BIRMINGHAM, Ala. - Women should have their first cervical cancer screening at age 21 and can be screened less frequently after that than previously recommended, according to newly revised evidence-based guidelines issued today by the American College of Obstetricians and Gynecologists (ACOG) and published in the December issue of Obstetrics & Gynecology.
Todd Jenkins, M.D., director of the University of Alabama at Birmingham (UAB) Division of Women's Reproductive Healthcare, is a member of the ACOG Committee on Practice Bulletins-Gynecology that issued the recommendations.
"This was part of a standard review of Pap test guidelines by the college and is a refection of our increased knowledge about the Human Papillomavirus, or HPV," said Jenkins, an associate professor of obstetrics and gynecology. "Doing a Pap test annually is not supported by recent scientific evidence. A review of the evidence to date has shown that screening at less frequent intervals prevents cervical cancer just as well as a yearly screening, costs less, and avoids unnecessary interventions that could be harmful to some women."
Jenkins said moving the recommended cervical screening age to 21 is important because it avoids unnecessary treatment of adolescents that can have economic, emotional, and future childbearing implications.
"Although the rate of HPV infection is high among sexually active adolescents, invasive cervical cancer is very rare in women under age 21, one or two in one million," Jenkins said. "The immune system usually clears the HPV infection on its own within eight to 24 months among most adolescent women. Because the adolescent cervix is immature, there is a higher incidence of HPV-related precancerous lesions, called dysplasia, among young women.
"However, the large majority of cervical dysplasias in adolescents resolve on their own without treatment, and an increase in premature births has recently been documented among women who have been treated with excisional procedures for dysplasia," he said. "Adolescents have most of their childbearing years ahead of them, so it is important to avoid unnecessary procedures that negatively affect the cervix."
Officials with the UAB Comprehensive Cancer Center also agree with ACOG's recommendations.
"The predictive value of this screening test is retained even with women getting a Pap test less frequently," said Edward Partridge, M.D., director of the UAB Comprehensive Cancer Center and chairman of the cervical cancer screening guidelines panel for the National Comprehensive Cancer Network. "Cervical cancer is related to HPV infections, and the progression from a viral infection to cancer is a very slow process - and most HPV infections resolve on their own."
Jenkins said that ACOG's new recommendations also include screening women ages 21 to 30 every two years instead of annually. Women age 30 and older who have had three consecutive negative cervical cytology test results may be screened once every three years with either the Pap or liquid-based cytology. Jenkins added that women who have been vaccinated against HPV should follow the same screening guidelines as unvaccinated women.
However, women with certain risk factors may still need more frequent screening, including those who have HIV, are immunosuppressed, were exposed to diethylstilbestrol (DES) in utero, and those who have been treated for cervical intraepithelial neoplasia (CIN) 2, CIN 3, or cervical cancer.
"Fifty percent of women who develop cervical cancer have never had a Pap smear," Jenkins said. "An additional 10 to 15 percent of women with cervical cancer have not had a Pap smear in more than five years, which means that 65 percent of women with cervical cancer have not had the appropriate screening.
"The majority of deaths from cervical cancer in the U.S. are among women who are screened infrequently or not at all," he said. "Those women need to be screened. These guidelines only apply to women who have been screened on a regular basis."
The committee also recommended that routine Pap tests should be discontinued in women, regardless of age, who have had a total hysterectomy-removal of the cervix along with the uterus- for noncancerous reasons, as long as they have no history of high-grade CIN.
Jenkins said ACOG's recommendations on the upper age limit for discontinuing cervical screening remain the same. It is usually recommended to stop cervical cancer screening at age 65 or 70 among women who have three or more negative cytology results in a row and no abnormal test results in the past 10 years.
Jenkins said it is important for all women to note that these recommendations do not in any way say - and women should not take from this - that an annual gynecologic exam is unnecessary.
"A Pap test is just a small part of an annual exam," he said. "Women still need and are advised to have an annual exam to screen for other gynecologic issues, including birth control and STD counseling."
About the UAB Division of Women's Reproductive Healthcare
In the UAB Division of Women's Reproductive Healthcare, services range from complete obstetric care to the medical and surgical treatment of complicated gynecological concerns. UAB OB/GYN is made up of physicians dedicated to caring for women in all stages of life with the latest technology.