Longer Intervals Recommended for PAP Smears

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:

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.