Experts Continue to Scale Back Cervical Cancer Screening

Neil Osterweil

April 30, 2015

BOSTON — Many women were raised on the mantra, "Pap smear once a year." But for women 21 years and older at average risk for cervical cancer, cytology screening once every 3 years should suffice, according to best-practice advice from the American College of Physicians (ACP).

"This will become a performance measure for cervical cancer screening in the future," said coauthor Tanveer Mir, MD, from the NYU Langone Medical Center in New York City.

There is also a recommendation against screening women younger than 21 for cervical cancer; clinicians should not test for human papillomavirus (HPV) infections in women younger than 30.

The advice was released here at ACP Internal Medicine 2015 and published online in the Annals of Internal Medicine to coincide with the presentation.

The advice is intended to serve as a roadmap for clinicians, helping them find the most clinically effective, cost-efficient, and direct path through a tangle of recommendations — some conflicting or confusing — issued by professional groups.

They are part of "ACP's overall initiative to help doctors and patients understand the benefits, harms, and costs of tests and treatment options so that they can pursue care together that improves health, avoids harm, and eliminates wasteful practices. This is high-value care," Robert Centor, MD, chair of the ACP Board of Regents, said during a news conference.

The best-practice advice is based on the same body of evidence used to develop guidelines issued by the US Preventive Services Task Force (USPSTF), by the American College of Obstetricians and Gynecologists (ACOG), and by the American Cancer Society (ACS) in collaboration with the American Society for Colposcopy and Cervical Pathology (ASCCP) and the American Society for Clinical Pathology.

Do No Harm

Although screening can reduce the incidence, severity, and death rate from cervical cancer by detecting precancerous lesions and treatable asymptomatic early disease, "harms can occur at any and all points along the sequence of care: collection of cervical specimens, diagnostic evaluation, cervical treatments, and post-treatment surveillance," according to the authors.

They caution that clinicians "have poor adherence to cervical cancer screening guidelines and begin screening too early, perform testing too often, and do not end screening in women who are at low risk on the basis of age criteria or because they have had hysterectomy."

Summary of Best-Practice Advice for Cervical Cancer Screening
Don't screen average-risk women younger than 21 years
Start screening average-risk women at age 21 with cytology (without HPV testing) once every 3 years
Don't screen average-risk women with cytology more often than once every 3 years
Use a combination of cytology and HPV testing once every 5 years in average-risk women 30 years and older who prefer screening less often
Don't perform HPV testing in average-risk women younger than 30 years
Stop screening average-risk women older than 65 years if they have had negative results on three consecutive cytology tests or on two consecutive cytology plus HPV tests in the previous 10 years, with the most recent test performed in the previous 5 years
Don't screen average-risk women of any age for cervical cancer if they have had a hysterectomy with removal of the cervix


Average Risk

According to the best-practice advice, women at average risk for cervical cancer have no history of either grade 2 cervical intraepithelial neoplasia (CIN) or more severe precancerous lesion, no history of cervical cancer, no immunocompromise (including no HIV infection), and no in utero exposure to diethylstilbestrol.

The authors point out that although women younger than 21 commonly have cytologic abnormalities of the cervix, these are rarely clinically important.

"If screened, many women in this age group will have colposcopy and biopsy, and some will be treated for lesions that have a high likelihood of regression," they explain.

Annual screening is no longer recommended because of the high rate of false-positive results associated with frequent screening. There is a long lag time between the development of precancerous lesions and invasive cervical cancer — a mean of about 10 years — so less frequent screening should be able to detect clinically significant disease in time, the authors explain.

For average-risk women 30 years and older who would rather not undergo testing every 3 years, clinicians can offer "cotesting" — a combination of cytology and HPV testing — once every 5 years.

Women older than 65 who have had no positive cytology results in the previous 5 years are unlikely to develop cervical cancer, and are at higher risk than younger women of being subjected to invasive procedures on the basis of false-positive results.

"Ending screening before age 65 years in women with life-limiting comorbid conditions seems reasonable, although the process by which an evidence-based recommendation can be made is unclear. Surgical removal of the cervix reduces risk for cervical cancer to zero, making screening after total hysterectomy extremely low-value," the authors point out.

Old Habits Die Hard

ACP President David Fleming, MD, who for nearly 20 years was a practicing internist in a small rural community, said that clinicians must take the lead in reducing the inappropriate and wasteful screening of women at average risk for cervical cancer.

"Often times our practices become a habit, a sort of style, mode of practice that we always do. It's an expectation not only of the physician, but also of the patient, and I have had patients who had hysterectomies where the advice had been that screening was no longer indicated, but they still want it, for reassurance," Dr Fleming told reporters.

"As part of the high-value care initiative, the challenge here is to change habits," Dr Centor explained. "It is a habit of most women to get cervical cancer screening on a regular basis, and to know the reasons you don't have to do it every year is a paradigm shift."

The authors estimate that approximately 60% of women are screened for cervical cancer before the age of 21, and that about 53% of women 75 to 79 years and 38% of those 80 years and older have been screened recently.

These recommendations are sound and are based on good clinical evidence, said Marcela del Carmen, MD, from Massachusetts General Hospital in Boston, who was not involved in the development of the best-practice advice.

"We know that the risk of having cervical cancer in women younger than 21 is exceedingly small, so there's really not much benefit in screening somebody in that population," she told Medscape Medical News.

"A lot of young women are HPV-positive. Of course HPV is a causative agent in the development of cervical cancer, but many of these are transient infections that are going to clear over time and not result in any consequence that is of clinical relevance," she explained.

"If you do a Pap smear alone, especially with the current liquid-based cytology options that are available, you can space the testing to every 3 years and still be able to pick up cervical cancer without the cost of committing to doing it every year, she said.

The best-practice advice is supported by the American Congress of Obstetricians and Gynecologists and endorsed by the American Society for Clinical Pathology. Some of the authors report receiving fees from the ACP. Dr del Carmen has disclosed no relevant financial relationships.

American College of Physicians (ACP) Internal Medicine 2015. Presented April 30, 2015.


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