Gynecologic cytology has recently been in the spotlight and this time it is not the methods of the profession that changed, but rather a defining transformation in the form of updated guidelines for Pap screening. The new cervical cancer screening guidelines released in March of this year have undoubtedly created a lasting impact on the profession.

What really stands out is the recommendation that most women get a pap smear every 3 years instead of every year; and that women younger than 21 not get tested at all, even if they're sexually active or at risk for Human Papilloma Virus (HPV) infection.

USPSTF
There are two sets of guidelines, and are both very similar in content. One is published by the United States Preventive Services Task Force (USPSTF) which was published in March in the Annals of Internal Medicine. ¹

The USPSTF is an independent non-Federal entity comprising of experts in prevention and evidence-based medicine.  They cover a broad range of clinical preventive health care initiatives and makes recommendations about three types of clinical preventive services: screening tests, preventive medications, and counseling.

ACS/ASCCP/ASCP
Another set of recommendations--published jointly by The American Cancer Society (ACS), American Society for Colposcopy and Cervical Pathology (ASCCP), and American Society for Clinical Pathology (ASCP) support the guidelines of the USPSTF.

In addition, this other set of recommendations points out that the obstetrics and gynecologic visit is still done annually, emphasizing that the visit has always been more than just a Pap smear. The decreased need for cervical screening actually constitutes a minor change to an important aspect of a woman's healthcare and allows the caregiver more time to address other important components of the patient's healthcare evaluation. ²

Both sets of guidelines specifically recommend that women should not have pap smears done every year, and both underscore the fact that most of the women who die from cervical cancer have never been screened at all.²

Highlights
These recommendations do not apply to women who have received a diagnosis of a high-grade precancerous cervical lesion or cervical cancer, women with in utero exposure to diethylstilbestrol, or women who are immunocompromised (HIV positive). ¹


Here is the summary of the changes:

Women Younger Than Age 21 Years

Screening for women younger than age 21 years is no longer recommended, regardless of sexual activity.

Women Ages 21 to 29 Years

Women aged 21 to 29 should get a pap test every 3 years but not a separate HPV screening.  HPV testing (alone or in combination with cytology) in women younger than age 30 years is not recommended. 

Co-testing on Women between the ages of 30 to 65

Women aged 30 to 65 should get both a pap test and an HPV screening (co-testing) every 3-5 years. Here is where the two sets of guidelines differ. The task force guidelines suggest running both tests every three years, but the American Cancer Society's guidelines state that pap tests should be done every three years only if HPV testing is not available or practical; otherwise women who opt for HPV testing can have pap tests done every five years instead. 

Women Older Than Age 65 Years

It is recommended that women older than age 65 years who have had adequate prior screening and are not otherwise at high risk are not tested. Some women who are older than 65 may not need to be screened at all. Those who had normal pap test results or who have tested negative for HPV in the last 10 years can stop getting pap tests and HPV screenings done, regardless of whether they're sexually active or not.

Women after Hysterectomy

Screening after hysterectomy among women who do not have a history is not recommended

Women vaccinated against HPV

This group should still be screened for cervical cancer. This is because the vaccine does not protect against all of the strains of HPV that cause cervical cancer; and since long-term effects of the vaccine are still unknown, the American Cancer Society recommends that women who have been vaccinated for HPV still start screening when they're 21. 

Updating Previous Recommendations
These changes are actually updates to the USPSTF Pap Screen recommendation of 2003 but now include detailed guidance on frequency of screening based on age and history.

This is the first time that USPSTF has recommended the combined use of cervical cytology and high-risk HPV DNA testing ("co-testing"). The previous USPSTF guidelines had indicated that evidence was insufficient to make a recommendation regarding the use of co-testing.

While less-frequent screening will reduce problems associated with false-positives, more frequent testing may be appropriate for women with conditions that place them at an increased risk of cervical cancer, such as being immunocompromised with human immunodeficiency virus (HIV) infection.

Impact on the Profession
Recommending less frequent screening for cervical cancer is not new. The American Cancer Society has recommended less frequent screening for some women since 1980; and the American Congress of Obstetricians and Gynecologists has made similar recommendations since 1989. Note that the new guidelines from USPSTF and ACS/ASCCP/ASCP are for women at average risk, and more appropriate testing is still made available to patients as determined by the physician. ²

As cytologists, we can argue about the reasoning. But how can we adjust to a professional mindset that annual screening may not be the best way to catch cancer in its early, most-treatable stages? We also realize that some of these abnormal cellular changes can resolve without intervention.  When it comes to invasive procedures, one cannot dismiss that treating young women for HPV infections can cause problems that lead to future infertility. And again, despite the push to vaccinate young girls and boys against HPV, experts agree that most HPV infections clear up on their own, and the ones that don't can take a while to develop into cervical cancer, which leaves supposedly adequate time for screening and treatment later in life.

These recommendations are seen by the profession as truly defining when it comes to screening frequency, particularly since they somehow contradict what we were taught. New studies and information are hallmarks of the changing times. Medical advancements create changes. Was it just a matter of time?

Yes, it is true that these new provisions now indicate less gynecologic cytology workload. We have adapted well to new methodologies and regulatory changes, but now it is the "need" that has changed. We still provide the same service and purpose for the patient and as always, the patient's gynecologic well-being is still foremost.

References

1. US Preventive Services Taskforce. Screening for Cervical Cancer. Available at: http://www.uspreventiveservicestaskforce.org/uspstf11/cervcancer/cervcancerrs.htm. Last accessed July 11, 2012.
2. ACOG. New Cervical Cancer Screening Recommendations. Available at: www.acog.org. Last accessed July 11, 2012.