Cervical Cancer Screening - Understanding the New Guidelines

The new cervical cancer screening guidelines will no doubt be confusing for many. “For years we as physicians have urged women to have annual Pap smears, and now, apparently suddenly, we have reversed course. But in truth, the new guidelines are not all that different from those that have been out for a while, and are based on good data,” says Dr. Elizabeth Roth of the Women’s Health Associates at Mass General. “Think of them more as a refinement of what we have been recommending for the last few years.”

We have outlined the most recent guidelines below, but bear in mind that you can always discuss your particular situation with your doctor. No set of guidelines covers every situation, and certainly there are women who should continue to get more frequent Pap smears. What is important to remember is that these guidelines in no way say that women do not need Pap smears, as worldwide cervical cancer continues to claim far too many lives from a disease that is treatable in the early stages. Screening can detect pre-cancerous changes in the cervix, and can also find cervical cancer early when it is most curable (5 year survival 92%).

How often is cervical cancer diagnosed?

The estimated yearly worldwide incidence of cervical cancer is almost 500,000 cases, with 250,000 deaths every year.

In the United States, we have seen a marked decline in deaths from cervical cancer since screening with Pap smears was instituted in 1941. Cervical cancer was once a leading cause of cancer death in American women, but according to American Cancer Society data the death rate dropped 74% between 1955 and 1992 and continues to decline. Let’s not reverse that trend.

In this country, even with screening programs in place, there are an estimated 11,070 new cases of cervical cancer and almost 4,000 deaths from this cancer annually. In the U.S., cervical cancer in Hispanic women occurs at a rate that is more than twice that of non-Hispanic white women. African-American women develop this malignancy about 50% more often than non-Hispanic white women.

HPV vaccine

There is hope that the relatively new Human Papillomavirus (HPV) vaccine will have a significant effect on cervical abnormalities, and thus on the development of cervical cancer. This is because HPV is the most common cause of cervical cancer. However, until more data are available, even women who have been vaccinated against HPV should continue to receive regular screening based on the recommendations below.

New guidelines

What follows is a summary of the latest guidelines released November 20, 2009 by the American College of Obstetricians and Gynecologists (ACOG) for cervical cancer screening:

  * Initial Pap screening should begin at age 21. Given the low risk of cervical cancer in women under the age of 20, the new recommendations seek to avoid the anxiety, stigmatization, and cost of working up abnormal Pap smears in women under age 21, who present with an abnormal Pap smear likely due to transient HPV infection.

  * For women between age 21 and 29, Pap smear screening should be carried out every two years rather than annually as previously recommended.

  * For women between age 30 and 65-70, Pap smear screening should be carried out every three years. Women without a history of cervical intraepithelial neoplasia (CIN) are low risk for the development of cervical cancer and more frequent screening is likely to identify transient lesions.

  * For women with a history of cervical intraepithelial neoplasia (CIN) 2 or 3 or a history of cervical cancer, routine screening with Pap smears every year needs to be continued for at least 20 years.

  * For women who are 65-70 or older who have had three or more consecutive, documented, normal Pap smears and no abnormal Pap smears within 10 years, Pap smear screening may be discontinued.

  * Both liquid based cytology and conventional cytology are similarly effective Pap smear technologies in screening for cervical cancer.

  * For women who have had a hysterectomy for benign, non-cancer indications, Pap smear screening may be discontinued. If a woman underwent a hysterectomy to treat CIN 2 or 3 or cancer, or a woman does not recall the indication for her hysterectomy, Pap smear screening should be continued.

  * The HPV test and Pap smear test can be used together to screen for cervical cancer in women 30 years of age or older. Use co-testing (Pap smear and HPV test) only every three years if the Pap smear is normal and the HPV test is negative.

- #  Massachusetts General Hospital

The American College of Obstetricians and Gynecologists (ACOG) recently released new guidelines for cervical cancer screening. Dr. Marcela Del Carmen from the Obstetrics and Gynecology Service and Dr. Elizabeth Roth from the Women’s Health Associates at Mass General help put this in context.

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