Curtailing cervical cancer.(Guest Editorial)

Updated guidelines on cervical cancer screening, released last year by the American College of Obstetricians and Gynecologists and the American Cancer Society, present both opportunities for improved screening and challenges in implementation.

These guidelines address when to start, when to cease, and how often to perform cervical cancer screening. Clinicians now have the option to screen less frequently when using human papillomavirus (HPV) testing as an adjunct to the Pap test for women aged 30 and older (CA Cancer J. Clin. 52[6]:342-362, 2002; ACOG Practice Bulletin. Cervical cytology screening. Washington, D.C. American College of Obstetricians and Gynecologists, 2003).

The guidelines from both organizations are similar in most respects; unlike previous recommendations, they delay initial screening and recognize a reduced need for annual cervical cytology tests in low-risk women.

The guidelines recommend that physicians begin screening for cervical cancer approximately 3 years after a patient's first vaginal intercourse, or no later than age 21. Although high-risk types of HPV are transmitted among sexually active adolescents at a high rate, statistics from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program indicate that there is almost no risk of cervical cancer in women under age 21, and cervical cancer incidence rises to only 1.7/100,000 for women who are between 20 and 24 years of age. Such a low risk of cervical cancer in women for whom fewer than 3 years have elapsed since their first intercourse, coupled with a very high rate of transient HPV infection and low-grade Pap test abnormalities, promoted a more rational approach to deciding at which age cytologic screening should begin.

Previously, both ACOG and the American Cancer Society (ACS) had recommended that cervical cancer screening begin by age 18 or after a woman's first sexual intercourse, whichever came first. Both organizations stressed that the Pap test should not be the basis for initiating regular gynecologic care. Adolescents who do not need screening for cervical cancer should still get appropriate contraceptive services, screening for other sexually transmitted diseases, and other preventive health care.

The ACS now recommends annual Pap tests from the first cytologic screening until the patient reaches age 30 if conventional Pap smears are used, or every 2 years if liquid-based Pap tests are performed.

The 2003 ACOG Practice Bulletin differs; it recommends annual Pap tests until age 30 for all women regardless of the type of Pap test used, and notes that ACOG does not believe there is adequate evidence to support extending screening intervals to 2 years for women who are having liquid-based Pap tests. For women over age 30, both groups recommend a Pap test every 2-3 years if three previous consecutive normal Pap test results have been obtained. Both organizations are careful to note that women with HIV disease or other immunosuppression should be followed at more frequent intervals, as recommended by the Centers for Disease Control and Prevention, and that women who were exposed to ...