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Title X Program Instruction Series

Department of Health & Human Services
Office of the Secretary
Assistant Secretary for Health
Office of Public Health and Science
Washington, DC 20201

To: Regional Health Administrators, Regions I-X

From: Deputy Assistant Secretary for Population Affairs

Subject: OPA Program Instruction Series, OPA 03-01: Screening for Cervical and Colorectal Cancer and Sexually Transmitted Diseases (STD)

In January 2001, "Program Guidelines for Project Grants for Family Planning Services" (Title X Program Guidelines) were revised and distributed to all Title X providers. The purpose of the Title X Program Guidelines is to assist current and prospective grantees in understanding and utilizing the family planning services grants program authorized by Title X of the Public Health Service Act, 42 U.S.C. 300, et seq.

Currently, Title X Program Guidelines, Section 8.3, specify that the initial physical examination for females must include a Pap smear. In that same section, the Guidelines specify that colorectal cancer screening must be provided for individuals over the age of forty, both males and females.

Since 2001, a number of professional organizations that establish national standards of care have published revised recommendations for cervical and colorectal cancer screening based on current evidence. In particular, the American College of Obstetricians and Gynecologists (ACOG), the American Cancer Society (ACS), and the U.S. Preventive Services Task Force (USPSTF) are recognized groups that have established revised recommendations for standards of care in one or both of these areas.

With the concurrence of agency medical directors, Title X providers should ensure that their medical protocols and practice related to cervical cancer and colorectal cancer screening correspond with current recommendations issued by the formerly mentioned professional groups (ACOG, ACS, USPSTF). Individual agency protocols should note the specific standard of care being utilized in the development of said protocols, as well as the date the protocols were revised. Specifics regarding initiating screening and screening intervals for cervical and colorectal cancer should be noted in the protocol. Clinical protocols should continue to take into account individual client risks, use of specific methods of contraception, as well as current national standards of care.

It is incumbent on grantee agencies to ensure that delegate agencies and clinics have and use protocols that meet these standards. Clinical protocols of Title X grantees, delegates, and clinics will continue to be monitored by the regional office, particularly during site visits and comprehensive program reviews.

Sexually transmitted diseases (STD) continue to be of concern for clients served in Title X service projects. For example, each year, young, sexually active females have the highest reported rates of chlamydia and gonorrhea, and other STDs are common. All clients served in Title X clinics should have a thorough history and physical assessment performed that includes screening for risk of STDs.

Regardless of whether or not an annual Pap test is conducted, clinicians should screen young, sexually active women (ages 15 - 24) at least annually for chlamydia. In high prevalence areas, gonorrhea screening should also be part of the routine annual STD screening tests for young, sexually active women. Clients who are symptomatic of other STDs should be screened according to the current Centers for Disease Control and Prevention STD Treatment Guidelines ( In addition tothese screening tests, providers should inquire about sexual behaviors, assess ongoing risk for STDs, and counsel about risk avoidance and risk reduction.

If you have questions, please contact Susan Moskosky, Director of the Office of Family Planning on (301) 594-4008.


Alma L. Golden, M.D., F.A.A.P.
Deputy Assistant Secretary
for Population Affairs


  1. American Cancer Society: Guideline for the Early Detection of Cervical Neoplasia and Cancer, Saslow et al.; CA A Cancer Journal for Clinicians, Vol. 52:6, November/December 2002.
  2. ACOG Practice Bulletin Number 45, Cervical Cytology Screening, August 2003.
  3. U.S. Preventive Services Task Force (USPSTF-January 2003): Cervical Cancer - Screening.
  4. U.S. Preventive Services Task Force (USPSTF- July 2002): Colorectal Cancer - Screening.

cc: Regional Program Consultants, Regions I - X