Applying the “New” Cervical Cytology Guidelines in Your Practice

 

Going forward, expect quality metrics for cervical cancer screening to evaluate your practice, not only on the percentage of eligible women who are screened for cervical cancer, but also for the average interval between tests in women who should be screened routinely every 3 to 5 years.

Between the 1940s and 2002, women in the United States were advised to have cervical cytology screening (the “Pap smear”) for cervical cancer performed annually at the time of their well woman visit.¹ Over the past decade, however, national guidelines have changed substantially, such that routine screening is started later, completed earlier, and intervals extended to every 3 to 5 years for most women. In the past, there were significant differences in the guidelines of the national organizations that published them, mainly reflecting the degree of understanding about the natural history of HPV infections at that time. Thankfully, the updated guidelines published in 2012 by the U.S. Preventive Services Taskforce (USPSTF)²—a consensus statement³ of the American Cancer Society, the American Society for Colposcopy and Cervical Pathology (ASCCP) and American Society for Clinical Pathology, as well as a Practice Bulletin⁴ issued by the American College of Obstetricians and Gynecologists (ACOG)—all contain virtually identical recommendations. The consistency of these guidelines from so many respected organizations have established a national standard of care regarding cervical cancer screening intervals, and consequently, clinicians should be careful to explain the rationale in a woman’s medical record if a decision is made to deviate from their content.

Table 1 summarizes the recommendations regarding when to begin and end cervical cancer screening, and for women who should be screened, how often it should be performed. Women falling under special consideration also were addressed in some of the guidelines and are contained in Table 2.

A real problem for clinicians is that there has been no national consumer education campaign regarding the rationale for the changes in the guidelines, and many women reject them as being financially motivated and not in the best interest of their health.⁵ Some clinicians are reluctant to change their screening practices as well, and in one study, physicians felt that patients were uncomfortable with extended screening intervals and were concerned that patients would not come for annual exams without concurrent cytology screening.⁶ Despite these obstacles, clinicians should take the time to discuss with each woman the interval that applies to her and to counsel her that being screened too often can be harmful to her health. Over-screening minimally improves lesion detection rates but it results in an excess risk of false positive tests, which can lead to unnecessary colposcopy and biopsies, with attendant anxiety and inconvenience, as well as unnecessary financial costs to the patient⁷ and the health delivery system. Health plans now recognize this as a patient safety issue.

In summary, while it is important to insure that women are screened often enough to detect pre-invasive cervical lesions, these guidelines remind us we must be equally vigilant about not screening so often that we jeopardize women’s health.

Table 1: When to Begin and End Cervical Cancer Screening

Girls and women younger than 21 years of age should not undergo cervical cancer screening. Cervical cancer screening should begin at age 21, regardless of risk factors, with women age 21 to 29 undergoing cytology (conventional cytology or liquid-based cytology) every 3 years Women between the ages of 30 and 65 can continue cytology-only screening every 3 years or may undergo screening every 5 years with cytology plus HPV testing (“co-testing”). The ACS and ACOG guidelines consider co-testing to be the preferred strategy in this age group, while the USPSTF considers them to be equivalent. Women greater than 65 years of age, who have had three consecutive negative cytology tests or two consecutive 5-year cytology plus HPV DNA co-tests, and with the most recent test no more than 5 years before age 65, should stop undergoing cytology screening. No screening is indicated for women who have had the cervix or entire uterus removed and who do not have any history of cervical intraepithelial neoplasia 2 (CIN2) or more severe diagnosis. HPV DNA testing should not be used routinely among women younger than 30 years of age.

 

Table 2: Special Considerations

Screening recommendations are not different for HPV-vaccinated women and unvaccinated women. Virginal women 21 years of age and older should be advised that their risk of cervical cancer is extremely low, but not zero. Once counseled, either they may decline cervical cancer screening entirely or can opt to be screened routinely. Pregnant women should be screened at the same intervals as non-pregnant women; for women who are entering antepartum care, an “off schedule” cytology screen is not needed routinely if prior results are available and negative. Women who have a compromised immune system may develop lesions more rapidly than women who are immunocompetent and therefore must be screened more often in order to detect an interval cancer.  This includes women with HIV infection, a major organ transplant with the use of an anti-rejection drug, and chronic corticosteroid use. ACOG recommends annual screening of these women, while the USPSTF and the ACS have no recommendation. Except for immunocompromised women, no woman, regardless of age, should undergo annual screening, either with cytology tests or HPV DNA tests. Women with a history of treated CIN2 or worse should undergo screening for at least 20 years, even beyond 65 years of age. However, while older guidelines recommend annual screening for these women, the new guidelines state that after their post-treatment surveillance is completed, they can be screened every 3 years with conventional cytology or every 5 years with co-testing. If a cytology test has not been performed or the result is not available, hormonal contraception should never be limited or withheld. There is no medical evidence that the use of hormonal contraceptives will adversely affect the diagnosis and treatment of cervical abnormalities. Having an abnormal result makes it even more important to provide effective contraception, as pregnancy would complicate, and in some cases delay, treatment for cervical abnormalities.

 

Michael Policar, MD, MPH, clinical professor of obstetrics, gynecology, and reproductive sciences, University of San Francisco; medical director, UCSF Family PACT Evaluation, California Office of Family Planning

References

1.          Chelmow D, Waxman A, Cain JM, Lawrence HC. The evolution of cervical screening and the specialty of obstetrics and gynecology. Obstet Gynecol. 2012;119(4):695-699.

2.         Moyer VA. Screening for cervical cancer: U.S. Preventive services task force recommendation statement. Ann Intern Med. 2012 Jun 19;156(12):880-91

3.         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 Apr;137(4):516-42, or CA Cancer J Clin. 2012 May-Jun;62(3):147-72, or J Lower Genit Tr Dis. 2012;16(3):1-29.

4.         American College of Obstetricians and Gynecologists. Screening for cervical cancer. Practice Bulletin No. 131. Obstet Gynecol. 2012; 120:1222-1238.

5.         Meissner HI, Tiro JA, Yabroff KR, Haggstrom DA, Coughlin SS. Too much of a good thing? Physician practices and patient willingness for less frequent pap test screening intervals. Med Care. 2010 Mar;48(3):249-59.

6.         Perkins RB, Anderson BL, Gorin SS, Schulkin JA. Challenges in cervical cancer prevention: a survey of U.S. obstetrician-gynecologists. Am J Prev Med. 2013 Aug;45(2):175-81.

7.         Bettigole C. The Thousand-Dollar Pap Smear. N Engl J Med. 2013; 369(16):1486-7.

Other helpful resources:

Sawaya GF. New guidelines: it’s complicated. Obstet Gynecol. 2013 121(4):703-4.

Hong JH, Lee JK. Updates on the current screening guidelines for the early detection of cervical cancer. J Gynecol Oncol. 2013; 24(3):212-214.

Smith RA, Brooks D, Cokkinides V, et al. Cancer screening in the United States, 2013: a review of current American Cancer Society guidelines, current issues in cancer screening, and new guidance on cervical cancer screening and lung cancer screening. CA: Cancer J Clin. 2013;63(2):87-105.

Karjane N, Chelmow D. New cervical cancer screening guidelines, again. Obstet Gynecol Clin N Am. 2013;40:211-223.

Feldman S. Making sense of the new cervical-cancer screening guidelines. N Engl J Med. 2011 365(23):2145-7