Cervical cancer is typically slow growing, and most cancers are found in
women who have never been screened or who have not been screened in the
past 5 years. Annual screening with PAP testing has been shown to lead
to a very small increase in cancers prevented, but greatly increases the
number of unnecessary procedures and treatments. Transient Human Papillomavirus
(HPV) infections are common (80% of people) and associated low-grade pre-cancer
is high. Most of these will lesions will regress within 1 to 2 years.
So treating these patients does not provide a benefit large enough to
outweigh the harms. The small fraction of lesions that do not regress
will, on average, require many years to progress to cancer.
Consequently 2 weeks ago several national agencies* announced extended
intervals for cervical cancer screening. For women 30 years and older,
co-testing with PAP & Hi-Risk HPV every 5 years is preferred to PAP
alone, but the later every 3 years is an acceptable strategy. In choosing
to make co-testing the preferred strategy, these agencies focused on evidence
from multiple randomized clinical studies showing that co-testing has
improved accuracy compared with PAP alone. Specifically, co-testing has
increased sensitivity (over 99%) for detecting advanced pre-cancer of
the cervix. Because of this improved performance, co-testing can be used
for screening at less frequent intervals than PAP alone. Recommendations
for other age group are noted in this table:
||21 years old (and after intercourse initiated)
|PAP Every 3 years
|PAP & HPV Every 5 years
||> or equal to 30 years old
||> 65 years old
Women with a history of advanced pre-cancer should continue annual screening
for at least 20 years
It is very important toemphasize that the revised recommendations do not imply the end of the
annual well woman visit. Counseling and education on topics varies by age:
- Adolescents and young women can benefit from counseling on healthy diet,
risky behaviors, family planning, and—if they are sexually active—testing
for sexually transmitted diseases. The focus for cervical cancer for this
age group should be on primary prevention through HPV vaccination.
- Women of reproductive age will benefit from counseling and shared decision
making on family planning, and treatment of excess menstrual bleeding.
- Women in the later reproductive years and perimenopausal women will benefit
from counseling on the menopausal transition, osteoporosis prevention,
and referral for mammography and colorectal cancer screening.
- Both women of reproductive age and postmenopausal women benefit from breast
cancer screening and evaluation and treatment urinary incontinence and
pelvic floor function.
This visit has always been more than just a “PAP smear,” and
the decreased need for cervical screening actually constitutes a minor
change to an important aspect of a woman’s health care.