new guidelines issued on cervical cancer screening 2012

7/29/2019 New Guidelines Issued on Cervical Cancer Screening 2012

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New Guidelines Issued on Cervical Cancer Screening

CME/CE

News Author: Joanna Broder

CME Author: Hien T. Nghiem, MD

CME/CE Released: 11/05/2012; Valid for credit through 11/05/2013

Clinical Context

In the United States, the incidence of cervical cancer has decreased by more than 50% in the past 30

years. This trend can be attributed to the widespread screening with cervical cytology testing. Human

papillomavirus (HPV) infection, especially a persistent infection, is usually necessary for the development

of squamous cervical neoplasia. Factors that determine whether an HPV infection will persist include

HPV genotype (specifically HPV-16 and HPV-18), cigarette smoking, a compromised immune system,

and HIV infection. As new technologies for cervical cancer screening (such as HPV genotyping),

continue to evolve, recommendations for managing results need to be updated.

The aim of this practice bulletin by the American College of Obstetricians and Gynecologists was to

provide a review of the best available evidence regarding cervical cancer screening.

Study Synopsis and Perspective

An annual Papanicolaou (Pap) test may soon be a thing of the past: According to new guidelines from

the American College of Obstetricians and Gynecologists, most women do not need cervical cancer

screening more frequently than once every 3 to 5 years.

"The evidence clearly shows that less frequent cervical cancer screening is warranted," said David

Chelmow, MD, chair of obstetrics and gynecology at Virginia Commonwealth University School of

Medicine in Richmond, in a press release. Dr. Chelmow worked with the Committee on Practice

BulletinsGynecology to develop the new guidelines,publishedin the November issue ofObstetrics &

Gynecology.

The new guidelines update those published in 2009 and echo recommendations that the American

Cancer Society, the American Society of Colposcopy and Cervical Pathology, and other medical groups

released earlier this year.

New Cervical Cancer Screening Recommendations

The biggest guideline change is aimed at women between the ages of 30 and 65 years. The preferred

method to screen women in this age group who have a negative Pap test now is by co-testing with the

Pap test (using the conventional Pap or the liquid-based method) combined with HPV testing every 5

years. If HPV testing is not available, women can get a Pap test by itself (without HPV co-testing) every 3

years, the authors note.

Population Recommended Screening Method Comments

Aged less than21 years

No screening

Aged 21 to 29 Cytology alone every 3 years
http://journals.lww.com/greenjournal/Abstract/2012/11000/Screening_for_Cervical_Cancer.49.aspxhttp://journals.lww.com/greenjournal/Abstract/2012/11000/Screening_for_Cervical_Cancer.49.aspxhttp://journals.lww.com/greenjournal/Abstract/2012/11000/Screening_for_Cervical_Cancer.49.aspxhttp://journals.lww.com/greenjournal/Abstract/2012/11000/Screening_for_Cervical_Cancer.49.aspx


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years

Aged 30 to 65years

Preferred: HPV and cytology co-testing every 5 years Acceptable:Cytology alone every 3 years

Screening by HPV testing alone is notrecommended

Aged morethan 65 years No screening necessary afteradequate negative priorscreening results

Women with a history of cervicalintraepithelial neoplasia [CIN] 2, CIN 3, oradenocarcinoma in situ should continueroutine age-based screening for at least 20years

After totalhysterectomy

No screening necessary Applies to women without a cervix and withouta history of CIN 2, CIN 3, adenocarcinoma insitu, or cancer in the past 20 years

After HPVvaccination

Follow the same age-specificrecommendations asunvaccinated women

Modified fromCA Cancer J Clin. 2012;62:147-172.

"We know that HPV infections are very common but most are transient and don't progress to cervical

cancer," Dr. Chelmow said in the press release. Only a fraction of women with chronic HPV infection will

have cervical abnormalities that cause cancer. In addition, even if cells are precancerous, it takes years

for them to convert into invasive cancer, according to the college.

