Who should be in this room, awaiting her screening?

The prevention of cervical cancer is one of the great triumphs of cancer screening.

Since George Nicholas Papanicolaou developed the Pap smear—the screening test—in 1943, the incidence of cervical cancer in the United Sates has declined by 50%. Most women who develop the disease have not undergone recommended screening or have had false-negative Pap smears. In areas of the world where Pap-smear screening does not exist, cervical cancer remains a leading cause of death for women.

For decades women were advised to have a Pap test every year—generally by a gynecologist, who would also review their general health and wellbeing. The need to go for a regular Pap smear reminded a woman that she should see her doctor annually.

Two years ago, however, panels of experts recommended that some women have less frequent screenings. Several factors influenced their recommendations: (1) a new understanding of the molecular origins of cervical cancer; (2) a better understanding of precancerous changes related to the disease; and (3) the fact that testing for HPV, the human papillomavirus, can now be added to the Pap smear for screening

The new guidelines are below. Should you follow them? A recent study has demonstrated that the vast majority of physicians (private-practice and academic) choose not to follow some of these new recommendations. These doctors continue to perform annual Pap smears. Why this is occurring is a question still to be answered. It may reflect physicians’ general uneasiness with these recommendations.

The Pap smear was designed to diagnose pre-cancerous changes in the cervix, so that these changes can be treated before they have a chance to become cancer. The smear is generally collected during the course of a regular pelvic exam. A small plastic spatula or brush is used to gently scrape cells off the cervix. The cells are placed into a container and sent to a laboratory, where they are looked at by the human eye, a computer, or a combination of both. The presence of normal or abnormal cells is then reported.

Human papillomavirus, a very common sexually transmitted virus, is now recognized as the cause of cervical cancer. Approximately 50% to 70% of sexually active women will be infected at some point during their lifetime. It is important to realize, however, that the vast majority of women who have an HPV infection do not have problems from it. Still, the presence of HPV may signal that a woman has some elevated risk of pre-cancerous and cancerous conditions of the cervix.

Recently—over the past six years or so—HPV testing on Pap smears has been incorporated into many physicians’ practices. This HPV test is generally done on cells that are removed at the time of the Pap smear. HPV testing is usually used for women over the age of 30. (This is because younger women tend to clear the virus from their body and have fewer consequences from it.)

The new screening guidelines recognize that women who are over the age of 30 and have had multiple normal Pap smears have a quite low risk of developing cervical cancer within the next few years.

Here are the new recommendations, issued by the American College of Obstetricians and Gynecologists: 

        •Women over 30 who have had three consecutive negative yearly Pap smears can be safely screened at three-year intervals.

The widespread use of HPV testing at the time of the Pap smear is one reason for the recommended reduction in screenings for women over the age of 30. Indeed, the new guidelines now recommend that women over 30 who have a negative Pap smear and negative HPV should undergo another Pap smear no sooner than three years later.

         •For women over 65 to 70 who have had no abnormal results in the past ten years it may be reasonable to discontinue screening.

Important note: These new, more relaxed screening recommendations apply only to women who are at average risk to develop cervical cancer. These recommendations do not apply to women who are at elevated risk to develop cervical cancer.

Elevated risk factors include, but are not limited to—

•women who are immunocompromised  (such as having HIV infection or using steroids

•women who have been exposed to the synthetic hormone DES

          •women who have previously been treated for some precancerous conditions of the cervix

A sexually active woman who has any of these elevated risk factors  should not discontinue her annual Pap-smear screening. These women should discuss their personal health history with their physician to determine how these new recommendations should be incorporated into their care. Women with elevated risk factors should continue to see their gynecologists on an annual basis in order to reassess their risk factors for cervical cancer and further refine their screening.

Special concerns about these new guidelines need to be addressed. What is the “real life” performance of these new recommendations? These recommendations are largely based on study populations that, for a variety of reasons, may not reflect “real world” situations. We anxiously await assessment of the new Pap-smear screening strategies as they are adopted and evolve with the use of HPV testing.

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