As a result of regular screening with the Papanicolaou (Pap) test, deaths from cervical cancer among American women have decreased by more than 70% during the last 50 years.1 When cervical cancer is detected early, the 5-year survival rate is approximately 92%.1
The American Cancer Society (ACS) has updated its recommendations for the early detection of cervical cancer for the first time since 1987 (Table).2 Included are new screening techniques (Box). Highlights follow.
Initial screening for cervical cancer is determined by either age or sexual activity. Begin screening women approximately 3 years after they first have vaginal intercourse or when they reach age 21, whichever comes first. Continue screening annually with conventional cervical cytology smears or every 2 years with liquid-based cytology.
This approach is more cost-effective than universal screening at age 18. The guidelines stress that preventive gynecologic care is crucial for adolescents and should be provided independent of the need for cervical cancer screening.
Women aged 30 or older can be screened every 2 to 3 years if they have had 3 consecutive normal/negative cytology results. Continue screening annually in women who have a history of in utero diethylstilbestrol (DES) exposure, are HIV-positive, or are immunocompromised as a result of organ transplantation, chemotherapy, or corticosteroid treatment.
The rationale for the change in screening interval is that a history of consecutive normal/negative cytology results is associated with a decreased risk of high-grade squamous intraepithelial lesions and cervical carcinoma.
WHEN TO DISCONTINUE SCREENING
Women aged 70 years or older with 3 or more consecutive normal/ negative cytology results and no abnormal results in the previous 10 years may discontinue screening. However, continue to offer these women other appropriate preventive health care.
Screen women who have not had a previous Pap test or whose previous results are unknown. Continue screening women who have a history of cervical cancer or in utero DES exposure or who are immunocompromised (including HIV-positive status) as long as they are in reasonably good health. Use discretion as to whether to continue screening women who test positive for human papillomavirus (HPV) DNA.
The selection of 70 years as the age at which to discontinue screening was based on an appraisal of the harms and benefits. Cervical cancer is rare among older women in the United States who have been screened. In addition, atrophy and cervical stenosis in older women can make it difficult to obtain adequate samples. False-positive results can lead to unnecessary invasive procedures, anxiety, and higher health care costs.
SCREENING AFTER HYSTERECTOMY
Total hysterectomy with removal of cervix. Screening is not necessary for women after a total hysterectomy with removal of the cervix for benign gynecologic conditions. Screen women who have a history of in utero DES exposure and/or a history of cervical cancer as long as they are in reasonably good health.
In women who have had their cervix removed, a cervical cytology test actually screens the vaginal cuff. Vaginal cancer is uncommon, although in utero DES exposure increases the risk.
High-grade cervical intraepithelial neoplasia. Screen women who have undergone a hysterectomy for high-grade cervical intraepithelial neoplasia(CIN 2/3) every 4 to 6 months. Screening should continue until 3 consecutive normal/negative cytology tests with no abnormal tests in an 18- to 24-month period are achieved. Screen women with a history of CIN 2/3 that was not the indication for hysterectomy until 3 consecutive normal/negative cytology tests with no abnormal tests in a 10-year period are documented.
Hysterectomy without removal of cervix. Continue screening women with a subtotal hysterectomy according to the guidelines.
1. American Cancer Society. Cancer Facts & Figures 2003. Available at: http://www.cancer.org. Accessed March 14, 2003.
2. Saslow D, Runowicz CD, Solomon D, et al. American Cancer Society guidelines for the early detection of cervical neoplasia and cancer. CA Cancer J Clin. 2002;52:342-362.