OBGYN Newsletter Jan. 2013
Understanding the New Cervical Cancer Screening Recommendations
In 2012, the American College of Obstetrics and Gynecology released a practice bulletin supporting new guidelines for cervical cancer screening. The goal is to avoid unnecessary interventions and save healthcare dollars. One important message lost in the advice is that the pap smear does not constitute the entire annual exam. Women still need to see a physician once a year after the age of 20 for other items such as a clinical breast exam, sexually transmitted disease testing, and pelvic exam of the reproductive organs. Visits maybe even more frequent if there are unresolved problems such as pelvic pain, heavy periods, or abnormal pap smear results.
The biggest guideline change is aimed at women between the ages of 30 and 65 years. The preferred method to screen women in this age group who have a negative Pap test now is by cotesting with the Pap test (using the conventional Pap or the liquid-based method) combined with human papillomavirus (HPV) testing every 5 years. If HPV testing is not available, women can get a Pap test by itself (without HPV cotesting) every 3 years.
We know that HPV infections are very common but most are transient and don't progress to cervical cancer. Only a fraction of women with chronic HPV infection will have cervical abnormalities that cause cancer. In addition, even if cells are precancerous, it takes years for them to convert into invasive cancer, according to the college.
The authors also suggest that women between the ages of 21 and 29 years get screened for cervical cancer every 3 years rather than every 2 years. Either the conventional Pap or the liquid-based method is reasonable, but the college advises that women younger than 30 years not receive screening with cotesting.
The guidelines are the same for women who have received the HPV vaccine as for those who have not, although not everyone should get screened for cervical cancer. Upholding recommendations from 2009, the college advises that women younger than 21 years not receive screening for cervical cancer or HPV, whether they are sexually active or not.
Young women have immune systems that can generally clear HPV infection in about 8 months, and if a cervical abnormality does occur resulting from HPV infection in this age group, it generally resolves with no need for treatment.
Even though very young women will not get screening, physicians can still guide them toward prevention of cervical cancer by encouraging the HPV vaccine and counseling them about safe sex practices.
According to the guidelines, physicians should stop screening in women older than 65 years if they meet certain qualifications (eg, no history of CIN grade 2 or higher, adenocarcinoma in situ, or cervical cancer) and have also had 3 consecutive negative cytology results or 2 consecutive negative cotest results within the previous 10 years.
Variations in practice may be warranted based on the needs of the individual patient, resources, and limitations unique to the institution or type of practice. Women with certain conditions will require more frequent screening. These populations include: women with HIV, women who have received organ transplants or are immunocompromised for other reasons,women who were exposed to diethylstilbestrol in utero, and women previously treated for CIN 2 or higher disease.
(Obstet Gynecol. 2012;120:1222-1242. Abstract)