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New Guidelines Issued On Cervical Cancer Screening

By Brenda Wilson

Published November 20, 2009 6:00 AM

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The American College of Obstetricians and Gynecologists issued new guidelines for cervical cancer screening, delaying the start of Pap smears for young women and cutting back on the frequency of the tests.

Only days ago, the U.S. Preventive Services Task Force caused a furor by recommending that women wait until they're 50 to start getting mammograms. But, "It's just pure coincidence that these guidelines have been released now," says Dr. David Soper, the chairman of ACOG's Gynecology Practice Bulletin Committee.

The organization is recommending that young women begin being screened every two years for cervical cancer between the ages of 21 and 29. Previous recommendations called for annual Pap smears three years after the onset of sexual activity or 21 years of age. ACOG was concerned that starting earlier would lead to harmful tests for women who are at a low risk of cancer.

The human papillomavirus, or HPV, that causes cervical cancer is common in sexually active young girls. Invasive cervical cancer in that age group, however, is rare. According to the National Institutes of Health, just one in a million girls is likely to develop cervical cancer between the ages of 15 and 19. The vast majority of the abnormalities that are detected on a Pap smear clear up on their own.

Dr. Alan Waxman, who wrote the guidelines for ACOG, says there was recognition that this is a sensitive period in a young girl's life. A Pap test can be very uncomfortable for the girl and sometimes for the physician doing the test.

"She's very, very sensitive to her body image," Waxman says. "She goes and gets her first Pap smear. It comes back abnormal."

Now she's confronted with the question of whether she has cancer, and she'll have to undergo additional tests that are intrusive and may be uncomfortable, he says.

The main reason for the change in the guidelines is the possible harm that may be done to young women who have an abnormal Pap smear and have to undergo repeated tests and treatment for cervical cancer. There's growing evidence that the treatment contributes to premature births in about 1 in 18 young women who have been treated for precancerous lesions.

It is too early to know what impact the HPV vaccine will have on screening, so ACOG recommends that women who have been vaccinated follow the same guidelines as women who have not been vaccinated.

Once a woman reaches age 30 and has had three normal Pap test results, the committee recommends that she be screened every three years. It is also reasonable, they say, to discontinue cervical cancer screening for women ages 65 to 70 who have three or more normal tests in a row — and have had no abnormal test results in the past 10 years.

What has happened is that the recommendations have caught up with the science, says ACOG's Soper. Most cervical cancer is caused by the HPV type 16 and HPV type 18. It can take five to 10 or 20 years for the HPV infection to cause premalignant changes in the cervix. So it is possible to detect as many cancers with less frequent screenings.

"You don't improve cancer detection by doing annual smears in women in the different age groups," Soper says. Doing the test every other year in women ages 21 to 29, and every three years in women older than 30, is just as good as doing the test annually. "There's no danger in this new guidance," Soper adds.

The American Cancer Society concurs, though it has yet to change its guidelines, which are currently under review, says Len Lichtenfeld, deputy chief medical officer. "There's a consensus building among experts," he says, "that starting before age 21 may not be appropriate."

Cervical cancer experts have been working together, so disputes like the one that arose over breast cancer screening have not arisen. Lichtenfeld says that's good news because it sends a straightforward message to women.

There are women who do need more frequent Pap smears: Women who are infected with HIV, who are immuno compromised, who have had a previous abnormal Pap smear, or who were exposed to diethylstilbestrol in utero should continue to be screened every year for cervical cancer.

ACOG still recommends that women visit the gynecologist annually, whether or not they're going to get a Pap smear.

View Transcript

RENEE MONTAGNE, host:

It's MORNING EDITION from NPR News. I'm Renee Montagne.

STEVE INSKEEP, host:

And I'm Steve Inskeep. Good morning.

For the second time in a week, women are being advised to reconsider the way they get tested for cancer.

MONTAGNE: Days ago, a panel of experts said women could wait before getting regular mammograms. That set off a widespread debate.

INSKEEP: Now, the recommendations are changing for the test for cervical cancer. Experts say there is no need for the test before age 21, and older women do not need the test as often.

NPR's Brenda Wilson explains.

BRENDA WILSON: The old recommendation from the American College of Obstetricians and Gynecologists, or ACOG, was that Pap smears should start three years after a girl began having sex or at least by age 21. But because cervical cancer is slow growing, ACOG says such early tests aren't needed. Not only that, they only have to be done every two years until she's 30.

Dr. ALAN WAXMAN (Obstetrics and Gynecology, University of New Mexico School of Medicine): The incidence of invasive cancer of the cervix in teenagers is exceptionally low. This is a cancer of women in their 30s, 40s and 50s.

WILSON: That's Dr. Alan Waxman. He wrote the new guidelines for ACOG's Gynecology Practice Committee. He says scientists now know that many young women become infected with the human papillomavirus or HPV that causes cervical cancer. That can cause abnormal Pap smears, even though most of the time it clears up on its own. And so subjecting a young girl to a frightening test is unnecessary.

Dr. WAXMAN: She's very, very sensitive to her body image. She goes and gets her first Pap test. It comes back abnormal. Now, she's confronted with the question of do I have cancer in my reproductive organs? She has to go through additional tests, which again, are intrusive, may be uncomfortable.

WILSON: The committee wanted to avoid subjecting women to treatments that might require surgery or procedures that pose a risk to a young woman's reproductive health.

Dr. WAXMAN: An increasing number of studies have come out showing that women who have had these treatments, have an increased risk of premature births if they get pregnant subsequently. Now, most women who get treated don't have prematurity, but when you think about treatment in teenagers, they've got their whole reproductive life ahead of them.

WILSON: When a woman turns 30, the committee recommends that if a woman has three normal tests, the screenings can then be done every three years. Dr. David Soper, a professor of Obstetrics and Gynecology at the Medical College of South Carolina, says that the committee started working on these recommendations in 2007.

Dr. DAVID SOPER (Obstetrics and Gynecology, Medical College of South Carolina): The recommendations really are just catching up with what the science is, and that is, that you do not improve cancer detection by doing annual smears in women at the various age groups. So I don't think there's any danger in this new guidance.

WILSON: The greatest danger, it turns out, is to women who don't ever get Pap smears or haven't had one in five years. They make up more than half of the 11,000 women who die from the disease in the United States. There's unlikely to be very much objection to the new guidelines in the medical community.

The American Cancer Society is about to undergo a similar review, according to its Deputy Medical Officer, Len Lichtenfield, who says there isn't the same intense disagreement over Pap smears as there is surrounding the issue of mammograms.

Dr. LEN LICHTENFIELD (Deputy Medical Officer, American Cancer Society): Within the cervical cancer community, experts who have been working together have pretty much have a consensus about what to do. And, I think, in a sense, that's good news because a fairly straightforward message to women.

WILSON: There are some women who do need more frequent Pap smears. Women who are infected with HIV, who have a suppressed immune system, or who have had a previous abnormal Pap smear should continue to be screened every year for cervical cancer.

And ACOG recommends that women should still visit the gynecologist annually, even if they're not going to get a Pap smear.

Brenda Wilson, NPR News. Transcript provided by NPR, Copyright National Public Radio.

Source: NPR

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