Updated Guideline on Cervical Cancer Screening Issued by ACOG

Marcia Frellick

December 24, 2015

An updated practice bulletin from the American College of Obstetricians and Gynecologists (ACOG) highlights changes in cervical cancer screening and prevention recommendations. These include discussion of the role of screening with human papillomavirus (HPV) testing alone, updates on efficacy of the HPV vaccine, and revised guidelines on cancer screening in HIV-positive women.

The practice bulletin was published in the January 2016 issue of Obstetrics & Gynecology.

Current guidelines came before the US Food and Drug Administration (FDA) approved a currently marketed HPV test for primary cervical cancer screening. ACOG states that this test alone can now be considered an alternative to current cytology-based cancer screening (the Papanicolaou test) in women aged 25 years and older. Screening should stop at age 65 years in women with a negative screening history.

ACOG still recommends cytology testing alone every 3 years for women aged 21 to 29 years. For women aged 30 to 65 years, cotesting with cytology and HPV testing every 5 years is preferred, and screening with cytology alone every 3 years is acceptable, according to the guidance. ACOG recommends against annual testing.

David Chelmow, MD, from the Department of Obstetrics and Gynecology at Virginia Commonwealth University Medical Center in Richmond, told Medscape Medical News that HPV testing alone as an alternative screening in women aged 25 years and older, "is not part of any major society's guidelines yet." Dr Chelmow drafted the practice bulletin for review by the Committee on Practice Bulletins–Gynecology.

He said the guidance on the HPV test as an alternative follows interim guidance in 2015 from the American Society for Colposcopy and Cervical Pathology and the Society of Gynecologic Oncology. "We include that in this practice bulletin, acknowledging that it is FDA-approved, and if people are going to use it, they should use it according to the interim guidance."

He added, "When one of those societies revises their full set of guidelines, we'll need to see if HPV testing is included in that. I suspect it will, but we're not at that point yet."

Edward Evantash, MD, says revising guidelines to recommend the HPV test alone would be a mistake. Dr Evantash, an obstetrician-gynecologist, is medical director and vice president of medical affairs at Hologic and was previously chief of the Division of General Obstetrics and Gynecology at Tufts Medical Center in Boston, Massachusetts.

He says the HPV test alone would miss cancers, and that there is very little evidence of its benefit. Results of a study that bring into question the benefit of the single HPV test were previously reported by Medscape Medical News. The evidence level in the practice bulletin is listed as level B.

"There is data that shows you will have a loss of sensitivity for detection of cancer and severe precancerous abnormalities when you use only one test for HPV as opposed to both tests.... There is more data that will be forthcoming, data that may not have been included in this, and we look forward to it being included in future practice bulletins," Dr Evantash told Medscape Medical News.

Guidance for HIV-Positive Women

HIV-positive women younger than 30 years can now undergo cytology testing once every 3 years instead of annually if they have had three consecutive normal annual cytology tests. ACOG recommends against cotesting for women younger than 30 years.

Women with HIV who are aged 30 years or older can undergo either testing with cytology alone or cotesting. Those with three consecutive normal annual cytology tests can then be screened annually, and those with one normal cotest result can also be screened annually.

ACOG recommends against starting screening before age 21 years unless a woman is HIV-positive, regardless of the age of onset of sexual intercourse. Only 0.1% of cases of cervical cancer occur before age 20 years, and evidence that screening is effective in this age group is lacking.

The practice bulletin also includes guidance on using the new 9-valent HPV vaccine, which covers an additional five high-risk strains of the virus.

"[G]iven the high degree of protection with any HPV vaccine and the risk of viral infection in unvaccinated women, eligible patients should be vaccinated with whichever vaccine is readily available to them [bivalent, quadrivalent, or 9-valent], and vaccination should not be delayed to obtain a specific vaccine type," the authors write.

"This is one of the things that gets lost when we talk about screening guidelines," Dr Chelmow said. "We have primary prevention here, and we woefully underuse the vaccine in this country: only 30% of eligible women. That's really the future of preventing cervical cancer."

Dr Chelmow is editor-in-chief of Medscape's Obstetrics and Gynecology textbook.

Obstet Gynecol. 2015;127:185-187. Abstract

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