"With co-testing, screening every five years provides an excellent balance between achieving extremely

low cancer rates while avoiding the potential harms of unnecessary interventions," Dr. Chelmow said in

the release.

"The new guidelines emphasize that there is no role for tests that look for low-risk types of HPV," Dr.

Chelmow said. "When co-testing, we should be using only tests for high-risk, oncogenic types of HPV."

The authors also suggest that women between the ages of 21 and 29 years get screened for cervical

cancer every 3 years rather than every 2 years. Either the conventional Pap or the liquid-based method

is reasonable, but the college advises that women younger than 30 years not receive screening with co-

testing.

The guidelines are the same for women who have received the HPV vaccine as for those who have not,

although not everyone should get screened for cervical cancer. Upholding recommendations from 2009,

the college advises that women younger than 21 years not receive screening for cervical cancer or HPV,

whether or not they are sexually active.

Young women have immune systems that can generally clear HPV infection in about 8 months, and if a

cervical abnormality does occur resulting from HPV infection in this age group, it generally resolves with

no need for treatment.

Although very young women will not get screening, clinicians can still guide them toward prevention of

cervical cancer by encouraging the HPV vaccine and counseling them about safe sex practices, the

authors note.
http://onlinelibrary.wiley.com/doi/10.3322/caac.21139/pdfhttp://onlinelibrary.wiley.com/doi/10.3322/caac.21139/pdfhttp://onlinelibrary.wiley.com/doi/10.3322/caac.21139/pdfhttp://onlinelibrary.wiley.com/doi/10.3322/caac.21139/pdf


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According to the guidelines, clinicians should stop screening in women older than 65 years if they meet

certain qualifications (eg, no history of CIN grade 2 or higher, adenocarcinoma in situ, or cervical cancer)

and have also had 3 consecutive negative cytology results or 2 consecutive negative co-test results

within the previous 10 years, with the most recent test occurring within the last 5 years.

The authors also note that "Variations in practice may be warranted based on the needs of the individual

patient, resources, and limitations unique to the institution or type of practice."

Women with certain conditions will require more frequent screening, the authors say. These populations

include:

women with HIV,

women who have received organ transplants or are immunocompromised for other reasons,

women who were exposed to diethylstilbestrol in utero, and

women previously treated for CIN 2, CIN 3, or cancer.

"It will take some time and a lot of effort to re-educate everyone that the annual Pap is no longer the

standard of care," Dr. Chelmow said in the release. "It is critical, however, that women understand thattheir annual well-woman visit is still very important for many other aspects of their health care."

Obstet Gynecol. 2012;120:1222-1242.

Study Highlights

The American Cancer Society, the American Society for Colposcopy and Cervical Pathology,

and the American Society for Clinical Pathology have recently updated their joint guidelines for

cervical cancer screening. An update to the recommendations from the US Preventive Services

Task Force has been issued.

These recommendations have been issued by the American College of Obstetricians and

Gynecologists for cervical cancer.

Level A recommendations are as follows:

o Cervical cancer screening should begin at age 21 years, regardless of the age of sexual

initiation or the presence of other behavior-related risk factors.

o Women 21 to 29 years should be tested with cervical cytology studies alone, and

screening should be performed every 3 years. Co-testing is not recommended in

women younger than 30 years.

o For women 30 to 65 years old, co-testing with cytology and HPV testing every 5 years is

preferred.

o Additionally, in women 30 to 65 years old, screening with cytology tests alone every 3

years is acceptable.

o Women who have a history of cervical cancer, have HIV infection, areimmunocompromised, or were exposed to diethylstilbestrol in utero should not follow

these routine screening guidelines.

o Both liquid-based and conventional methods of cervical cytology collection are

acceptable for screening.

