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August 6, 2003 — In its most comprehensive revision of Pap test and other cervical cancer screening recommendations in over a decade, The American College of Obstetricians and Gynecologists (ACOG) has issued a new, evidence-based practice bulletin, "Cervical Cytology Screening." ACOG notes that an increasing number of women will no longer need annual testing for cervical cancer and that screening also can abegin later than previously recommended. However, annual pelvic examinations are still advised for women across a broad age range.
ACOG's new recommendations differ only slightly from recently revised recommendations of the American Cancer Society (ACS) and the US Preventive Services Task Force (USPSTF), but ACOG's new practice bulletin may have a higher impact on the clinical practices of the nation's obstetrician-gynecologists.
"Many of these changes have come about not only because of the technological changes in cancer screening over the years, but also because scientists now have a better understanding of the development of cervical cancer," says ACOG's vice president for practice activities, Stanley Zinberg, M.D.
Among ACOG's new recommendations:
Changes in Screening Frequency
· First screen — Screening of cervical cytology (cervical cells) should begin by approximately three years after first sexual intercourse or by age 21, whichever comes first. (Previously, ACOG called for screening by the onset of sexual activity or by age 18, whichever occurred first.)
· Women age 30 and older — There are two acceptable screening options for women in this age group, says ACOG. Under either option, women may not need annual screening:
1. Testing using cervical cytology alone. If a woman age 30 or older has negative results on three consecutive annual cervical cytology tests, then she may be rescreened with cervical cytology alone every two to three years.
2. The combined use of a cervical cytology test and an FDA-approved HPV test — Once women test negative on both tests they should be rescreened with the combined tests no more frequently than every three years. If only one of the tests is negative, however, more frequent screening will be necessary. (The combined testing is not appropriate for women under age 30, since they frequently test positive for HPV that will clear up on its own.)
Exceptions
· More frequent cervical screening may be required for higher-risk women who are infected with HIV, are immunosuppressed (such as those receiving kidney transplants), were exposed to DES in utero, or were previously diagnosed with cervical cancer.
· Hysterectomy — Women who have had a hysterectomy with removal of the cervix for benign reasons and with no history of abnormal or cancerous cell growth may discontinue routine cervical cytology testing. Women who have had such a hysterectomy but who have a history of abnormal cell growth (classified as CIN 2 or 3) should be screened annually until they have three consecutive, negative cervical cytology tests; then they can discontinue routine screening.
· When to Discontinue Screening — Physicians can determine on an individual basis when an older woman can stop having cervical cancer screening, based on such factors as her medical history and the physician's ability to monitor the patient in the future. (Whereas ACS calls for cessation of testing in non-high-risk women at age 70, and the USPSTF by age 65, ACOG notes that due to limited studies of older women it is difficult to set an across-the-board upper age limit for cervical cancer screening.)
· Annual Exams Continue — Regardless of the frequency of cervical cancer screening, annual gynecologic examinations, including pelvic exams, are still recommended.
Recognition of Different Cytology Testing Methods
No matter what recommended regimen for cervical cytology testing a woman follows, evidence-based data indicate that both liquid-based and conventional methods of cervical cytology are acceptable for use in testing, says ACOG. (Although ACS recommends that women under age 30 undergo their screening only every two years if the liquid method is used, ACOG does not make such a distinction, indicating there are limited data to support this approach.)
The incidence and death rates from cervical cancer in the U.S. have dropped almost 50 percent since the widespread use of Pap tests beginning in the early 1970s. Cervical cancer still remains the third most common gynecological cancer in the U.S. Worldwide, it is the second most common cancer among women and the most common cause of death from a gynecologic cancer.