Updated Guidelines Released for Cervical Cancer Screening

Roxanne Nelson

March 14, 2012

March 14, 2012 — Protocols for cervical cancer screening have been evolving over the past few years. The latest guidelines, from 6 working groups and a recent symposium cosponsored by the American Cancer Society (ACS), the American Society for colposcopy and Cervical Pathology (ASCCP), and the American Society for Clinical Pathology (ASCP), bring physicians and patients up to date.

They address issues such as age-appropriate screening strategies, high-risk human papillomavirus (HPV) testing, follow-up management, and screening strategies for women who have been vaccinated against HPV16 and HPV18 infection.

"These are reasonable and well-considered guidelines," said Maurie Markman, MD, senior vice president of clinical affairs and national director of medical oncology at Cancer Treatment Centers of America in Philadelphia, Pennsylvania, who was not involved in developing the guidelines.

"However, the decision regarding the specific screening strategy to be employed in an individual woman should be made by that woman in consultation with her personal physician," he told Medscape Medical News.

The new ACS/ASCCP/ASCP guidelines, first proposed last October, as reported at that time by Medical Medscape News, were published online today in CA: A Cancer Journal for Clinicians.

"The new guidelines clarify several points, especially the importance of balancing the benefits of screening against the harms of overscreening," said Mark H. Stoler, MD, FASCP, past president of the ASCP and professor of pathology, cytology, and gynecology at the University of Virginia Health System, Charlottesville. "What we want is the best possible test at the best interval."

"The conundrum in the United States is a balance of what the patients want and what providers think is best; we come from a background where more is better," he told Medscape Medical News. "Women have been told for decades that they need an annual Pap smear.... There will be a significant educational process to get the message out that more is not always the best way to go."

The new guidelines strike a balance between the benefits of screening tests and the harms of overtesting, which can include unnecessary invasive procedures and worry, he explained.

Collaborative Effort

The ACS, ASCCP, and ASCP worked collaboratively from 2009 to 2011 to convene an expert panel to develop new screening recommendations on the basis of a systematic review of the available peer-reviewed evidence. The 6 working groups addressed the following areas: optimal cytology screening intervals; screening strategies for women 30 years and older; the management of discordant combinations of cytology and HPV results; exiting women from screening; the impact of HPV vaccination on future screening practices; and the potential utility of molecular screening.

Main Recommendations

These guidelines are for general screening, and do not address high-risk populations. These would include women with a history of cervical cancer, exposure in utero to diethylstilbestrol, or those who are immunocompromised.

Age to Begin Screening
It is now recommended that cervical cancer screening begin at 21 years of age, regardless of sexual activity or other risk factors. The rationale for this recommendation is that cervical cancer is rare in adolescents and young women, and might not be prevented with cytology screening. The incidence of cervical cancer screening in this age group has not changed, even with the increased screening strategies of the past 4 decades.

Screening at 21 to 29 Years of Age
Screening with cytology is recommended every 3 years for women 21 to 29 years of age. This interval appears to provide the "best balance of benefits and harms." HPV testing should not be used as a standalone test or a cotest with cytology in this age group because of the high prevalence of HPV infection in young women.

Screening at 30 to 65 Years of Age
Women 30 to 65 years of age should be screened with both cytology and HPV testing every 5 years (preferred) or with cytology alone every 3 years (acceptable). Evidence is insufficient to support a screening interval longer than 3 years for cytology alone, even among women who have had a series of negative tests. Cotesting at 5-year intervals provides a cancer risk similar to or lower than screening with cytology alone at 3-year intervals.

Screening With HPV Alone
In most clinical settings, women should not be screened with HPV testing alone. Although HPV testing is promising, there is a "lack of a well-defined and evaluated management strategy for positive tests that precludes their practical implementation in the majority of clinical settings in the United States at this time."

Screening in Women Older Than 65 Years
When there is evidence of adequate negative previous screening and no history of cervical intraepithelial neoplasia of grade 2 or higher (CIN2+) in the previous 20 years, cervical cancer screening can be stopped in women older than 65 years. Once screening is discontinued, it should not be resumed for any reason, even if the woman has a new sexual partner. The rationale for this recommendation is that the prevalence of advanced lesions or cervical cancer is rare in women who have been adequately screened in the United States. Because the transmission of a new carcinogenic HPV infection will most likely clear on its own, the benefit of screening in this population does not outweigh potential harms.

Screening in Women With No History of CIN2+ After Hysterectomy
Women of any age who have had a hysterectomy and their cervix removed should not be screened for vaginal cancer, and evidence of adequate negative previous screening is not required. The rationale for this recommendation is that vaginal cancer is uncommon, and abnormal vaginal cytology is rarely of clinical importance.

Screening in Women After HPV Vaccination
The same screening recommendations apply to women who have and who have not received an HPV vaccination (Gardasil or Cervarix). The guidelines point out that the current vaccines do not cover all carcinogenic HPV types, and because recommendations include vaccinating women up to 26 years of age, many will receive the vaccine after they have already been exposed to HPV.

Evolving Evidence

"Until the next update, these recommendations reflect the participants' judgment of the best evidence-based practice for the prevention of cervical cancer morbidity and mortality through currently available screening tests that maximizes protection against cervical cancer while minimizing the potential harms associated with false-positive results and overtreatment," conclude the authors.

The US Preventative Services Task Force (USPTF) also issued proposed guidelines in October 2011, but they differed from the new ACS/ASCCP/ASCP guidelines in their recommendations about HPV testing.

The USPTF initially recommended against HPV testing in women older than 30 years of age, either alone or in combination with Pap tests. However, on the basis of new data, the finalized guidelines from the USPTF, which have also just been released, are now in agreement with the ACS/ASCCP/ASCP guidelines on the issue of cotesting women in this age group.

CA Cancer J Clin. Published online March 14, 2012. Abstract


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