Screening Teens for Cervical Cancer

What's New?

Cora C. Breuner, MD, MPH


April 17, 2012

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Editor's Note:

The American Cancer Society (ACS), the American Society for Colposcopy and Cervical Pathology (ASCCP), and the American Society for Clinical Pathology (ASCP) recently released updated cervical cancer screening guidelines. The guidelines provide clinicians with evidence-based recommendations on 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. Virtually simultaneously, the US Preventive Services Task Force (USPSTF) also issued recommendations for screening, with less emphasis on follow-up than is provided in the ACS/ASCCP/ASCP guideline. Medscape asked Cora Collette Breuner, MD, MPH, a member of the Division of Adolescent Medicine at Seattle Children's Hospital, Professor of Pediatrics at the University Of Washington School of Medicine, and a member of the American Academy of Pediatrics National Committee on Adolescence, to talk about the implications of the new guidelines for pediatric providers.

My name is Dr. Cora Collette Breuner, I am a pediatrician at Seattle Children's Hospital, and a board-certified adolescent medicine specialist. I also work at the University of Washington. I am a pediatrician, an adolescent medicine specialist, and a mom.

I would like to help clear up some of the confusion about when cervical cancer screening should occur. We know that cervical cancer is a devastating illness, and it occurs predominately in women between the ages of 40 and 44. What we didn't know is when to start the screening process for cervical cancer. Now, finally, we have some clarification as to when the cervical cancer screening should occur.

The other confusion is about HPV testing. We know that HPV infections are linked to cervical cancer, but we also know that most women under the age of 25 years will clear the HPV infection and never develop cervical cancer.

These 2012 screening guidelines from the USPSTF are supported by ACS, and also by the ASCCP. Also, these guidelines are being reviewed to be supported by the American College of Family Medicine, as well as the American Congress of Obstetricians and Gynecologists.

The guidelines are going to make a huge difference in the way we monitor women for cervical cancer. There are many [changes] and they do not just include screening in women under 21 years of age. The changes affect women all the way to over 65 years of age. They are as follows:

  • The USPSTF recommends against screening, because cervical cancer is so rare, in women under 21 years of age. This recommendation applies despite multiple sexual partners or early initiation of sexual activity. It doesn't matter. The incidence of cervical cancer in this age group is rare.

  • In women over 21 years of age, the recommendations are for Papanicolaou (Pap) smear screening every 3 years. This is not with HPV screening. In other words, HPV screening is not recommended in women under 30 years of age -- just Pap smears every 3 years. In women aged 30-65 years, that screening can be stretched to every 5 years if the testing occurs with cytology and HPV testing.

  • USPSTF recommends against screening women over 65 years of age who have had adequate prior screening and are not otherwise at risk for cervical cancer.

The guidelines reviewed thousands of trials and different kinds of studies from all over the world. They help determine what is the right evidence-based practice to dictate what we do in our everyday practice.

Again, no Pap smears before 21 years of age, unless women have been DES exposed in utero, or if they are immunocompromised (ie, have HIV or have a preexisting invasive lesion on their cervix that is cancerous).

It is very important to recognize that what these guidelines are recommending is that a piece of the annual visit doesn't have to happen. In other words, cervical cancer screening doesn't need to happen under 21 years of age. However, all the other screening that must occur in this population should still occur: blood pressure screening, weight, height, counseling on contraception, counseling on domestic violence. All of these things are important and they should continue to occur every single year.

Finally, I would like to end with a huge thank you to the USPSTF group on pulling together multiple trials using an evidence-based system to help practitioners take care of the patients in our practice, solidly knowing that what we are doing is based on evidence and outstanding research, and simplifying an occasionally complex problem that we now know is much more simple because of what this task force was able to put together.

Thank you very much.


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