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ACP: Who to Screen for Cervical Cancer and When

ACP: Who to Screen for Cervical Cancer and When

  • Part of ACP care initiative which encourages high value care, based on informed consent, shared decision making, and patient preference, with a full discussion of risks and benefits of screening. Why is this needed? Cervical cancer screening simply happens too early, too often, and in women at low risk (eg, older women or those who’ve had total hysterectomy with removal of the cervix). Recent screening occurs in 60% of women by age 21, 53% of women aged 75-79 years, 38% of women over age 80. Over-screening contributes to higher health care costs without improving patient outcomes. In 2010, cervical cancer screening and follow-up cost an estimated $6.6 billion.
  • ACP 7 Best Practice Advice Statements. 1: Do not screen average-risk women who are under 21 years of age. 2: Start screening average-risk women at age 21, and screen once every 3 years using cytology tests alone. 3: Do not screen average-risk women with cytology more often than once every 3 years. 4: In average-risk women aged 30 and over who would like screening less often than every 3 years, physicians can opt for cytology plus HPV testing once every 5 years. 5: Do not perform HPV testing in average-risk women under age 30. 6: Stop screening average-risk women over age 65 who have had 3 consecutive negative cytology results, or 2 consecutive negative cytology and HPV results within the past 10 years, with the most recent test within the past 5 years. 7: Do not screen an average-risk woman of any age if she has had a hysterectomy with removal of the cervix.
  • “Average risk” means a woman is asymptomatic; has no previous history of precancerous lesion (cervical intraepithelial neoplasia grade 2 [CIN2] or higher) or cervical cancer. Is not immune-compromised, including patients with HIV; and, has had no in utero exposure to the synthetic estrogen diethylstilbestrol.
  • The harms of over-screening for cervical cancer include discomfort of speculum exams and colposcopies; pain and bleeding with biopsies; extended surveillance (patient anxiety, cost); potential obstetrical complications with some excisional treatments (some studies have linked excisional procedures to 70% increased risk for preterm delivery, 90% increase in neonatal mortality related to severe prematurity; loop excision and ablational treatments may have fewer adverse obstetrical outcomes than cone biopsies); false positives: potential risk for unnecessary hysterectomy.
  • 2012 was a first: recommendations issued by these professional associations agreed on populations, ages at which to begin/end screening, appropriate intervals, appropriate tests: the US Preventive Services Task Force; the American College of Obstetricians and Gynecologists; the American Cancer Society, in collaboration with the American Society for Colposcopy and Cervical Pathology, and the American Society for Clinical Pathology.
  • Women under age 21 commonly have cytologic abnormalities, but rarely have clinically important cervical lesions. CIN2 regresses in about 40% of patients over a 6-month period, meaning that some younger women are likely treated for lesions that have a likelihood of regression. The average time that a high-grade precancerous lesion progresses to cervical cancer is 10 years. Cervical cancer is uncommon among older women with prior normal results. Hysterectomy with removal of the cervix reduces cervical cancer risk to 0. The US Preventive Services Task Force, American College of Obstetricians and Gynecologists, American Cancer Society, American Society for Colposcopy and Cervical Pathology, and the American Society for Clinical Pathology no longer recommend annual cervical cancer screening. USPSTF: More information, here. ACOG: More information, here. ACS, ASCCP, ASCP: More information, here.
  • ACP best practices advice encourages average-risk women to have cervical cancer screening at the right time, during the right interval, and with the right test. ACP 7 Best Practice Advice statements for cervical cancer screening in average-risk women lays out criteria for when to begin screening (age 21), the frequency of screening (once every 3 or 5 years), and when to stop screening (over age 65, or history of hysterectomy with removal of the cervix). Average risk means asymptomatic, no history of precancerous lesion or cervical cancer, not immune-compromised, and no in utero exposure to diethylstilbestrol. The intent of the ACP best practices advice is to maximize benefit while minimizing harm in cervical cancer screening.

The American College of Physicians (ACP) released the ACP Best Practices for Cervical Cancer Screening in Average-Risk Women1 at the ACP annual conference in Boston on April 30, 2015.

Widespread screening has without doubt reduced the mortality associated with cervical cancer and an estimated 89% of the target population of approximately 70 million women report having been screened in the past 5 years. However, the ACP, supported by groups including the American Congress of Obstetricians and Gynecologists and the American Society for Clinical Pathology, declares there is still too much screening going on.

In order to minimize potential harm to women and maximize the benefits of cervical cancer screening, the ACP Best Practice Advice, highlighted in this slide show, lays out criteria for:

When to begin screening (age 21)

Frequency of screening (once every 3 or 5 years)

When to stop screening (age >65 years, or history of hysterectomy with removal of the cervix)

Source: Sawaya GF, Kulasingam S, Denberg T, et al. Cervical cancer screening in average-risk women: best practice advice from the clinical guidelines committee of the American College of Physicians. Ann Intern Med. Published online on April 20, 2015.

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