Hello. I’m Andrew Kaunitz, Professor and Associate Chair of the Department of Obstetrics and Gynecology at the University of Florida College of Medicine in Jacksonville, Florida. Today, I’d like to discuss Updated Guidelines for Cervical Cancer Screening: Less Is More.
The profound impact that annual pap smears have made in reducing the incidence of and mortality from cervical cancer represents a triumph of preventive medicine. Over time, we have learned that beginning screening at age 21 years and performing cytology less often than annually will not compromise outcomes. We also have come to appreciate the role human papillomavirus (HPV) plays in causing cervical neoplasia.
Over the last decade, cotesting, which employs cytology along with testing for 12 or 13 oncogenic HPV types, has been found to be superior to cytology alone in identifying preinvasive lesions in women older than 30 years of age, while allowing women with negative cytology and HPV results to be safely screened less often.[1]
The American Cancer Society (ACS), the American Society for Colposcopy and Cervical Pathology (ASCCP), and the American Society for Clinical Pathology (ASCP) have now published new, evidence-based guidelines that will change how we screen for cervical cancer.[2] To summarize:
• Screening should begin at age 21 years. Cytology alone is recommended every 3 years for women 21-29 years of age.
• For women 30-65 years of age, cotesting every 5 years is recommended. If HPV testing is not available, cytology alone should be continued every 3 years.
• Cytologic findings of atypical squamous cells of undetermined significance (ASCUS) accompanied by HPV-negative results should be managed the same as with a normal screening result.
I anticipate the greatest confusion will surround the management of women who are cytology negative but HPV-positive:
• Option #1 in this setting is to repeat cotesting in 1 year. At that time, women who retest HPV-positive or have low-grade squamous intraepithelial lesion changes on cytology should undergo colposcopy. Women with normal or ASCUS cytology and who are HPV-negative at 1 year should return to routine screening.
• Option #2 is immediate testing for HPV types 16 and 18. Women who test positive for either of these viral types should undergo colposcopy. Women who test negative for both of these viral types should be cotested in 12 months, with management of results as outlined in Option #1.
Women with all other abnormalities should be managed as per existing guidance from ASCCP.[3]
Most women can discontinue screening after age 65 years or after hysterectomy. Once discontinued, screening should not resume even if a woman reports having a new sexual partner.
Following spontaneous regression or appropriate treatment, women with a history of CIN2 (cervical intraepithelial neoplasia grade 2) or a more severe lesion should continue screening for at least 20 years, even if this extends beyond age 65 years.
New recommendations issued by the US Preventive Services Task Force[4] are now similar to the updated guidance from ACS/ASCCP/ASCP that is summarized here.
As we implement these new guidelines in our practices, our challenge as women’s health clinicians will include educating our patients not only that cervical cancer screening can be performed less frequently without placing them at risk, but also that well-woman visits and pelvic examinations provide health benefits above and beyond early detection of cervical cancer.
References
1. Chelmow D, Waxman A, Cain JM, Lawrence HC 3rd. The evolution of cervical screening and the specialty of obstetrics and gynecology. Obstet Gynecol. 2012;119:695-699. Abstract
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. CA Cancer J Clin. 2012 Mar 14. [Epub ahead of print]
3. Wright TC Jr, Massad LS, Dunton CJ, et al; 2006 ASCCP-Sponsored Consensus Conference. 2006 consensus guidelines for the management of women with abnormal cervical screening tests. J Low Genit Tract Dis. 2007;11:201-222. Abstract
4. Moyer VA; on behalf of the US Preventive Services Task Force. Screening for cervical cancer: US Preventive Services Task Force recommendation statement. Ann Intern Med. 2012 March 14. [Epub ahead of print]
Andrew Kaunitz, MD
Authors and Disclosures