o In women who have had a hysterectomy with removal of the cervix (total hysterectomy)

and have never had CIN 2 or higher, routine cytology screening and HPV testing should

be discontinued and should not be restarted for any reason.
http://journals.lww.com/greenjournal/Abstract/2012/11000/Screening_for_Cervical_Cancer.49.aspxhttp://journals.lww.com/greenjournal/Abstract/2012/11000/Screening_for_Cervical_Cancer.49.aspxhttp://journals.lww.com/greenjournal/Abstract/2012/11000/Screening_for_Cervical_Cancer.49.aspxhttp://journals.lww.com/greenjournal/Abstract/2012/11000/Screening_for_Cervical_Cancer.49.aspx


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o Screening by any modality should be discontinued after age 65 years in women with

evidence of adequate negative prior screening results and no history of CIN 2 or higher.

The following recommendations are based on limited and inconsistent scientific evidence (level

B):

o Women with cytology results indicating atypical squamous cells of undetermined

significance and negative HPV co-testing results have a very low risk for CIN 3 and

should continue with routine screening as indicated for their age.

o Women with a history of CIN 2, CIN 3, or adenocarcinoma in situ should continue to

undergo routine age-based screening for 20 years after the initial post-treatment

surveillance period, even if it requires that screening continue past age 65 years.

o Women should continue to be screened if they have had a total hysterectomy and have

a history of CIN 2 or higher in the past 20 years or have ever had cervical cancer.

Continued screening for 20 years is recommended in women who still have a cervix and

have had history of CIN 2 or higher. Therefore, screening with cytology testing alone

every 3 years for 20 years after the initial post-treatment surveillance period seems

reasonable for women with a hysterectomy.

o Women 30 years and older with negative cytology and positive HPV co-testing results

should be treated in 1 of 2 ways:

Subsequent co-testing in 12 months. If the subsequent cervical cytology test

result is low-grade squamous intraepithelial lesion or higher or if the HPV test

result is still positive, the patient should be referred for colposcopy. Otherwise,

the patient should return to routine screening.

Immediate HPV genotype-specific testing for HPV-16 alone or HPV-16/18

should be performed. Women with positive results from tests for HPV-16 alone

or HPV-16/18 should be referred directly for colposcopy. Women with negative

results from tests for HPV-16 or HPV-16/18 should be co-tested in 12 months,

with management of results as described.

The following recommendations are based primarily on consensus and expert opinion (level C):

o Women who have received the HPV vaccine should be screened according to the sameguidelines as women who have not been vaccinated.

Clinical Implications

Persistent HPV infection strongly predicts a subsequent risk for CIN. Factors that determine

whether a HPV infection will persist include HPV genotype (specifically HPV-16 and HPV-18),

cigarette smoking, a compromised immune system, and HIV infection.

Cervical cancer screening should begin at age 21 years. In women 21 to 29 years old, cervical

cytology testing is recommended every 3 years. For women 30 to 65 years old, co-testing with

cytology and HPV testing every 5 years is preferred; however, screening with cytology testing

alone every 3 years is acceptable.

CME Test

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To receiveAMA PRA Category 1 Credit, you must receive a minimum score of 70% on the post-

test.


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3 INTERNAL 178541

A 24-year-old woman presents to you for her routine Pap examination. During her previous

visit, you treated her for bacterial vaginosis infection. Currently, she has no vaginal discharge

or other vaginal symptoms. The patient smokes 5 cigarettes per day; otherwise, she has no

other health issues. Which of the following factors would put this patient at risk for persistent

HPV infection?RADIOBUTTON 0

Age

History of bacterial vaginosis infection

Compromised immune system

Cigarette smoking

178363

The results of this patient's examination are normal. When should she return for her next

cervical cancer screening examination?

RADIOBUTTON

1 year

3 years

5 years

7 years

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This article is a CME/CE certified activity. To earn credit for this activity visit:http://www.medscape.org/viewarticle/773678
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new guidelines issued on cervical cancer screening 2012

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