (negative HPV test) and the Pap test is normal: Then there is no risk of developing cervical cancer at the time the test was done.
• The test detects human papillomaviruses that increase the risk of cervical cancer.
• The test detects human paillomaviruses that will only cause genital warts.

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

The next steps will depend on the result of the HPV test and the appearance of the cells in the Pap smear. If the abnormalities are minor, the test can be repeated one year later. If the abnormalities are major, other testing, like a colposcopy, are done soon afterwards.

Decisions on whether to treat changes in the tissue will depend on how advanced the changes are. Mild and moderate dyplasias are usually just monitored because they often go away on their own. Cells that have changed a lot often develop into cancer, so doctors recommend surgery to remove them.

The main advantage of cervical screening is that abnormal cells which 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 detecting 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 isn’t 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.

Based on the projections, conization will be carried out in

• about 110 to 120 out of 1,000 women who haven’t had an HPV vaccine.
• 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. 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). These could include HPV tests for women under the age of 35, for instance. That costs between 50 and 100 euros.

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 in time. 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 between periods or unusual discharge.