Less Frequent Testing for Cervical Cancer Proposed

Zosia Chustecka

October 19, 2011

October 19, 2011 — Less frequent testing for cervical cancer is recommended in 2 separate proposed guidelines issued today — one from the United States Preventative Services Task Force (USPTF), and the other from the American Cancer Society (ACS), working in collaboration with the American Society for Colposcopy and Cervical Pathology (ASCCP) and the American Society for Clinical Pathology (ASCP).

The 2 sets of guidelines are similar, and both recommend against testing every year, which has been the convention until now; instead, both recommend testing every 3 years for women 21 to 65 years of age.

 

They also both endorse Papanicolaou (Pap) tests, as has been the convention, and say that testing for human papillomavirus (HPV) is not ready for prime time and should not be used alone, although it can provide additional useful information.

The proposed guidelines from the ACS/ASCPP/ASCP are posted online and are open for comments. There are plans for discussion at a symposium in November, and the final guidelines will be issued in mid-2012.

The USPSTF proposed guidelines are also posted online and are open for comments until November 16. These guidelines were based on 2 reviews of the literature just published in the Annals of Internal Medicine, as reported by Medscape Medical News.

The 2 groups worked independent of each other to formulate their guidelines, but they coordinated the release of their draft recommendations, according to the ACS, "to enable stakeholders to consider both sets of recommendations concurrently with the goal of creating consistent guidance that will lead to less confusion for providers and the public."

Proposed ACS/ASCCP/ASCP Guidelines

The proposed guidelines from the ACS/ASCCP/ASCP contain several changes from the existing guidelines, as outlined below, which will result in women undergoing fewer tests during their lifetime.

The changes include:

  • Instead of beginning screening 3 years after starting sexual intercourse, the new starting age will be 21 years. This applies equally to women who have and have not been vaccinated against HPV.

  • Pap testing (conventional or liquid based) is recommended every 3 years for women 21 to 29 years of age. This replaces the current recommendation for annual testing with a conventional Pap test or testing every 2 years with a liquid-based Pap test.

  • Pap testing is recommended every 3 years for women 30 years and older, although the preferred strategy is Pap testing plus HPV testing every 3 to 5 years.

  • It is recommended that women who have had normal results on 3 Pap tests in a row, or if over the past 10 years there have not been any abnormal Pap tests and 2 or more HPV tests have been negative, testing can be stopped at 65 instead of 70 years of age.

In addition, the draft ACS/ASCCP/ASCP document states that there is insufficient evidence to recommend for or against a comprehensive program for primary screening with HPV testing alone.

New Proposed USPSTF Guidelines

Similarly, the draft document from the USPSTF recommends:

  • no screening in women younger than 21 years of age, regardless of sexual history

  • screening with Pap tests every 3 years in women 21 to 65 years of age

  • no screening in women older than 65 years of age who have had adequate previous screening and who are not otherwise at high risk for cervical cancer.

However, the USPSTF differs in its guidelines on the use of HPV testing, recommending against its use in women younger than 30 years of age, either alone or in combination with Pap tests. The USPFT concludes that there is "insufficient" evidence to assess the balance of benefits and harms of HPV testing, alone or in combination with cytology, for screening for cervical cancer in women 30 years and older.

Approached for a reaction to the proposed guidelines, Maurie Markman, MD, national director for medical oncology and vice president of patient oncology services at Cancer Treatment Centers of American in Philadelphia, Pennsylvania, told Medscape Medical News that both sets of guidelines are "reasonable" and that "they reflect data that have been widely reported."

However, Dr. Markman raised a concern about how these recommendations might be used. "Insurance companies or Medicare should not use these guidelines to deny coverage of a procedure. For example, there could be a case where a 19-year-old sexually active women and her physician both want a cervical cancer screening test. That is perfectly reasonable. It would be absurd and indefensible for insurance to refuse payment for those tests based on these guidelines. I am strongly opposed to anyone saying that the 20- to 65-year-old guideline is written in stone. We don't ever want to get to the point where some organization or external board (however well intentioned) regulates the practice of medicine by assuming the right to make decisions that should be made by the individual patient and her doctor," Dr. Markman said.

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