Most women should wait 3-5 years between Pap tests, says ACOG

National groups now in alignment on less frequent screenings

An annual Pap smear might soon become a thing of the past. Most women should be screened for cervical cancer no more often than once every three to five years, according to new cervical cancer screening guidance issued by the American College of Obstetricians and Gynecologists (ACOG).1 The recommendations fall in line with information released in 2012 by the American Cancer Society, the American Society for Colposcopy and Cervical Pathology, and the American Society for Clinical Pathology.2

The biggest change in ACOG’s cervical cancer screening guidelines is for women ages 30-65. For women in this age group who have negative test results, ACOG calls for a screening strategy of testing with the Pap test, using the conventional Pap or liquid-based method, combined with human papillomavirus (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, the ACOG guidance states.

Science indicates that while HPV infections are common, most are transient and don’t progress to cervical cancer, says David Chelmow, MD, chair of the Department of Obstetrics and Gynecology in the Virginia Commonwealth University School of Medicine in Richmond. “The evidence clearly shows that less frequent cervical cancer screening is warranted,” says Chelmow, who led development of the ACOG guidance. “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.”

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Women younger than 21 should not be screened for cervical cancer or HPV, regardless of whether they have had sexual intercourse, the guidance notes. While the prevalence of HPV is high among sexually active adolescents, invasive cervical cancer is rare in women younger than 21, the guidance notes.1 Most cervical abnormalities that occur related to HPV infection in this age group typically spontaneously resolve and require no treatment, the guidance states.

Although women younger than age 21 will not receive screening, clinicians can emphasize prevention of cervical cancer by encouraging the HPV vaccine and providing counseling about safe sex practices, the guidance points out.1 HPV-vaccinated women should follow the same cervical cancer screening guidelines as unvaccinated women.

For women ages 21-29, cervical cancer screening should be performed once every three years instead of once every two years. Clinicians may opt to use the conventional Pap or the liquid-based method. Women younger than 30 should not be screened with co-testing, according to the practice bulletin.

“The new guidelines emphasize that there is no role for tests that look for low-risk types of HPV,” notes Chelmow. “When co-testing, we should be using only tests for high-risk, oncogenic types of HPV.”

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 also have had 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, the guidance states.

Regardless of age, women who have had a hysterectomy with removal of the cervix and have no history of CIN 2 or CIN 3 should discontinue routine cervical cancer screening, the practice bulletin advises.

Women with certain conditions will require more frequent screening, the practice bulletin advises. These populations include:

  • women with HIV;
  • women who have received organ transplants or are immunocompromised for other reasons;
  • women who were exposed to diethylstilbestrol in utero;
  • women previously treated for CIN 2, CIN 3, or cancer.

Emphasize well-woman care

Planned Parenthood Federation of America health centers already have changed their cervical cancer screening guidelines to align with those issued by the American Cancer Society, United States Preventive Services Task Force, and other professional medical organizations, noted Vanessa Cullins, MD, MPH, vice president for external medical affairs.

“We are pleased to see that the new ACOG guidelines call for nearly identical evidenced-based protocols, which will help patients and their healthcare providers balance the benefits and risks of being screened for cervical cancer,” said Cullins in a statement issued with release of the ACOG guidance.

The new changes in recommendations are significant for physicians and patients alike, notes Chelmow. It will take time and effort to re-educate both audiences 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 important for many other aspects of their healthcare, he says.

Be sure your practice captures the important aspects of the well-woman exam. According to guidance issued by ACOG in July 2012, an annual well-woman visit provides an excellent opportunity for counseling patients about maintaining a healthy lifestyle and minimizing health risks.3 To assess overall health, a physical exam generally includes checks of blood pressure, weight, body mass index, palpation of the abdomen and lymph nodes, and an assessment of the patient’s overall health.

ACOG advises annual pelvic exams begin at age 21. For younger women, an internal exam is not recommended unless a patient has signs of a menstrual disorder, vaginal discharge, pelvic pain, or other reproductive-related symptom. Screening for sexually transmitted infections is an important part of the annual exam; however, testing can be performed using urine samples or vaginal swabs without an internal pelvic exam, the guidance notes.

Clinical breast exams (CBEs) also are part of the well-woman visit, ACOG notes. The organization, along with the American Cancer Society and the National Comprehensive Cancer Network, continues to recommend CBEs every one to three years for women ages 20-39. The ACOG recommendations call for annual CBEs and annual mammograms for women age 40 and older.

Although most women no longer need annual Pap tests based on recent cervical cancer screening guidelines, they still need annual well-woman exams with their provider for other important screenings, evaluations, and immunizations based on their age and individual risk factors, ACOG states. Remember that decisions on whether to perform internal pelvic exams and/or breast exams always should be made with the patient’s consent. [Did you receive the CTU bulletin on this latest ACOG guidance? To receive breaking news as it occurs, provide your e-mail address to AHC Media customer service at (800) 688-2421 or customerservice@ahcmedia.com.]

References

  1. Screening for cervical cancer. Obstet Gynecol 2012; 120:1,222-1,238.
  2. Saslow D, Solomon D, Lawson HW, et al. American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer. Am J Clin Pathol 2012; 137(4):516-542.
  3. The American College of Obstetricians and Gynecologists Committee on Gynecologic Practice. Committee opinion number 534: Well-woman visit. Obstet Gynecol 2012; 120:421.