By Ted Catranis, M.D., P.C.
The incidence and death rates from cervical cancer in the US have dropped almost 50% since the widespread use of Pap tests beginning in the early 1970s. However, cervical cancer still remains the third most common gynecological cancer in the US. Worldwide, it is the second most common cancer among women and the most common cause of death from a gynecologic cancer.
It is important to note that these are SCREENING guidelines. That means they apply to women who have not previously been diagnosed with cervical cancer or other cervical diseases.
While most doctors still recommend that all women over the age of 18 have annual Pap smears with their pelvic exams, the American College of Obstetricians and Gynecologists (ACOG) has issued new, evidence-based practice guidelines regarding Pap smear frequency (8/03). ACOG notes that while some women need more frequent screening, an increasing number of women no longer need annual cervical cancer screening. They have also noted that cervical cancer screening can often begin later than previously recommended. This is somewhat misleading, however, because most women associate their annual Pap smear with their annual internal, pelvic exam. ACOG cautions that annual pelvic examinations are still advised for all women over age 21.
ACOG's new recommendations are based in part on newly available screening tests as well as a new appreciation for the pathology and evolution of cervical cancer. To summarize ACOG's new recommendations:
Changes in Screening Frequency
*First Pap test: Women should have their first Pap test (a screening of cervical cells) approximately 3 years after first sexual intercourse or by age 21, whichever comes first. *Women up to age 30: Women this age should undergo annual Pap testing since women under age 30 have a higher likelihood than older women of acquiring high-risk types of HPV that may cause precancerous cervical changes. *Women age 30 and older: ACOG says there are two acceptable screening options for women in this age group. Under either option, women may not need annual screening:
*Testing using Pap smears alone. If a woman age 30 or older has negative results on three consecutive annual Pap smears, she may then have her repeat Pap smears every 2-3 years. *Testing using a combined Pap test with an FDA-approved test for high-risk types of HPV: Using this new option, women receive both a Pap test and a genetic test that looks for certain high-risk types of the human papillomavirus (HPV), the virus known to cause 99% of cervical cancers (HPV DNA test). If women test negative on both tests, they may have repeat testing with the combined tests every 3 years. If only one of the tests is negative, however, more frequent screening will be necessary.
Of course, there are exceptions to all guidelines, and these are no exception! More frequent cervical screening may be required for higher-risk women who are infected with HIV, are immunosuppressed (such as those receiving kidney transplants or who take immunosuppressant medication), were exposed to DES in utero, or were previously diagnosed with cervical cancer.
- Women who have had a hysterectomy with removal of the cervix for benign (i.e. non-cancerous) reasons and with no history of abnormal or cancerous cell growth may discontinue routine Pap smear testing.
- Women who have had such a hysterectomy but who have a history of abnormal cell growth (classified as CIN 2 or 3) should be screened annually until they have three consecutive, negative vaginal cytology tests; then they can discontinue routine, annual screening
- When to Discontinue Screening -- Physicians can determine on an individual basis when a woman over 65 can stop having cervical cancer screening, based on such factors as her medical and sexual history and the physician's ability to monitor the patient in the future. Unfortunately, there are limited studies of women in this age group making it difficult to set an across-the-board upper age limit for cervical cancer screening.
- Annual Exams Continue: Regardless of the frequency of cervical cancer screening, annual gynecologic examinations, including pelvic exams, are still recommended.