05 June 2026
Since January 2025, cervical cancer screening for women aged 30 and over has been carried out differently. The smear is now first tested for the presence of human papillomavirus (HPV), and only then, depending on the result of that first test, are the cells examined. There is a good reason for this: the new testing method is better at detecting lesions that may develop into cervical cancer. Yet in Belgium, more than 30% of women are still not screened adequately, and just over 10% have never been tested at all. We need to do better.
“Cervical cancer mainly affects women between the ages of 35 and 65. Worldwide, it is the fourth most common cancer in women and, among women under 30, even the third most common. It is also the fourth leading cause of cancer-related death in women,” says Dr Kobe Dewilde, a gynaecologist affiliated with UZ Leuven and specialised in HPV infections. As a co-author of the new national screening guideline, [1] he was closely involved in developing and implementing the new screening approach. Thanks to vaccination and screening, cervical cancer has become less common in Belgium, with 610 new diagnoses in 2023, placing it 13th among the most common cancers in women. But for him, that is no reason to rest on our laurels.
“Virtually all cases of cervical cancer are caused by HPV,” Dr Dewilde explains. “More than 200 types of HPV are known, 12 of which are oncogenic and can cause cervical cancer and other cancers. These are the high-risk types. Types 16 and 18 are the most important. Together, they are responsible for more than three-quarters of all cases of cervical cancer.”
HPV is a widespread and highly contagious virus, so HPV infection is very common. Nearly 90% of sexually active men and women will come into contact with the virus at some point in their lives. However, in the vast majority of cases – around 90% – the body clears the virus relatively quickly, within two to three years. Not every HPV infection therefore leads to cancer. Only when a high-risk HPV infection persists can precancerous lesions develop. These are abnormal cells that may eventually turn into cancer. “This process takes a long time, on average 10 to 15 years,” he says (see Box). “The risk of developing cervical cancer as a result of an HPV infection is small, around 1%, but because so many women become infected, it still represents a significant group in absolute numbers.”
[1] Clinical Guidance: Supporting the introduction of the HPV test in cervical cancer screening in Belgium. Source: Sciensano
How does a tumour develop?
When an HPV infection persists for a long time, viral DNA enters the cells of the cervix. This DNA can become integrated into the cell’s own DNA. As a result, the cell starts producing viral proteins, particularly E6 and E7. These proteins disrupt crucial cellular control systems that normally regulate cell division and eliminate cells with errors. The result is that “faulty” cells continue to multiply unchecked instead of disappearing, eventually leading to cancer.
The main risk factors for an HPV infection not clearing on its own are smoking and immune deficiency. Dr Dewilde explains: “Smoking affects the immune system in such a way that the virus is cleared less effectively, increasing the risk of precancerous lesions. The risk is also clearly higher in people with a weakened immune system, for example after a transplant or in the case of AIDS. Inflammation of the cervix, on the other hand, makes you more susceptible to HPV infection. Age also plays a role: as you get older, your body seems to find it harder to clear the virus.”
Cervical cancer screening is still performed using a cervical smear taken by your GP or gynaecologist. During the procedure, a speculum is inserted into the vagina to allow better access to the cervix. Using a soft brush, the doctor collects cells from the cervix and the vaginal lining. The smear is sent to a laboratory for analysis, but the testing procedure and screening frequency differ according to a woman’s age.
Women aged 25 to 29 are advised to have a cervical smear every three years. The smear is first checked for abnormal cells – the traditional Pap test. If severe abnormalities are found, the woman is referred for a colposcopy, a close-up examination of the cervix. If the abnormalities are mild or inconclusive, an HPV test is performed on the same smear sample. If the test is negative for high-risk HPV, the next screening can take place after three years. If the test is positive, a new smear is taken after one year for both cytology and HPV testing. If the results are reassuring, the next screening is due again in three years; otherwise, the woman is referred for a colposcopy.
For women aged 30 to 64, the recommendation is to have a cervical smear every five years. Here, the testing procedure is reversed: the smear is first tested for HPV. If the test is negative for high-risk HPV, the next screening can take place after five years. Only if high-risk HPV is detected are the cells examined. If HPV type 16 or 18 is present, the woman is referred immediately for a colposcopy. In the case of other high-risk HPV types, the next step – either referral for a colposcopy or a repeat HPV test within a maximum of one year – depends on the result of the cell examination.
“Screening women younger than 25 serves no purpose,” Dr Dewilde stresses. “HPV is simply much more common in that age group, so you end up detecting many temporary abnormalities that disappear on their own, while the risk of a tumour or a precancerous lesion is extremely low. The result is mainly unnecessary anxiety and additional investigations, without any real health benefit.”
Why did we switch from the traditional Pap test to HPV testing for women aged 30 and over? The findings that ultimately drove this change were already brought together more than ten years ago by Professor Marc Arbyn. Professor Arbyn is affiliated with the Cancer Centre at Sciensano and Ghent University and is an internationally recognised researcher in cervical cancer screening. “His meta-analysis, a study that combines the results of many other studies, showed that women who have a negative HPV test are less likely to develop precancerous lesions or cervical cancer in the years that follow than women who have a negative Pap test, and that this difference persists for longer,” Dr Dewilde explains. “That is because the HPV test is more sensitive: during an initial screening, it detects more precancerous lesions that we can treat, which means fewer cancers appear at subsequent screenings. As a result, the interval between two screenings can safely be extended to five years, instead of three years with the traditional cervical smear.”
