American Cancer Society: Start cervical cancer screening at age 25 years, phase out Pap
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An updated guideline issued by the American Cancer Society recommends cervical cancer screening with the HPV test every 5 years from age 25 years to 65 years.
“We now have stronger evidence to support starting cervical cancer screening at the later age of 25 years [rather than age 21 years] and to recommend screening with the HPV test as the preferred test, phasing out the Pap test and cotesting with the Pap test and HPV testing,” Debbie Saslow, PhD, managing director of cancer control interventions-HPV/GYN cancers at American Cancer Society, told Healio. “The update is based on decades of studies comparing the effectiveness of HPV testing with cytology, and bolstered by evidence of the impact of HPV vaccination, including a dramatic decline in cervical precancers and, more recently, cervical cancers among young women. Screening and management for the detection of cervical cancer and its precursors are based on a more robust understanding of the risk from persistent HPV infection.”
The society’s previous guideline, issued in 2012, recommended initiation of cervical cancer screening at age 21 years. Since then, HPV vaccination has led to decreased rates of precancerous cervical changes among women aged 20 to 24 years, data have shown. In addition, screening has not been shown to lower the rate of cervical cancer among women in this younger age group, whose HPV infections mostly become undetectable in 1 to 2 years, according to a press release.
The society estimated that the change to primary HPV testing starting at age 25 years would prevent 13% more cervical cancers and 7% more cervical cancer deaths than the previously recommended strategy.
The updated guideline also recommends that health care providers transition to primary HPV testing only, based upon data that suggest higher accuracy with the HPV test, which can be administered less often than the Pap test. However, HPV/Pap cotesting every 5 years or Pap testing alone every 3 years are acceptable options, because some laboratories have not yet transitioned to primary HPV testing.
“The recommendations do not take away access for anyone,” Saslow told Healio. “We deliberately retained suboptimal screening strategies (cotesting and the Pap test alone) as acceptable options so that no one would have a problem accessing cervical screening. The American Cancer Society will be working with our partners and the health community from now until the next guideline update to ensure a transition to primary HPV testing with the goal of complete access so that we can discontinue cotesting and cytology.”
Saslow said primary HPV testing has been supported by a tremendous amount of data, and other countries around the world have already made the transition.
“[Although] the driving force of American Cancer Society guidelines is the scientific evidence, we hope that such streamlined guidance will improve screening rates, which despite decades of use, are still not optimal,” Saslow said. “Screening women who have not previously been screened or have not been screened regularly will prevent more cervical cancers.”
For more information:
Debbie Saslow, PhD, can be reached at American Cancer Society, 250 Williams St., Suite 600, Atlanta, GA 30303; email: debbie.saslow@cancer.org.
Perspective
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Jubilee Brown, MD
Health care is a complex interplay of illness, wellness, physical and psychological well-being, and economics. The necessity of the Pap smear incorporates each of these components.
We have known for decades that cytological evaluation of cervical cells allows the detection of premalignant cellular change and thereby prevention of cervical cancer. The public also has assimilated this information, and it is now standard practice for a woman in her adulthood to see a gynecologist for her annual Pap smear.
The suggestion that the Pap smear need only be performed every 5 years, as outlined above, appears to be based in theoretical and economic benefit while unfortunately neglecting the other components of well-woman care and cancer prevention.
The extensive work by Huh and colleagues has revolutionized cervical cancer screening by incorporating high-risk HPV detection in addition to evaluation of cervical cytology. However, the elimination of cervical cytology and thereby “eliminating the Pap smear” stands to risk the health of many unless we incorporate a significant public health and education initiative at the same time.
From a scientific standpoint, HPV infects up to 80% of the population, often in adolescence and early adulthood, and is usually cleared prior to causing any abnormality. Abnormal cytology found on a Pap smear is unlikely to be clinically relevant without a concurrent or preceding high-risk HPV infection. Therefore, the proposed idea of using HPV testing as a screening tool prior to performing cervical cytology is valid. Decreasing the frequency of HPV screening also may be economically appropriate and scientifically valid.
However, the authors fail to realize that “going for a Pap smear” is more than a cytological evaluation. This often is the only time that a young woman seeks health care. The gynecologist often is her only physician and her only portal to medical care. It is through the gynecologist that contraception is discussed, family planning occurs, endometriosis and other maladies are detected, and early obstetrical care is delivered — all on a scheduled annual basis.
In the absence of a significant public health educational campaign, the elimination of the annual Pap smear in favor of an HPV test performed at infrequent intervals may prompt a significant decline in preventive health care. This is a very slippery slope, and the long-term outcomes not only for cervical cancer incidence, but also for population health, may be devastating. The economic gains of eliminating the Pap may be quickly outpaced by unforeseen costs due to a decrease in preventive care, cancer screening and contraception. Therefore, to suggest an abrupt change in cervical cancer screening may have long-lasting, unanticipated effects.
Prior to adoption of a health care model, the downstream effects of such changes require extensive discussion from experts in the field of gynecology and public health that focus on the woman as a whole person and not just the cells of her cervix.
Reference:
Huh W, et al. Gynecol Oncol. 2015;doi:10.1016/j.ygyno.2014.12.022.
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Michael D. Randell, MD, FACOG
American Cancer Society is threatening to limit access to proven life-saving screening strategies in future guidelines, and it is a disservice to patients. Evidence clearly shows cotesting with Pap and HPV tests outperforms either test alone in detecting cervical precancer and cancer. A study by Kaufman and colleagues, published in July, showed HPV testing alone misses twice as much cervical cancer as cotesting. As a practicing obstetrician and gynecologist who interacts with patients every day, I want to ensure that I am screening my patients with the most accurate methods available and know that cotesting is best in detecting cancer and saving lives.
I also am appalled by the removal of screening altogether for women between the ages of 21 and 24 years, for whom the Pap test has much value given the incidence of transient HPV infections. Based on vaccination assumptions, American Cancer Society is unnecessarily taking away preventive health care from these patients. It is diverging from leading government and medical institutions like the American College of Obstetricians and Gynecologists, of which I am a fellow. Instead of simplifying, these new guidelines will lead to confusion, and worst of all, unnecessary disease and death from a preventable cancer.
The American Cancer Society should reevaluate and revise its guidelines to ensure that optimal screening of cervical cancer includes the well-documented and proven Pap test.
Reference:
Kaufman HW, et al. Am J Clin Pathol. 2020.doi:10.1093/ajcp/aqaa074.
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