Currently, screening programmes for cervical cancer usually rely on cytology as the first-line screen. 1 Women who are found to be cytologically abnormal are triaged by carcinogenic human papillomavirus (HPV) DNA testing or by repeat cytology, or are referred directly for a colposcopic examination. At colposcopy, biopsies are taken from any apparent lesions. Treatment is decided on the basis of the combined cytological, colposcopic, and histological diagnoses during the patient’s history. These decision processes are formalised in complex consensus management algorithms that narrow down the clinical management options to a single course of action. 2, 3 Consensus clinical management algorithms for cervical cancer screening need updating as and when new technologies, such as carcinogenic HPV testing4–6 and HPV vaccination, 7, 8 prove their value. However, with each new technology, the number of branches in an algorithm, which reflect every combination of possible test results with possible patient histories, increases exponentially. Therefore, reaching evidence-based consensus on the appropriate course of clinical action for a given scenario will become increasingly difficult, and compliance by clinicians with complicated algorithms could suffer as a result. HPV vaccination against the major causal HPV types will be particularly challenging to incorporate into algorithms, since the amount of partial protection provided by vaccination varies greatly according to age at vaccination. In the future, the algorithmic approach might collapse entirely under the even greater complexity posed by the advent of HPV type-specific tests, HPV RNA tests, and new biomarkers of risk (eg, p16 assays). 9 A new approach is needed to make best use of new technologies10 as they become available. Instead of providing clinicians with algorithms, we propose to provide clinicians with their patient’s risk of developing cervical cancer. 11 As a surrogate for cervical cancer, we propose to use cervical precancer, best defined as histological cervical intraepithelial neoplasia grade 3 (CIN3) or more severe (CIN3+), or less precisely by CIN2+, a common treatment threshold. Clinical trials and longitudinal studies on hundreds of thousands of screened women, which incorporate the latest clinical tests, are generating vast quantities of data on the subsequent risk of cervical precancer. The risk of cervical precancer can be calculated at the time of screening, for women sent immediately to colposcopy, or at 1-year, 2-year, or 3-year follow-up intervals, as desired. Importantly, as new tests are introduced and as more data accrue, the risk estimates are readily updated once data-based evidence of effectiveness for those new tests is solid.

The risk of cervical precancer is a unifying concept to guide management, regardless of which combination of tests a woman has undergone, because risk of cervical precancer boils down a complex battery of test results over time into a single percentage that forms a basis for action. For example, if guidelines would handle all women with the same risk of cervical precancer in the subsequent 5 years the same, regardless of which tests provide this assessment, then management could be simplified greatly and applied consistently. For example, the lowest-risk women (eg, 33-years-old, HPV-and cytology-negative) might be reassured, based on the risk calculation, that their 5-year risk of CIN3+ is less than 1%. Guidelines, to be developed by the clinical community, might judge that further screening is therefore unnecessary for at least 5 years. Similarly, guidelines might agree that an immediate precancer risk of greater than 10% justifies referral to …