Breaking Health News, December 31, 2003

Guidelines For Cervical Cancer Testing Updated, More Detailed

January Is Cervical Health Awareness Month

< December 31, 2003 > -- Since the Pap test was introduced more than half a century ago, the death rate from cervical cancer has plummeted.

The question now is not whether women should be screened for the highly treatable disease, but how often and with what test.

"Cervical cancer screening has been fantastically successful because we've had such a tremendous impact on mortality over the last 50 years," says Dr. Diane Solomon, senior investigator in the breast and gynecologic cancer research group at the National Cancer Institute (NCI).

"Cervical cancer is virtually 100 percent curable when it's in the precancerous stage," Dr. Solomon says.

Catching it early is critical; more than half of the deaths from this type of cancer occur in women who were not adequately screened.

An estimated 12,200 new cases were expected in 2003, and approximately 4,100 deaths were estimated to occur, according to the American Cancer Society (ACS).

Today, women have more screening options than ever. That means more choices need to be made and what better time to start making them than in January, which is Cervical Health Awareness Month.

Experts Explain Updated Guidelines

Cervical cancer is caused by the ubiquitous human papillomavirus (HPV). At some point in time, the majority of women will have the virus, which is sexually transmitted.

However, most will get rid of it quietly and painlessly, often without realizing they are infected, experts say.

"Most women never know they have it and don't need to be concerned they have it," says Dr. Debbie Saslow, director of breast and gynecologic cancer at the ACS.

In the extreme minority of cases, however, the virus progresses to cancer.

"Only a very small number of HPV infections that are persistent become a risk for cervical cancer," Dr. Solomon says.

Because it probably takes decades for an HPV infection to become cancer, screening tests have ample time to stop the disease in its tracks.

A number of organizations have issued guidelines for cervical cancer screening, guidelines that were recently confirmed by a study in the New England Journal of Medicine.

The guidelines recommend that women under 30 should have annual Pap tests. Those over 30 who have had three normal (or negative) Pap tests in a row can extend the interval between screenings to three years.

"Cervical cancer is so slow-growing that getting screened every year [for low-risk women] is really overkill," Dr. Saslow says. Women who get screened too often can end up with abnormal results that are medically meaningless but can cause huge amounts of anxiety.

Women should start screenings three years after becoming sexually active or when they turn 21. Previous guidelines had recommended starting at age 18, which is now considered too early.

Those 65 and older who have been screened and have been getting normal Pap results can stop if they want. It is also not necessary to get screened if you had your cervix removed as part of a hysterectomy.

Before a woman stops getting tested, however, she should make sure that her cervix really was removed, as it is in 99 percent of these procedures.

Pap Testing Defined

The Pap test, which is done as part of a routine pelvic exam, involves using a Q-tip or similar tool to take a sample from the cervix (the neck of the uterus and easily accessible through the vagina). The sample is smeared on a slide, then sent to a lab for analysis.

"The Pap has a high failure rate, but that hasn't been a big problem because cervical cancer is so slow you can get it the next year," Dr. Saslow says. "But people are still not comfortable with the fact that the Pap test misses a lot."

The newer liquid-based Pap test takes the sample in the same way but, instead of scraping it on a slide, dips it into liquid. The liquid provides a more purified sample, a more representative sample and also eliminates mucus, blood, and other elements that may affect results.

On the downside: the cost is double and the sensitivity is increased, meaning the test may flag things that really are not a cause for concern.

The HPV test looks specifically for the HPV virus, as opposed to the abnormal cells that are targeted in the above two tests. This means that women under the age of 30, most of whom will have the virus, should not take the test, health experts say.

"In young women, the cost-benefit balance of using the HPV test to augment screening is not beneficial," Dr. Solomon says. "Too many women are HPV-positive and the risk of cancer is so low, it's more an issue of over treatment."

Even for those over 30, many more women are going to test positive than are going to develop cancer. The HPV test is done with a Pap test so if the Pap is normal and the HPV is positive, women will have to wait a year before deciding if they need to take another step.

On the other hand, if a woman tests negative on the HPV and the Pap tests, her odds of developing cancer are virtually nil.

"If you get a negative HPV test, your chance of getting cervical cancer in the next few years is almost zero," Dr. Saslow says. "The reassurance is extremely high, but the problem is a lot of people are going to test positive and they don't need to be that worried."

Always consult your physician for a diagnosis.

Online Resources

(These links are provided for the education and convenience of our Neighbors. AAMC is not responsible for the content of Internet sites.)

American Cancer Society

American College of Obstetrics and Gynecology

Centers for Disease Control and Prevention (CDC)

HealthierUS.Gov

National Institutes of Health (NIH)

National Women's Health Information Center

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Who Should Have Pap Tests?

A woman should always consult with her physician about when and how often a Pap test and pelvic examination should be performed.

According to the National Cancer Institute (NCI), the American Cancer Society (ACS), and the American College of Obstetrics (ACOG), general guidelines include:

• Cervical cancer screening should begin approximately three years after a woman begins having sexual intercourse, but no later than at 21 years old.
• Experts recommend waiting approximately three years following the initiation of sexual activity because transient human papillomavirus (HPV) infections and cervical cell changes that are not significant are common and it takes years for a significant abnormality or cancer to develop. Cervical cancer is extremely rare in women under the age of 25.
• Women should have a Pap test at least once every three years.
• The American Cancer Society (ACS) and the American College of Obstetrics and Gynecology (ACOG) recommend annual cervical cytology screening with regular Pap tests or biannual (every two years) screening with liquid-based tests (Thinprep) until age 30. Women under age 30 have a higher likelihood than older women of acquiring high-risk types of HPV that cause premalignant cervical disease, which should be ruled out before extending the testing intervals.
• ACS and ACOG recommend that at or after age 30, women who have had three normal test results in a row may get screened every two to three years. However, women with certain risk factors such as human immunodeficiency virus (HIV) infection, a weak immune system, in utero DES exposure, or a previous diagnosis of cervical cancer may need more frequent screening.
• Women 65 to 70 years of age who have had at least three normal Pap tests and no abnormal Pap tests in the last 10 years may decide, upon consultation with their healthcare provider, to stop cervical cancer screening.
• Women who have had a total hysterectomy (removal of the uterus and cervix) do not need to undergo cervical cancer screening, unless the surgery was done as a treatment for cervical precancer or cancer.

Women should seek expert medical advice about when they should begin screening, how often they should be screened, and when they can discontinue cervical screenings, especially if they are at higher than average risk of cervical cancer due to factors such as HIV infection.

Always consult your physician for a diagnosis.