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New Cervical Cancer Guidelines: Less Screening

Combining a Pap test with a human papillomavirus (HPV) test can safely extend the interval between cervical cancer screenings from three years to five years in many women between the ages of 30-65, according to new recommendations.

March 14, 2012 -- Combining a Pap test with a human papillomavirus (HPV) test can safely extend the interval between cervical cancer screenings from three years to five years in many women between the ages of 30-65, according to new recommendations.

If women opt for the Pap test alone, the new guidelines are similar to the old ones, recommending screening every three years.

A key addition to the new guidelines is the recommendation concerning HPV testing. Previously, researchers from the U.S. Preventive Services Task Force (USPSTF) said they didn’t have enough evidence to specifically recommend for or against the test. Now, if HPV tests and Pap tests are negative, women aged 30-65 can extend the cervical cancer screening interval to five years.

“People need to get screened, but they don’t need to do it too often,” says Virginia Moyer, MD, MPH, a professor of pediatrics at Baylor Medical College and chair of the U.S. Preventive Services Task Force, which published an updated version of its 2003 recommendations online in the Annals of Internal Medicine.

The American Cancer Society, the American Society for Colposcopy and Cervical Pathology, and the American Society for Clinical Pathology also released new sets of guidelines that are nearly identical to those from the USPSTF.

The harms of more frequent screening -- such as a greater chance of  abnormal test results that can lead to further, sometimes invasive testing -- outweigh the benefits of early detection of slow-growing precancerous changes in the cervix, the authors of the guidelines conclude. Often, those precancerous changes resolve without any treatment. Persistent infection with certain types of HPV can lead to cervical cancer.

No Pap Tests Before Age 21

Women should begin screening at age 21, according to the recommendations. Previous USPSTF guidelines recommended that women begin screening within three years of becoming sexually active or at age 21, whichever came first. In its new update, though, the task force says it found little evidence that sexual history should affect the age at which women begin to get screened. And, the guidelines note, there is no evidence that screening women younger than 21 reduces diagnoses of or deaths from cervical cancer.

HPV testing is not recommended for women in their 20s because people in that age group can have HPV infections that resolve without treatment.

Women over age 65 can stop getting screened if they’ve had at least three consecutive negative Pap tests or at least two negative HPV tests within the previous 10 years, according to the guidelines. But women who have a history of a more advanced precancer diagnosis should continue to be screened for at least 20 years.

And women of any age who’ve had a hysterectomy with removal of the cervix and no history of cervical cancer or advanced precancerous abnormalities do not need to be screened, according to the guidelines.

The guidelines do not apply to women with a history of cervical cancer or prenatal exposure to the drug diethylstilbestrol (DES) or to women whose immune systems aren’t functioning normally, such as those with HIV. Such women may need more intensive screening.

As a result of cervical cancer screening, death rates from cervical cancer in developed countries have plummeted. This year, the American Cancer Society estimates that more than 12,000 women will be diagnosed with the disease and more than 4,200 will die. A majority of cases occur in women who hadn’t been screened in more than five years, if ever.

Skip the Annual Checkup?

Pap tests are the reason many women go in for annual checkups, and the task force cautions women not to skip seeing a doctor regularly. However, Moyer says, that doesn’t necessarily mean yearly appointments. “The value of the annual visit with your physician is going to be determined by the individual patient and the physician,” she says.

Just because they don’t need a Pap test doesn’t mean women should go years without seeing a doctor, says Howard W. Jones III, MD, director of gynecological cancer at the Vanderbilt-Ingram Cancer Center, who wasn’t involved in writing the new guidelines. After all, Jones says, high cholesterol, high blood pressure, and diabetes can go undetected for years in people who aren’t screened for them.

Whether women still need routine pelvic exams is another question, says Maryam Guiahi, MD, an assistant professor of obstetrics and gynecology at the University of Colorado School of Medicine.

In an article published last year, Guiahi and her co-authors concluded that new technology, such as urine tests and do-it-yourself vaginal swabs for screening for sexually transmitted infections, and new guidelines, such as longer intervals between Pap smears, make routine pelvic exams obsolete.

But Guiahi says she still gets patients who expect a Pap test at every visit. She tells them that frequent screening isn’t recommended. It’s not a tough sell. “Once you explain it ... many women are amenable to not taking their pants off.” 

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