Washington, DC -- Most women should be screened for cervical cancer no more often than once every three to five years, according to new guidelines issued today by The American College of Obstetricians and Gynecologists (The College). In addition to extending the interval between Pap tests, co-testing with the Pap test and the human papillomavirus (HPV) test is preferred to the Pap test alone but should be limited to women age 30 and older and used only once every five years.
Today’s guidelines align with recommendations released earlier this year by the American Cancer Society, the American Society for Colposcopy and Cervical Pathology, and other medical groups.
“These recommendation changes are significant for physicians and patients alike,” said David Chelmow, MD, who led the development of The College’s guidelines. “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. 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.”
Widespread Pap screening has lowered the cervical cancer rate in the US by more than 50% over the past 30 years. Most cervical cancers in the US occur among women who were never screened or inadequately screened. Cervical cancer is caused by certain oncogenic (cancer causing) strains of HPV, a common sexually transmitted infection. Most women with healthy immune systems effectively eliminate HPV infections. Only a small fraction of women with persistent HPV infection will develop cervical abnormalities that lead to cancer.
The biggest change in the cervical cancer screening guidelines is for women ages 30–65. For women in this age group who have negative test results, the preferred screening strategy is now co-testing with the Pap test (using the conventional Pap or liquid-based method) combined with HPV testing once every five years. A Pap test alone (without HPV co-testing) once every three years is acceptable for women in this age group if HPV testing is not available.
“We know that HPV infections are very common but most are transient and don’t progress to cervical cancer,” Dr. Chelmow said. According to The College, the majority of truly precancerous cervical cells take years to turn into invasive cervical cancer. “The evidence clearly shows that less frequent cervical cancer screening is warranted. 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.”
The College continues recommending that women younger than 21 should not be screened for cervical cancer (or HPV) regardless of whether they have had sexual intercourse. Although the prevalence of HPV is high among sexually active adolescents, invasive cervical cancer is very rare in women younger than 21. The immune system, particularly in young women, effectively clears the HPV infection in an average of eight months. The majority of cervical abnormalities that occur related to HPV infection in this age group typically spontaneously resolve and require no treatment.
Women ages 21–29 should now receive cervical cancer screening once every three years instead of once every two years. Screening using either the conventional Pap or the liquid-based method is acceptable. Women younger than 30, however, should not be screened with co-testing.
“The new guidelines emphasize that there is no role for tests that look for low-risk types of HPV,” said Dr. Chelmow. “When co-testing, we should be using only tests for high-risk, oncogenic types of HPV.”
Cervical cancer screening should be discontinued in women older than 65 if they have no history of cervical intraepithelial neoplasia (CIN) 2, CIN 3, adenocarcinoma in situ, or cervical cancer and who have also had either three consecutive negative Pap test results or two consecutive negative co-test results within the previous 10 years, with the most recent test performed within the past five years.
Women, regardless of age, who have had a hysterectomy with removal of the cervix (total hysterectomy) and have no history of CIN 2 or CIN 3 should discontinue routine cervical cancer screening.
HPV-vaccinated women should follow the same cervical cancer screening guidelines as unvaccinated women.
The College recommends that women with a history of cervical cancer, or who are HIV-positive, immunocompromised, or were exposed to diethylstilbestrol (DES) in utero should not follow routine cervical cancer screening guidelines. These women may need more frequent screening.
Practice Bulletin #131 “Screening for Cervical Cancer” is published in the November 2012 issue of Obstetrics & Gynecology.
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Other recommendations issued in this month’s Obstetrics & Gynecology:
Committee Opinion #540 “Risk of Venous Thromboembolism Among Users of Drospirenone-Containing Oral Contraceptive Pills” (NEW!)
ABSTRACT: Although the risk of venous thromboembolism is increased among oral contraceptive users compared with nonusers who are not pregnant and not taking hormones, and some data have suggested that use of drospirenone-containing pills has a higher risk of venous thromboembolism, this risk is still very low and is much lower than the risk of venous thromboembolism during pregnancy and the immediate postpartum period. When prescribing any oral contraceptive, clinicians should consider a woman’s risk factors for venous thromboembolism and refer to the U.S. Medical Eligibility Criteria for Contraceptive Use issued by the Centers for Disease Control and Prevention. Patient education materials, including product labeling, should place information regarding oral contraceptive use and venous thromboembolism risks in context by also providing information about overall venous thromboembolism risks and venous thromboembolism risks during pregnancy and the postpartum period. Decisions regarding choice of oral contraceptive should be left to clinicians and their patients, taking into account the possible minimally increased risk of venous thromboembolism, patient preference, and available alternatives
Committee Opinion #541 “Professional Relationships with Industry” (NEW!)
ABSTRACT: The American College of Obstetricians and Gynecologists (the College) has a long history of leadership in ensuring that its educational mission is evidence based and unbiased. A predecessor to this Committee Opinion was published in 1985, making the College one of the first professional associations to provide guidance on this issue. The College has continued to update the ethical guidance on physician interactions with industry periodically. Obstetrician–gynecologists’ relationships with industry should be structured in a manner that will enhance, rather than detract from, their obligations to their patients. The ideal behaviors set forth in this Committee Opinion will contribute toward maintaining patient trust in the specialty and avoiding conflicts of interest by College members.
Committee Opinion #542 “Access to Emergency Contraception” (NEW!)
ABSTRACT: Emergency contraception includes contraceptive methods used to prevent pregnancy in the first few days after unprotected intercourse, sexual assault, or contraceptive failure. Although the U.S. Food and Drug Administration approved the first dedicated product for emergency contraception in 1998, numerous barriers to access to emergency contraception remain. The purpose of this Committee Opinion is to examine the barriers to the use of oral emergency contraception methods and to highlight the importance of increasing access.