Check the new screening guidance for cervical cancer and breast cancer

Guidelines may change schedules for mammography, Pap smears

Women's health clinicians will take a hard look at cancer screening regimens now that new guidance has been issued by the U.S. Preventive Services Task Force (USPSTF) and the American College of Obstetricians and Gynecologists (ACOG).1,2

The USPSTF guidelines on breast cancer screening were issued in early November 2009. ACOG released its practice bulletin on cervical cancer screening in mid-November 2009. The two guidance documents stand as separate entities; the timing of publication is coincidental.3

The national task force recommendations on breast cancer screening update guidance issued in 2002. According to the new guidelines, the USPSTF:

  • recommends against routine screening mammography in women ages 40-49. The decision to start regular, biennial screening mammography before age 50 should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms, the USPSTF notes;
  • recommends biennial screening mammography for women ages 50-74. The USPSTF concludes that current evidence is insufficient to assess the additional benefits and harms of screening mammography in women age 75 or older;
  • recommends against teaching breast self-examination (BSE);
  • concludes that current evidence is insufficient to assess the additional benefits and harms of clinical breast examination beyond screening mammography in women age 40 or older.4

ACOG's new practice bulletin on cervical cancer screening states that most women younger than age 30 should undergo testing once every two years instead of annually, using standard Pap or liquid-based cytology. Women ages 30 and older who have had three consecutive negative cervical cytology test results may be screened once every three years with the Pap or liquid-based cytology.

Women with certain risk factors might need more frequent screening, including those who have HIV, are immunosuppressed, were exposed to diethylstilbestrol in utero, and have been treated for cervical intraepithelial neoplasia (CIN) 2, CIN 3, or cervical cancer.2 ACOG advises that routine cervical cytology testing should be discontinued in women, regardless of age, who have had a total hysterectomy for noncancerous reasons, as long as they have no history of high-grade CIN.

There are no changes in recommendations on the upper age limit for discontinuing cervical screening. ACOG advises that it is reasonable to stop cervical cancer screening at age 65 or 70 among women who have three or more negative cytology results in a row and record no abnormal test results in the past 10 years. The guidance also recommends that women who have been vaccinated against human papillomavirus (HPV) should follow the same screening guidelines as unvaccinated women.

National professional organizations have questioned the new USPSTF guidance on breast cancer screening. ACOG continues to maintain its current advice that women in their 40s receive mammography screening every one to two years and women age 50 or older go for annual screening.5 Clinicians also should continue to counsel women that BSE has the potential to detect palpable breast cancer and can be recommended for use, states ACOG.5

The American Cancer Society also continues to recommend annual screening using mammography and clinical breast examination for all women beginning at age 40. "Our experts make this recommendation having reviewed virtually all the same data reviewed by the USPSTF, but also additional data that the USPSTF did not consider," said Otis Brawley, MD, American Cancer Society's chief medical officer in a press statement.6 "When recommendations are based on judgments about the balance of risks and benefits, reasonable experts can look at the same data and reach different conclusions."

The USPSTF recommendations ignore valid scientific data and place many women at risk, according to a press statement issued by the American College of Radiology and the American Roentgen Ray Society.7 Mammography is not a perfect test, but it has unquestionably been shown to save lives, including those in women ages 40-49, the statement says.

"These new recommendations seem to reflect a conscious decision to ration care," said Carol Lee, MD, chair of the College's Breast Imaging Commission in the statement. "If Medicare and private insurers adopt these incredibly flawed USPSTF recommendations as a rationale for refusing women coverage of these life-saving exams, it could have deadly effects for American women."

ACOG previously recommended that cervical cancer screening begin three years after first sexual intercourse or by age 21, whichever occurred first. By moving the baseline cervical screening to age 21 in its new guidance, ACOG maintains the change represents a conservative approach to avoid unnecessary treatment of adolescents.

While the rate of HPV infection is high among sexually active adolescents, invasive cervical cancer is very rare in women under age 21, because the immune system clears HPV infection within one to two years among most teen women.8 Because the adolescent cervix is immature, there is a higher incidence of HPV-related precancerous lesions; however, the large majority of these dysplasias in teens resolve on their own without treatment.9 Recent research indicates a significant increase in premature births among women who have been treated with excisional procedures for dysplasia.10

In a statement regarding the new publication, Alan Waxman, MD, who headed the ACOG cervical cancer guidance development, said, "Adolescents have most of their childbearing years ahead of them, so it's important to avoid unnecessary procedures that negatively affect the cervix. Screening for cervical cancer in adolescents only serves to increase their anxiety and has led to overuse of follow-up procedures for something that usually resolves on its own."11

References

  1. U.S. Preventive Services Task Force. Screening for breast cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2009; 151:716-726.
  2. American College of Obstetricians and Gynecologists. Cervical cytology screening. Practice Bulletin No. 109. Accessed at journals.lww.com/greenjournal/documents/ PB109_Cervical_Cytology_Screening.pdf.
  3. Grady D. Guidelines push back age for cervical cancer tests. New York Times; Nov. 20, 2009. Accessed at www.nytimes.com/2009/11/20/health.
  4. American College of Obstetricians and Gynecologists. Interpreting the U.S. Preventive Services Task Force breast cancer screening recommendations for the general population. Accessed at www.acog.org/from_home/Misc/uspstfInterpretation.cfm.
  5. American College of Obstetricians and Gynecologists. ACOG statement on revised U.S. Preventive Services Task Force recommendations on breast cancer screening. Nov. 16, 2009. Accessed at www.acog.org/from_home/publications.
  6. American Cancer Society. American Cancer Society responds to changes to USPSTF mammography guidelines. Accessed at www.cancer.org/docroot/MED.
  7. American College of Radiology and American Roentgen Ray Society. USPSTF mammography recommendations will result in countless unnecessary breast cancer deaths each year. Accessed at www.eurekalert.org/pub_releases.
  8. Brown DR, Shew ML, Qadadri B, et al. A longitudinal study of genital human papillomavirus infection in a cohort of closely followed adolescent women. J Infect Dis 2005; 191:182-192.
  9. Fuchs K, Weitzen S, Wu L, et al. Management of cervical intraepithelial neoplasia 2 in adolescent and young women. J Pediatr Adolesc Gynecol 2007; 20:269-274.
  10. Kyrgiou M, Koliopoulos G, Martin-Hirsch P, et al. Obstetric outcomes after conservative treatment for intraepithelial or early invasive cervical lesions: Systematic review and meta-analysis. Lancet 2006; 367:489-498.
  11. American College of Obstetricians and Gynecologists. First cervical cancer screening delayed until age 21. Accessed at www.acog.org/from_home/publications.