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New guidelines balance benefits and harms of screening
Sawaya GF. N Engl J Med. 2009; doi:10.1056/NEJMp0911380.
The new guidelines issued for cervical cancer screening by the American College of Obstetricians and Gynecologists are based on solid research evidence and balance fairly the harms and benefits of cancer screening, according to George F. Sawaya, MD, from the department of obstetrics, gynecology, and reproductive services at the Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco.
Sawaya published his opinions about the three major changes made to the guidelines in a perspective piece in The New England Journal of Medicine.
The first major recommendation issued by ACOG was that women younger than age 21 should avoid screening for cervical cancer. The evidence used for this recommendation is “compelling,” Sawaya said. “Although cervical cancer is rare before the age of 21, cytologic abnormalities are common and can lead to labeling, anxiety, extended surveillance, and invasive procedures, such as colposcopy. If colposcopy is performed, the ACOG guidelines devoted to the management of histologic abnormalities recommend restraint in the treatment of most biopsy-confirmed precancerous lesions identified in young women.”
The next major change to the recommendations was that women aged 21 to 29 should be screened every two years and women 30 and older who have had three consecutive negative results for intraepithelial lesions and malignancy should reduce screening to once every three years. “This recommendation is based on evidence showing that among women in this age group, as the number of previous normal tests increases, the likelihood of underlying cervical neoplasia decreases substantially,” he wrote. Based on this evidence, continuing to screen these women will result in “needless interventions” that have little effect on the incidence of cervical cancer, according to Sawaya.
Finally, ACOG recommended that screening be discontinued for women aged between 65 and 70 who have had at least three consecutive negative cytology test results and no abnormal test results in the previous 10 years. This is also recommended by the ACS and the U.S. Preventive Services Task Force, Sawaya wrote.
Regardless of the recommendations, when new guidelines for cancer screening are issued, it is important that physicians discuss changes with their patients and answer questions that patients may have. In this case, “clinicians should inform women that the changes in the guidelines have not been prompted by financial considerations but by careful consideration of the estimated balance between benefits and harms,” he wrote.