Cervical Cancer Screening Guidelines Evolve for Teens, Young Women, and Seniors

Pap tests — when to get them, when to repeat them, and when to stop getting them — are the focus of updated guidelines on screening for cervical cancer. New recommendations from the American College of Obstetricians and Gynecologists (ACOG) are promoting a change in the frequency of cervical cytology screening (Pap smears). Published in the December 2009 issue of Obstetrics & Gynecology, the ACOG recommendations are in keeping with contemporary medicine's use of evidence-based guidelines, notes George Sawaya, MD, in the New England Journal of Medicine.

Smarter About the Harms
Three points are worth noting:

• Wait until age 21: Cervical cancer screening should begin when a woman is 21 years old, regardless of her sexual history. ACOG guidelines now advise that females under the age of 21 should not have a Pap smear because they have a very low risk of cervical cancer. Routine screening before this age promotes unneeded and possibly harmful consequences due to overtreatment. This may have adverse impact on finances, emotions, fertility, and even future pregnancies.
• Test every 2 years in your 20s: The ACOG now recommends Pap tests every 2 years for women between 21 and 29 years of age.
• Testing in your 30's and older: ACOG's recommendation for women over 30 with no risk factors hasn't changed and remains at every three years after 3 consecutive tests with negative results.
• If your history is good, stop at 65 to 70: ACOG recommends discontinuing cervical cancer screening between the ages of 65 and 70 years, if you have had three or more negative Pap smears and no other abnormal test results in the past 10 years. For sexually active women with new or multiple partners or with other risk factors, screening may still be appropriate.

These changes help protect women from the potentially harmful aftereffects of overscreening for cervical cancer, yet maintain the strong, proven benefit of Pap smear testing, notes Sawaya. Variations in frequency may be warranted "based on the needs of the individual patient, resources, and limitations unique to the institution or type of practice," the guidelines note. Examples of those needing annual testing are women with weakened immune systems, cervical abnormalities, HIV infection, or exposure to the chemical DES (diethylstilbestrol).

Women vaccinated against human papillomavirus (HPV) are advised to follow the frequency guidelines as outlined above for unvaccinated women. HPV screening is not recommended for women under 21 years of age. It is also not recommended to test women between 21 and 30 years unless their Pap smear is abnormal. It is recommend that women over 30 years old should be co-tested for HPV at the time their Pap smear is obtained.

Reassuringly, the American Cancer Society (ACS) commented that these recommendations aren't very different than its guidelines (last updated in 2002). The US Preventive Services Task Force's guidelines (from 2003) recommend that females who have been sexually active get tested at least every 3 years. Like the ACOG's prior guidelines, the Task Force advised a first test at age 21 or 3 years after sexual activity began (sexual activity may expose the woman to HPV). The Task Force recommended stopping at age 65 under appropriate conditions; likewise, the ACS agrees with stopping at age 70.

Cervical Cancer Screening is Still Important, But Not Annual for Most Women
Over the last 30 years, the number of cervical cancer cases have decreased by 50% due to the intense promotion of routine screening. The majority of cases are in women who have never had regular cervical cancer screening or have not been screened within the last five years. This is particularly true of women immigrating to the U.S. who have not had regular GYN visits.

Critical to each woman is to discuss with your physician the schedule you should be following based on your age and history and to be aware of how testing may impact your physical and mental health. Given the variability, a timely reminder (phone call, postcard, or e-mail) that you are due for this screening test may be more important than ever. Find out how your health care provider can help you manage this.

Tests: Pap Smear, HPV
Conditions: Cervical Cancer, Sexually Transmitted Diseases
Screening: Young Adults, Cervical Cancer

National Cancer Institute: Risks of Cervical Cancer Screening

Cervical cytology screening. ACOG Practice Bulletin No. 109. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009;114:1409-20.

Joseph, GF. 20 Nov 2009. New ACOG cervical cancer screening recommendations (letter to ACOG members). American College of Obstetricians and Gynecologists. Available online at http://www.acog.org/departments/dept_notice.cfm?recno=20&bulletin=5021 through http://www.acog.org. Accessed 4 Dec 2009.

First cervical cancer screening delayed until age 21: less frequent pap tests recommended (press release). 20 Nov 2009. American College of Obstetricians and Gynecologists. Available online at http://www.acog.org/from_home/publications/press_releases/nr11-20-09.cfm through http://www.acog.org. Accessed 6 Dec 2009.

Sawaya, GF. 25 Nov 2009 (Epub ahead of print). Cervical-cancer screening—new guidelines and the balance between benefits and harms. New Engl J Med. Available online at http://content.nejm.org/cgi/content/full/NEJMp0911380 through http://content.nejm.org. Accessed 6 Dec 2009.

Screening for cervical cancer (topic page). Jan 2003. US Preventive Services Task Force. Agency for Healthcare Research and Quality, Rockville, MD. Available online at http://www.ahrq.gov/clinic/uspstf/uspscerv.htm through http://www.ahrq.gov. Accessed 6 Dec 2009.

Snowden, RV. 20 Nov 2009. ACOG revises cervical cancer screening guidelines. American Cancer Society. Available online at http://www.cancer.org/docroot/NWS/content/NWS_1_1x_ACOG_Revises_Cervical_Cancer_Screening_Guidelines.asp through http://www.cancer.org. Accessed 6 Dec 2009.