Cervical Screening and the Abnormal Pap: The Evidence Behind the Pathway

A 34-year-old agricultural labourer comes to the district hospital outpatient clinic. She has had bleeding after intercourse for two months. Her husband has brought the card from a screening camp at the primary health centre: VIA negative, eight weeks ago. She has two children and would like a third. She has come 60 km by bus, and she asks whether she can go home today. This is an illustrative case, not a real patient.

The Cervical Screening and Pap pathway will tell you what to do with her: who is due for which test, what to do with each abnormal result, which lesions may be ablated and which must be excised, and how long she must be followed. What it no longer carries is some of the why: the natural history that makes this cancer preventable, why India uses the test it uses, and the reasoning behind screen and treat and behind the conditional management of CIN2. That has moved here, so that the tool stays quick at the bedside. By the end of this article you will know what the card in her hand can and cannot tell you.

1. A cancer that can be prevented twice

Start with why screening works at all. Almost every case begins with a persistent infection by a high-risk human papillomavirus type and passes through a detectable precancerous phase lasting years. Very few cancers offer two independent chances that far ahead of the disease. The first chance is before exposure: vaccination. The second is after it: finding and treating the precursor lesion.

“Then why do Indian women still die of it?” India carries a large share of the global burden. The biology is not different and the tools are not unavailable. Coverage is low, and the woman who does screen positive often never gets from that result to a diagnosis, or from a diagnosis to treatment. The weak link is rarely the laboratory. It is the next step, and the next step is ours.

2. Three frameworks at once

A resident in India works inside three sets of rules at the same time. The national programme runs VIA, visual inspection of the cervix after acetic acid. WHO recommends HPV DNA testing. And the 2019 ASCCP guidelines govern what a hospital with colposcopy does with an abnormal cytology report. Here is who is screened, with what and how often, as the tool carried it on 4 November 2026. The tool now shows it as two smaller tables.

India is changing. In April 2025 the validation of HPV detection tests developed in India was announced, four point-of-care tests were evaluated and two were found suitable for use in the National Programme. Until a state or a district has actually switched, VIA is what a primary health centre has, and the honest course is to use it well while knowing what it misses.

3. What the negative VIA on her card means

“But she was screened. Her VIA was negative.” It was, and here is how much that is worth. VIA is what the national programme runs, and there are good reasons for that: it is inexpensive, needs no laboratory, gives an immediate result, and permits treatment at the same visit. It also has a sensitivity in the region of a third in comparative evaluations, against roughly 98 per cent for HPV DNA testing. Both facts are true simultaneously.

A test that finds about one lesion in three is useful across a population and weak in one woman. So a negative VIA is a weak negative, and it must never overrule a symptom. Our patient has postcoital bleeding. She needs a speculum examination today, a biopsy of anything you can see, and a referral. The card from eight weeks ago adds nothing to that decision. The common mistake is not a false positive; it is a false negative used as reassurance.

4. Why screen and treat exists

Now think about the bus ride. In a conventional pathway a woman screens positive, is referred for colposcopy, returns for biopsy, returns again for the result, and returns a fourth time for treatment. Attrition at each step is substantial, and for a woman who has travelled from a village and lost a day’s wages each time it is entirely rational. Screen-and-treat compresses this into one visit by treating an eligible lesion immediately with ablation.

“So why not ablate everyone who is positive?” Because ablation leaves no specimen. That trade is acceptable only when the lesion meets every eligibility criterion. A lesion that runs into the canal, or a glandular abnormality, must be excised, never ablated, or the evidence of a cancer is destroyed without curing it. The tool checks the criteria one by one.

5. CIN2, and why its management is conditional

Our patient’s biopsy comes back as CIN2. Of all the histological grades, CIN2 has the poorest reproducibility between pathologists, and a substantial proportion regresses spontaneously, particularly in women under 30. That is why its management is genuinely conditional rather than automatic.

