Guidance issued on cervical cancer screening: Update your practice now
Guidance issued on cervical cancer screening: Update your practice now
Increased interval doesn't replace need for annual well-woman visits
Get ready to add two sets of guidance on cervical cancer screening to your practice database: the most current recommendations from the U.S. Preventive Services Task Force (USPSTF) and joint cervical cancer prevention guidelines issued by the American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology (ACS/ASCCP/ASCP).1,2 The two sets of recommendations are largely congruent and move practice forward toward efficient and effective cervical cancer screening, according to an editorial issued on their release.3
Healthcare providers should welcome these new recommendations with enthusiasm and incorporate them into routine clinical practice, says Jeffrey Peipert, MD, PhD, Robert J. Terry professor of obstetrics and gynecology and vice chair of clinical research at Washington University in St. Louis School of Medicine. Peipert served as co-author of the current editorial.
"More frequent screening than recommended not only offers no benefit, but it can cause harm," says Peipert. "We should embrace the guidelines."
The new guidelines from USPSTF and ACS/ASCCP/ASCP are for women at average risk, points out an announcement from the American College of Obstetricians and Gynecologists (ACOG).4 More frequent testing might be appropriate for women with conditions that place them at an increased risk of cervical cancer, such as immunocompromise or human immunodeficiency virus (HIV) infection, notes ACOG. The association is evaluating the two sets of guidance in developing its own recommendations on the subject. (See resource box at end of this article for online links to guidance sets.)
"Each set of recommendations was developed under a separate work plan, with its own policies and procedures for evidence collection and analysis," states ACOG. "The very similar recommendations are reassuring because although they were developed independently and by different methodology, they drew on a common evidence base, which was interpreted the same way by different groups of experts."
How important is the interplay between new molecular tests and traditional cytology in shaping the new guidance? Critical, says Mark Stoler, MD, FASCP, past president of the ASCP and professor of pathology, cytology and gynecology at the University of Virginia Health System, Charlottesville. The new guidance, which relies on the interaction between conventional and liquid-based cytology, results in a much better process for women, says Stoler. The "better" comes from more sensitive screening with less frequent doctor visits, he notes.
Take a closer look
Cervical cancer screening should not begin until age 21, regardless of sexual activity, both guidelines state. Women ages 21-29 should be screened at three-year intervals with cytology alone. Testing for human papillomavirus (HPV) should not be part of screening in this age group because the virus is highly prevalent and cytologic abnormalities often are transient.3
However, there are slight differences in the two sets of recommendations for women ages 30 to 65. The ACS/ASCCP/ASCP recommendations define the preferred method of screening as cytology with HPV testing ("cotesting") at five-year intervals. These recommendations say use of cytology at three-year intervals is also "acceptable," especially if access to HPV testing is not practical.3
The USPSTF guidance notes both methods provide similar benefits and calls for cotesting for women who desire to lengthen the screening interval. The ACS/ASCCP/ASCP guidelines also note that there is insufficient evidence to change screening intervals in this age group in women with a history of negative screens.3 For women 65 and older who have been adequately screened and have no history of cervical intraepithelial neoplasia 2 (CIN2) or greater do not need to continue cervical cancer screening regardless of sexual activity, the two sets of guidance concur. Adequate screening consists of negative results on two screens in the past 10 years, with one screen occurring in the past five years.3 Women who have had a hysterectomy and do not have a history of CIN2 or greater should not have screening.3
None of the screening recommendations apply if a woman has a history of cervical cancer, was exposed to the synthetic hormone diethylstilbestrol when in the womb, or if her immune system is suppressed due to HIV or other conditions or medications.
How about HPV vaccine?
What role does the human papillomavirus (HPV) vaccine play in the new recommendations? While the USPSTF guidance does not address vaccination, the ACS/ASCCP/ASCP guidelines recommend that women who have received HPV vaccination continue routine screening. While evidence shows the vaccine to be highly effective at preventing cancer associated with HPV 16 and 18, 30% of cases of cervical cancer are attributable to other HPV strains.5
With the new guidances now in hand, clinicians should press toward better uptake of the HPV vaccine in their younger patients, states the current editorial.
The United States is lagging behind such countries as the United Kingdom and Australia in HPV vaccination, with only 32% of eligible women receiving the complete HPV 16/18 vaccine.6
Remember to encourage all young women and men, whether or not they have been vaccinated against HPV, to use condoms consistently and correctly, says Robert Hatcher, MD, MPH, professor of gynecology and obstetrics at Emory University School of Medicine in Atlanta. Condoms are highly effective in preventing the transmission of HPV, chlamydia, HIV, and other sexually transmitted infections, says Hatcher.
Use visits wisely
With these new guidelines, the challenge as women's health clinicians will be to help patients understand that performing cervical cancer screening less frequently is safe, says Andrew Kaunitz, MD, professor and associate chair in the Obstetrics and Gynecology Department at the University of Florida College of Medicine — Jacksonville. On the other hand, clinicians also must help patients understand that the benefits of well-woman visits extend well beyond cervical cancer screening, he notes.
Remind women that during a typical well-woman exam, providers assess current health status; nutrition; physical activity; sexual practices; contraception needs; and tobacco, alcohol, and drug use. The standard physical exam also includes checks of height, weight, body mass index, and blood pressure. Annual breast and abdominal exams begin at age 19 and pelvic exams at 21, notes ACOG.4
"The well-woman visit has always been more than just a 'Pap smear,' and the decreased need for cervical screening actually constitutes a minor change to an important aspect of a woman's health care," states ACOG.
References
- Moyer VA; on behalf of the U.S. Preventive Services Task Force. Screening for cervical cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2012. Accessed at http://bit.ly/yvpy4P.
- 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.
- Kizer N, Peipert JF. Cervical cancer screening: primum non nocere. Ann Intern Med 2012; Mar 14. Accessed at http://bit.ly/IZzlJe.
- American College of Obstetricians and Gynecologists. New cervical cancer screening recommendations from the U.S. Preventive Services Task Force and the American Cancer Society/American Society for Colposcopy and Cervical Pathology/American Society for Clinical Pathology. Press release. March 14, 2012. Accessed at http://bit.ly/xTYlAf.
- Merck. Monographs in medicine: human papillomavirus. West Point, PA: Merck; 2008.
- Centers for Disease Control and Prevention (CDC). National and state vaccination coverage among adolescents aged 13 through 17 years - United States, 2010. MMWR 2011; 60:1,117-1,123.
Resources
- To access the U.S. Preventive Services Task Force guidance, go to http://bit.ly/cyDcWj.
- To access the joint cervical cancer prevention guidelines issued by the American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology, go to http://bit.ly/w7Ny8w. Under "Guidelines," select the guidance title, "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."
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