The Papanicolaou Smear Reimagined: A Narrative Review of Cervicovaginal Cytology and Molecular Biospecimens for Ovarian Cancer Detection

The Papanicolaou (Pap) smear, a cornerstone of cervical cancer prevention, has emerged as a compelling, though unconventional, biospecimen for the detection of ovarian cancer (OC). This structured narrative review synthesizes the evolving evidence on the utility of cervicovaginal cytology and molecular analysis of Pap test material for OC detection. While conventional cytology provides a proof of concept, its sensitivity is low, ranging from incidental detection of OC in 0.004% of routine screens to 19.3% in patients with known OC. Specific cytologic findings, however, carry significant predictive value: atypical glandular cells (AGC) confer a two-fold increased OC risk, and psammoma bodies (PB) are strongly associated with serous malignancies. Driven by the sensitivity limitations of morphology, the field has undergone a paradigm shift towards molecular detection. Foundational studies confirmed tumor-derived DNA, including hallmark TP53 mutations, is detectable in Pap samples years before diagnosis, though sensitivity is constrained by low DNA abundance and confounded by background clonal mutations. To overcome this, strategies have expanded to target broader genomic signatures, such as somatic copy number alterations (EVA test: 75% sensitivity, 96% specificity), and multi-gene mutation panels (PapSEEK: 33–45% sensitivity). The most promising advances lie in multi-omic approaches, particularly DNA methylation biomarkers, which have demonstrated sensitivities up to 81% with high specificity. Collectively, this evidence argues against repurposing the Pap test as a standalone OC screen but supports its strategic integration into a risk-stratified clinical algorithm. We propose a “reflex-to-molecular” model where high-risk cytology (e.g., AGC, PB) automatically triggers advanced molecular testing on the same sample. This model efficiently leverages existing infrastructure to triage high-risk women for definitive diagnostics. Prospective validation of this integrated approach is the essential next step toward transforming this test into a sentinel for malignancies of the upper female reproductive tract.