Put Down the Pap and Step Away: Updated Cervical Cytology Screening Guidelines
Abstract & Commentary
By Alison Edelman, MD, MPH, Associate Professor, Assistant Director of the Family Planning Fellowship Department of Obstetrics & Gynecology, Oregon Health & Sciences University, Portland, is Associate Editor for OB/GYN Clinical Alert.
Dr. Edelman is a consultant to Schering-Plough and receives grant/research support from the Society for Family Planning.
Synopsis: Updated cervical cytology screening guidelines by the American College of Obstetrics and Gynecologists recommend a decreased frequency of pap smears for women younger than age 30.
Source: Cervical cytology screening. American College of Obstetrics and Gynecologists (ACOG) Practice Bulletin. No. 109, December 2009. Available at: www.acog.org/publications/educational_bulletins/pb109.cfm. Accessed Dec. 8, 2009.
American College of Obstetrics and Gynecologists (ACOG) recently published updated recommendations on the frequency of cervical cytology screening. The main changes were in women younger than age 30, including the first pap to occur no earlier than age 21 (no longer based on the date of sexual debut) and a pap every 2 years for women age 21-29 years. No changes were made to the frequency of pap testing in women older than age 30 (healthy, immune-intact women with three consecutive negative paps may be screened every 3 years).
November was a busy month for women's health care with big changes in screening practices. If you tend toward the paranoid, you may wonder if this is part of a conspiracy to decrease costs. Let me reassure you that the recent pap recommendations have been in the pipeline for well over a year and the changes aren't actually that drastic (see table). These changes are not as controversial as the mammography recommendations and have the support of the American Society for Colposcopy and Cervical Pathology (ASCCP) and the American Cancer Society.1
There are some general caveats to decreasing the frequency of pap smears for any age group. These recommendations are for "low-risk" women, which means not immunocompromised (i.e., HIV/AIDs, transplant patients), or those with prior exposure to diethylstilbestrol (DES). Additionally, women who have undergone previous treatment for CIN 2, CIN 3, or cervical cancer are at risk for recurrent disease and are advised to have annual screening for at least 20 years.2-4
How do these recommendations translate to the office? Unfortunately, you probably have some women younger than age 21 who are already being followed for dysplasia. Become familiar with the ASCCP's guidelines published in 2006 for management of abnormal cytology and histology in adolescent women.2,5 You can download the clinical algorithms at: www.asccp.org/consensus.shtml. The recommendations vary significantly from the management of adult women with a lot more watchful waiting and a lot fewer excisional procedures.
Educating and reassuring our patients about these new screening guidelines can be challenging and time-consuming. Interestingly, my patients younger than age 30 seem thrilled by the prospect of avoiding a pelvic exam and have been very accepting of the new recommendations, while my patients older than age 30 are still skeptical regarding the triennial pap, even though this recommendation has been around for almost 10 years. In any case, here are my "60-second" counseling points, which hopefully will keep your busy clinic running on time, too:
- There are many good reasons for delaying pap screening until women are age 21, including: HPV infection is common but resolves, most dysplasia regresses spontaneously, cervical cancer is extremely rare (1-2 cases/1,000,000), and avoiding screening prevents unnecessary invasive testing (which in turn prevents preterm birth).6-8
- Triennial screening in low-risk women age 30 years and older has similar benefits to annual screening. A study of 31,000 women found no cancers with spacing paps every 3 years, but theoretic models estimate the possibility of delayed identification of 3 additional cancer cases/100,000.9 But it's important to remember that cervical cancer is a slow-growing cancer.
- For women age 30 and older, if risk factors change (e.g., a new partner) then screening becomes more frequent again.
- Get vaccinated: HPV vaccine for eligible patients.
- MD Consult Press Release: ACOG recommends changes in cervical cancer screening. Available at: www.mdconsult.com/das/news. Accessed Dec. 8, 2009.
- Wright TC, et al; 2006 American Society for Colposcopy and Cervical Pathology-sponsored Consensus Conference. 2006 consensus guidelines for the management of women with cervical intraepithelial neoplasia or adenocarcinoma in situ. Am J Obstet Gynecol 2007;197:340-345.
- Soutter WP, et al. Long-term risk of invasive cervical cancer after treatment of squamous cervical intraepithelial neoplasia. Int J Cancer 2006;118:2048-2055.
- Pettersson F, Malker B. Invasive carcinoma of the uterine cervix following diagnosis and treatment of in situ carcinoma. Record linkage study within a National Cancer Registry. Radiother Oncol 1989;16:115-120.
- Wright TC, et al. 2006 consensus guidelines for the management of women with abnormal cervical cancer screening tests. Am J Obstet Gynecol 2007;197:346-355.
- Ho GY, et al. Natural history of cervicovaginal papillomavirus infection in young women. N Engl J Med 1998;338:423-428.
- Watson M, et al. Burden of cervical cancer in the United States, 1998-2003. Cancer 2008;113:2855-2864.
- Kyrgiou M, et al. Obstetric outcomes after conservative treatment for intraepithelial or early invasive cervical lesions: Systematic review and meta-analysis. Lancet 2006;367:489-498.
- Sawaya GF, et al. Risk of cervical cancer associated with extending the interval between cervical-cancer screenings. N Engl J Med 2003;349:1501-1509.