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Leading Scientists Collaborate to Update Guidelines for Cervical Cancer Screening

Thursday, March 15, 2012

Guidelines for the early detection of cervical cancer have been updated to include recommendations on testing for human papillomavirus (HPV) in addition to the traditional Pap test. The updates, which revise guidelines released in 2002, were developed by leading scientists working through a collaboration of several U.S. medical societies that includes ASCP, the American Cancer Society (ACS), and the American Society for Colopscopy and Cervical Pathology (ASCCP). The revised guidelines are based on a systematic evidence review, contributions from six working groups, and a recent symposium cosponsored by ASCP, ACS, and ASCCP and attended by 25 organizations. The full guidelines are published in the April 2012 issue of the American Journal of Clinical Pathology.1

The new screening recommendations encompass age-appropriate screening strategies, including the use of cytology (Pap test) and high-risk HPV testing alone or in combination, follow-up testing for women after screening, including the use of genotyping, and future considerations for HPV testing alone, as well as screening strategies for women vaccinated against HPV.

“This was a remarkable multidisciplinary effort that, in terms of cervical cancer screening, focused on doing what is best for women at every life stage, regardless of cost.” — Mark H. Stoler, MD, FASCP, former ASCP President
“This was a remarkable multidisciplinary effort that, in terms of cervical cancer screening, focused on doing what is best for women at every life stage, regardless of cost,” said Mark H. Stoler, MD, FASCP, former ASCP President and Professor of Pathology, Cytology, and Gynecology and Associate Director of Surgical Pathology and Cytopathology at the University of Virginia Health System, Charlottesville, Va. “The careful balancing of benefits versus harm, based on broadly accepted principles, has led to guidelines that are based on state-of-the-art evidence while also incorporating the collective wisdom of many experts and disciplines.”

During the past 60 years, regular Pap testing and treatment of the women with abnormalities has been responsible for cervical cancer dropping from being the No. 1 cause of cancer death among women, to a rank of 14 for all cancer deaths in the United States for women.1 Despite these advances, in 2011 an estimated 12,710 cases of invasive cervical cancer were diagnosed and an estimated 4,290 women died.2 Pap testing is less effective in identifying women who are at risk of adenocarcinoma, a rarer histologic type of cervical cancer than squamous cell carcinoma, but one that represents approximately 20 percent of cervical cancers in the United States.

Now scientists and physicians know that persistent cervical infection with high-risk HPV genotypes is necessary for the development of cervical cancer and its immediate precursor lesion cervical intraepithelial neoplasia grade 3 (CIN3). It is clearly the treatment of precancer (CIN3) that prevents the development of cancer, and the process that led to the revised guidelines focused on how to best identify patients with precancer who need treatment while minimizing the potential harms to patients from extensive screening.

Two types of cervical cancer screenings, the Pap test and molecular tests for HPV, often work well in tandem. The Pap test has successfully lowered cervical cancer deaths. However, false-negative results are common,and any single test is not as sensitive as previously thought for detecting CIN3. On the other hand, HPV tests are more sensitive than the Pap test for precancer and may also be better at forecasting which women will develop CIN3+ over the next five to 15 years.3

The following is a summary of the scientists’ key recommendations:

  • Cervical cancer screening should begin at age 21.
  • Women 21 to 29 years old should be screened with Pap test alone every three years.
  • Women 30 to 65 years old should be screened with Pap and HPV tests (co-testing) every five years (preferred) or with Pap test every three years (acceptable).
  • Women who co-test HPV positive but cytology negative should be followed with either (1) repeat co-testing within 12 months or (2) immediate HPV genotype-specific testing for HPV 16 alone or for HPV 16 and HPV 18. If co-testing is repeated at 12 months, women testing positive on either test should be referred to colposcopy; women testing negative on both tests should return to routine screening.
  • In most clinical settings, women ages 30 to 65 years old should not be screened with HPV testing alone as an alternative to co-testing at five-year intervals or Pap test alone at three-year intervals.
  • Women at age 65 with adequate negative screening in the last 10 years and no history of cancer may stop screening.
  • Women at any age following a hysterectomy with removal of the cervix who have no history of CIN2+ should not be screened for vaginal cancer using any modality.
  • Recommended screening practices should not change on the basis of HPV vaccination status.

The guidelines are also being published jointly in CA: A Cancer Journal for Clinicians (ACS), and the Journal of Lower Genital Tract Disease (ASCCP). For the full article in the American Journal of Clinical Pathology, go to http://ajcp.ascpjournals.org/.

References

  1. Saslow D, Solomon D, Herschel W, et al. American Cancer Society, American Society for Colopscopy and Cervical Pathology, and American Society for Clinical Pathology Screening Guidelines for the Prevention and Early Detection of Cervical Cancer. Am J Clin Pathol. 2012;137:4:516–542.
  2. Centers for Disease Control and Prevention, Department of Health and Human Services. Statistics and surveillance: 2009 adult vaccination coverage, NHIS—The National Health Interview Survey. March 2, 2011. Available at: http://www.cdc.gov/vaccines/stats-surv/nhis/2009-nhis.htm. Accessed Feb. 1, 2012.
  3. Siegel R, Ward E, Brawley O, Jemal A. Cancer statistics, 2011: The impact of eliminating socioeconomic and racial disparities on premature cancer deaths. CA: A Cancer Journal for Clinicians. 2011;61(4):212–236.


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