Ask Dr. Pat · Health

Cervical Cancer and Pap Smear Guidelines

Dr. Melissa Frey Responds:

In the United States there are approximately 13,000 new cases of cervical cancer each year and 4,000 deaths. There are two main types of cervical cancer, squamous cell carcinoma, the more common type, and adenocarcinoma. Cervical cancer screening has been very effective in reducing the incidence and mortality associated with this disease by identifying precancerous lesions, also called cervical intraepithelial neoplasia (CIN), and early cervical cancers that have not yet spread to surrounding organs and structures and can be cured with surgery.

Infection with human papilloma virus, or HPV, drives the development of cervical dysplasia and cervical cancer. HPV is extremely common, affecting the majority of sexually active men and women. HPV is spread by having vaginal, anal or oral sex or skin-to-skin genital contact with a partner who has the virus. Infected people can transmit the virus even when they have no signs or symptoms. Factors that increase a woman’s risk of acquiring an HPV infection include early age of first sexual intercourse, having multiple sexual partners, tobacco use and anything that causes suppression of the immune system (including rheumatologic diseases, like lupus, that require long-term steroid use and HIV infection).

The main screening methods for cervical dysplasia and cervical cancer are the Papanicolaou test (also called the Pap test) and the HPV test. For the Pap test, cells are collected from the cervix and vagina using a brush or spatula and reviewed by a cytologist who can identify abnormal cells. HPV testing detects the presence of strains of the HPV virus. Cervical cancer screening via Pap and HPV testing is extremely important as it can detect precancerous disease that is easily treated or early-stage cancer that can be cured with surgery. The current recommendations for cervical cancer screening in the United States for immunocompetent women (or women without illness compromising their immune system) based on age are:

Age less than 21 years – No screening

Age 21-29 years – Pap test every 3 years

Age 30-65 – Pap test and HPV every 5 years

Age 65 and older with a history of an abnormal Pap – Routine screening for at least 20 years

Age 65 and older with all prior screening normal – No additional screening

It is imperative that women do not stop cervical cancer screening with Paps and HPV testing when they reach their 40s. Although HPV is most prevalent among younger women, young women are generally able to clear an HPV infection within 8 to 24 months. Conversely, HPV is less common among women over 30, but when older women get HPV they cannot clear it as effectively and have an increased risk of developing a persistent infection. In the United States, only about 15 percent of cervical cancer occurs in women younger than 35 years. Approximately 25 percent of new cases occur in women age 34-44 years and the remaining 60 percent occur in women age 45 years and older. This highlights the need for continued Pap/HPV screening in women in their 40s and beyond.

After undergoing a cervical cancer screening test, it is important to follow up with the results. The first section of a Pap result should state whether or not an adequate specimen was obtained, using the terms either “satisfactory for evaluation” or “unsatisfactory for evaluation.” For Paps that are unsatisfactory, there were not enough cells captured with the brush/spatula and this should prompt repeat Pap testing. Next, the Pap report should state whether or not the “endocervical cell/transformation zone,” or EC/TZ, component is present. The transformation zone is a specific area of the cervix that is at greatest risk for developing cancer and therefore should be sampled with the Pap. If the specimen states that the EC/TZ is not present, a woman should ask her gynecologist about the next step. If the Pap is otherwise normal and the HPV testing is negative, the Pap usually does not need to be repeated immediately, however this plan needs to be individualized based on a woman’s age, history and other risk factors. The Pap report will also describe the interpretation of the results. A normal or negative Pap test is usually described as “negative for intraepithelial lesion or malignancy”. An abnormal Pap will be classified as either squamous (related to the squamous form of cervical dysplasia/cancer) or glandular (related to the adenocarcinoma form). There will then be a specific diagnosis. For squamous lesions this diagnosis can be atypical squamous cells of undetermined significance, or ASCUS; low-grade intraepithelial lesion, or LSIL; high-grade intraepithelial lesion, or HSIL; or squamous cell cancer. For glandular lesions this can be atypical glandular cells, or AGC; endocervical adenocarcinoma in situ, or ACIS; or adenocarcinoma. Occasionally the term “cannot exclude high-grade” will be included in the report, indicating that there is concern for a more aggressive underlying finding but overall the results are equivocal.

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  • Holly March 20, 2017 at 8:55 am

    Thank you, Dr. Pat for reminding us that death from cervical cancer is preventable if you take care to see your Doctor. I have a friend whose sister died of it, and it was so tragic.
    I hope that changes to the ACA will not discourage women from seeking preventative care!