Pap Tests Less Frequent Under New Guidelines

Joanna Broder

October 25, 2012

An annual Papanicolaou (Pap) test may soon be a thing of the past: According to new guidelines from the American College of Obstetricians and Gynecologists, most women do not need cervical cancer screening more frequently than once every 3 to 5 years.

"The evidence clearly shows that less frequent cervical cancer screening is warranted," David Chelmow, MD, chair of obstetrics and gynecology at Virginia Commonwealth University School of Medicine in Richmond, said in a press release. Dr. Chelmow worked with the Committee on Practice Bulletins–Gynecology to develop the new guidelines, published in the November issue of Obstetrics & Gynecology.

The new guidelines update those published in 2009 and echo recommendations that the American Cancer Society, the American Society of Colposcopy and Cervical Pathology, and other medical groups released earlier this year.

New Cervical Cancer Screening Recommendations

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, the authors note.

Population Recommended Screening Method Comments
Aged less than 21 years No screening  
Aged 21 to 29 years Cytology alone every 3 years  
Aged 30 to 65 years Preferred: HPV and cytology cotesting every 5 years
Acceptable: Cytology alone every 3 years
Screening by HPV testing alone is not recommended
Aged more than 65 years No screening necessary after adequate negative prior screening results Women with a history of cervical intraepithelial neoplasia [CIN] 2, CIN 3, or adenocarcinoma in situ should continue routine age-based screening for at least 20 years
After total hysterectomy No screening necessary Applies to women without a cervix and without a history of CIN 2, CIN 3, adenocarcinoma in situ, or cancer in the past 20 years
After HPV vaccination Follow the same age-specific recommendations as unvaccinated women  

Modified from CA Cancer J Clin. 2012;62:147-172 .

“We know that HPV infections are very common but most are transient and don’t progress to cervical cancer,” Dr. Chelmow said in the press release. 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.

"With co-testing, screening every five years provides an excellent balance between achieving extremely low cancer rates while avoiding the potential harms of unnecessary interventions," Dr. Chelmow said in the release.

"The new guidelines emphasize that there is no role for tests that look for low-risk types of HPV," Dr. Chelmow said in the release. “When co-testing, we should be using only tests for high-risk, oncogenic types of HPV."

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 counselling them about safe sex practices, the authors note.

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, with the most recent test occurring within the last 5 years.

The authors also note that "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, the authors say. 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, CIN 3, or cancer.

"It will take some time and a lot of effort to re-educate everyone that the annual Pap is no longer the standard of care," Dr. Chelmow said in the release. "It is critical, however, that women understand that their annual well-woman visit is still very important for many other aspects of their health care."

Obstet Gynecol. 2012;120:1222-1242. Abstract