The tool offers two paths: treat, or observe with 6-monthly colposcopy and testing for up to 2 years in a young woman who has not completed her family, provided she will actually return. She is 34, she wants another child, and she lives 60 km away on one bus a day. Observation depends entirely on her coming back. Treating her now is the safer choice, and that is a judgement about her circumstances, not her histology. If she is excised, tell her that excision raises the risk of preterm birth with the depth of tissue removed, so that her next pregnancy is managed with that history known.

Try this

A 38-year-old woman’s cytology report reads “atypical glandular cells”. The colposcopy is normal. The resident writes “colposcopy normal, routine screening”. Is that right? Illustrative case.

Answer. No. A glandular abnormality often sits in the canal, where the colposcope cannot see. She needs endocervical sampling, and, because she is 35 or above and not pregnant, endometrial sampling as well. A normal colposcopy does not clear an AGC report; it means the lesion has not been found yet. And a glandular abnormality is never ablated.

Take-home points

• A negative VIA is a weak negative; it never overrules a symptom such as postcoital bleeding.
• Know which framework you are working in: the national programme, WHO or ASCCP.
• Ablate only a lesion that meets every eligibility criterion; never ablate a glandular abnormality.
• Observation of CIN2 depends on her coming back; where she may not, treat at the point of contact.
• A woman treated for CIN2 or worse never returns to ordinary population screening.

Read with this: Doctor, I Feel Fine. Why Do I Need a Health Check-up?, for the conversation with the woman who has no symptoms.

Declaration: the author built and maintains the tool. It is free to use. The figures in this article are those the tool carried in its Reference and Evidence tabs on 4 November 2026, with the sources it named.

References

1. Ministry of Health and Family Welfare, Government of India. Operational Framework: Management of Common Cancers. New Delhi: MoHFW; 2016.
2. World Health Organization. WHO guideline for screening and treatment of cervical pre-cancer lesions for cervical cancer prevention. 2nd ed. Geneva: WHO; 2021.
3. World Health Organization. WHO guidelines for the use of thermal ablation for cervical pre-cancer lesions. Geneva: WHO; 2019.
4. Perkins RB, Guido RS, Castle PE, et al. 2019 ASCCP Risk-Based Management Consensus Guidelines for Abnormal Cervical Cancer Screening Tests and Cancer Precursors. J Low Genit Tract Dis. 2020;24(2):102-131.
5. Egemen D, Cheung LC, Chen X, et al. Risk Estimates Supporting the 2019 ASCCP Risk-Based Management Consensus Guidelines. J Low Genit Tract Dis. 2020;24(2):132-143.
6. Nayar R, Wilbur DC. The Bethesda System for Reporting Cervical Cytology: Definitions, Criteria, and Explanatory Notes. 3rd ed. Cham: Springer; 2015.
7. Indian Council of Medical Research. Consensus Document for Management of Cervical Cancer. New Delhi: ICMR.
8. ICMR-National Institute of Cancer Prevention and Research. Training module for Visual Inspection with Acetic Acid (VIA). Noida: ICMR-NICPR.
9. Sankaranarayanan R, Esmy PO, Rajkumar R, et al. Effect of visual screening on cervical cancer incidence and mortality in Tamil Nadu, India: a cluster-randomised trial. Lancet. 2007;370(9585):398-406.
10. Shastri SS, Mittra I, Mishra GA, et al. Effect of VIA screening by primary health workers: randomized controlled study in Mumbai, India. J Natl Cancer Inst. 2014;106(3):dju009.
11. Kyrgiou M, Athanasiou A, Paraskevaidi M, et al. Adverse obstetric outcomes after local treatment for cervical preinvasive and early invasive disease according to cone depth: systematic review and meta-analysis. BMJ. 2016;354:i3633.
12. International Agency for Research on Cancer. Validation of HPV detection tests developed in India for use in cervical cancer screening. Announced New Delhi, 23 April 2025.