Why, then, do we not test directly for the virus in women under 30, but first look for abnormal cells? “Because HPV infections are much more common before the age of 30, we would detect too many infections that would disappear on their own, while the likelihood of abnormal cells and cervical cancer at that age is many times lower.” This age cut-off was determined by a panel of researchers from Sciensano, GPs, gynaecologists, pathologists and virologists. Data from the Belgian Cancer Registry played a decisive role.
Although strong scientific evidence has shown for more than ten years that HPV testing is more effective than the traditional cervical smear, it took until 2025 for Belgium to adapt its screening programme. This had less to do with doubts about the science and more with the time needed to align medical guidelines, reimbursement policies, laboratory operations and the organisation of the population screening programme.
“Overall, HPV testing prevents more cases of cervical cancer. That is why it is the best choice,” says Dr Dewilde. But what about the admittedly very few rare tumours that are not caused by HPV – won’t those be missed? “In Belgium, we have built in an additional safety net,” he says. “If someone has symptoms, such as abnormal bleeding, cytology can still be requested. That is why it remains important to consult a doctor whenever you have symptoms. But once again: switching to HPV screening actually results in fewer cases of cervical cancer being missed across the board.”
Prevention is better than cure, and that is why vaccination at a young age is the best way to prevent cervical cancer, reducing the risk of precancerous lesions and cancer by up to 90%. Nevertheless, screening from the age of 25 remains important, even for vaccinated women, because no vaccine offers complete protection. Dr Dewilde explains: “Screening is needed to detect precancerous lesions. These are areas of abnormal cells that can evolve into cancer. They usually cause little or no symptoms. Sometimes you may notice bleeding during or after sexual intercourse, or unusual vaginal discharge with an abnormal colour or smell, but they often remain undetected for a long time. Screening also allows us to diagnose and treat in time women who have not been vaccinated or for whom the vaccine does not provide full protection. It is important, however, to follow the recommended screening intervals, because even after a negative test you can still contract an HPV infection, or a latent virus may become active again. A follow-up smear three or five years later will pick that up.”
He is not trying to alarm women. Interval cancers – cancers that develop between two screening moments after a previous normal result – do occur, but they are very rare and less common with HPV testing than with the traditional Pap test. The figures from the Centre for Cancer Detection (CVKO) also show that screening really does work: women who have been screened at least once are usually diagnosed at an earlier stage than women who have never had a cervical smear.
Vaccination coverage in Belgium, particularly in Flanders, is good – and fortunately so, because vaccination at a young age remains the best protection. However, Dr Dewilde warns against a false sense of security: “Whatever you do, don’t think: I’ve been vaccinated, so I no longer need cervical screening. Because that’s when we run into problems!”
Screening uptake, however, still needs to increase – a stated objective of both the Flemish and French-speaking Community health policies. “In Flanders, we are flirting with the 70% target set by the World Health Organization (WHO),” he says (see box). “Over the past few years, numerous initiatives have been tested to better engage hard-to-reach groups, such as local outreach programmes, collaboration with intercultural mediators, and providing information in schools from an early age. We seem to be hitting a ceiling: studies show that sending yet another reminder letter or invitation has little effect.”
Dr Dewilde expects the greatest impact from self-sampling tests. Several types are available, for example tests in which you collect a vaginal sample yourself using a small brush, or tests based on a urine sample. These samples are then analysed in a laboratory for high-risk HPV. Not that he advocates self-testing for everyone: “Never change a winning team! But for those women who, for whatever reason, are harder to reach through a GP or gynaecologist, self-tests can make a real difference. Pilot studies show that they genuinely increase screening uptake in this group. We also see that an opt-out approach, where the self-test is included with the invitation by default, leads to higher participation than an opt-in system.”
Dr Dewilde cannot emphasise it enough: vaccination and screening are the cornerstones of a strategy aimed at eliminating cervical cancer. “In fact, cervical cancer should no longer exist,” he says. “The WHO target is fewer than 4 cases per 100,000 women per year. Completely eradicating cervical cancer is unfortunately not possible – nothing in medicine is ever 100%. There will probably always be rare tumours that slip through the net, but there should be very, very few of them. In Belgium, we have the tools to do even better than the WHO benchmark. So I hope that in a few years’ time I’ll be out of a job and able to sink my teeth into another medical problem – now that would be something,” he concludes.
“Whatever you do, don’t think: I’ve been vaccinated, so I no longer need cervical screening.”
WHO targets
The World Health Organization aims to reduce cervical cancer to a very rare disease by 2080 (fewer than 4 cases per 100,000 women). To achieve this, it established the 90-70-90 targets for 2030: by then, 90% of girls worldwide should be vaccinated against HPV, 70% of women should participate in screening, and 90% of women with precancerous cervical lesions should receive appropriate treatment. Source
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