New Cervival Cancer Screening Guidelines: No More 'Annual' Pap Smears

On the heels of the mammogram mess, women now given guidelines on pap smears.

ByLAUREN COX and Dr. JOSHUA HUNDERT via via logo
November 19, 2009, 6:36 PM

Nov. 20, 2009— -- Pap smears may no longer be called "annuals" if doctors follow new cervical cancer screening recommendations from the American College of Obstetricians and Gynecologists.

The group announced today that women should start getting cervical cancer screenings at age 21 instead of 18, and that women could wait longer between the screenings -- regardless of when a woman starts having sex.

Women in their 20s with normal Pap smear results now should get screenings every two years instead of every year, and women in their 30s can wait three years between screenings, according to the new ACOG guidelines.

After a week of uproar over the controversial recommendations for less mammogram screenings for women, doctors say they will have to wait and see how the public reacts to the new pap smear guidelines.

"This is not a radical change in screening practices. This is something that's been coming gradually since the 1980s," said Dr. Alan G. Waxman, who helped write the new guidelines.

Some doctors hailed the decision as a way to reduce a host of problems caused by excessive screening; yet, a few others worried it might trigger more women to neglect annual checkups with gynecologists.

Waxman said the move toward fewer screenings will reduce unnecessary treatment in young women and protect them from future pregnancy complications.

On one hand, college-aged women have very high HPV infection rates. Dr. John Curtin, of The Cancer Institute at NYU Langone Medical Center in New York City said 70 percent of all college-aged sexually active people have contracted HPV. These high infection rates translate into a high number of abnormal pap smears.

However, the ACOG guidelines point out that only 0.1 percent of cervical cancer occurs in women under 21 years of age in part, doctors believe, because young women's immune systems are strong enough to fight off HPV before it causes cancer. When dysplasias progress to cancers it's usually a result of older women missing screenings for years at a time; 50 percent of women diagnosed with cervical cancer each year never had a pap smear before, according to the ACOG statement.

And some research has suggested the diagnostic surgery that often follow an abnormal result can pose problems for future pregnancies in some women.

"The driving force behind the change was the numerous studies that show women who are treated for cervical dysplasias are more likely to have a preterm birth," said Waxman, who is a professor at the University of New Mexico in Albuquerque.

Waxman explained that the LEEP procedure to remove precancerous tissue often caused by an infection with the human papillomavirus, or HPV, also weakens the cervix. In fact, it's estimated, one in 18 women who've had a LEEP procedure will go on to give birth prematurely.

But, he added, new studies have shown "with most of the cervical abnormalities in adolescents, most of them get better by themselves. ... The thought is that these are the people who have most of their child-bearing years in front of them."

The ACOG recommendations cite studies showing that up to 90 percent of these infections are cleared on their own in adolescents within a few years.

The measure also was intended to reduce anxiety in young women who may struggle with the news that they are infected with a sexually transmitted virus known to cause cancer.

"I was convinced I was dying, that I had cancer. There was not enough education back then," said Nicole C., a resident of La Porte, Texas, who was diagnosed at age 22 with cervical dysplasia -- an abnormal Pap smear -- caused by HPV. "My doctor at the time made me feel horrible about myself, accusing me of not being truthful about how many partners I'd had."

Reducing Anxiety Now and Later On

Nicole, who asked that her last name not be used for privacy reasons, had her first abnormal Pap smear in 1998. As the years passed, more of her friends were diagnosed with cervical dysplasia in their 20s.

As Nicole started serving as an impromptu counselor to explain how HPV is spread, she aimed to soothe fears and reduce the stigma.

"If I had known more back then, I would not have freaked out about it," she said. "I wished they had done that [changed the guidelines] years ago."

Many doctors say they recognize the same anxiety on their young patients' faces.

"Yes, the diagnosis of an abnormal Pap can cause emotional distress to an adolescent girl, and I have certainly seen that," said Dr. Elizabeth Alderman of Montefiore Medical Center in the Bronx, N.Y. "[Cervical biopsies] and repeat Pap smears with visits cost a lot of money."

In fact, some doctors felt the new recommendations did not go far enough.

Dr. Diane Harper of the University of Missouri-Kansas, who specializes in HPV infections, felt that ACOG is behind the other recommending bodies in the United States that argue screening should start at age 25, not age 21.

"There is ample evidence that screening earlier than 25 years is only costly with many false positives," said Harper. "The rest of the world is going to an every-five-or-six-year screening interval ... and ACOG is now just endorsing the three-year interval for HPV negative and Pap negative [women]."

Doctors speaking to also said they felt the best way to prevent more cancer deaths wasn't to re-screen women who are already seeing doctors regularly, but to try to get women who aren't getting screenings at all into the doctors.

"Whether we screen everybody every two or three years isn't probably not going to make a big difference I don't think, just as long as they are getting screened," said Curtin. "The fact remains there are unscreened patients and they are at risk for cancer."

Doctors speaking to also said they felt the best way to prevent more cancer deaths wasn't to re-screen women who are already seeing doctors regularly, but to try to get women who aren't getting screenings at all into the doctors.

"Whether we screen everybody every two or three years is probably not going to make a big difference, just as long as they are getting screened," said Curtin. "The fact remains there are unscreened patients and they are at risk for cancer."

Negative Effects of Fewer Pap Smears Unknown

On the other hand, many women admit that the only reason they go to a doctor is for an annual Pap smear and contraception. For those reasons, some doctors worry such women won't receive any medical checkups at all.

"Honestly, the first time it was discovered, I was going to Planned Parenthood for contraception because I had just become sexually active. It was only my second partner," said Alicia, a 32-year-old woman from New Orleans who also did not want her last name used.

Alicia had her first abnormal Pap smear when she was 18.

"I cried, and I really, really freaked out," she said.

But the task of treating her abnormal Pap smears made her aware of her health.

"That was a pivotal moment in my life," she said. "I started doing things better. I started getting into gardening and doing things to calm down."

Dr. Donnica Moore, president of Sapphire Women's Health Group and an obstetrician-gynecologist by training, worried that the new guidelines might keep women who've had a normal Pap smear, or no symptoms, away from the doctor.

"Women may now assume -- incorrectly -- that if they only need a Pap smear every two or three years, then they only need to see their gynecologist every two to three years, and for many of these women, their gynecologist is their primary care physician," said Moore. "Thus, they will not be getting a routine physical, breast exam, blood pressure measurement, and sexually-transmitted infection testing."

Changing Recommendations on Pap Smears

However, Friday's changes aren't the first to affect cervical cancer screenings. Over the years, doctors have scaled back on cervical cancer screening schedules after more research proved less frequent screenings were effective.

"It is about time this occurred," said Dr. Mark Einstein of the Montefiore Medical Center in the Bronx, N.Y. "Oftentimes, young women are put into a 'high-risk' category, clinically, because they have a [positive] Pap test that is essentially just a sign of an HPV infection -- but it is not clinically relevant. This leads to anxiety and over-testing."

Dr. Joanna Cain of Brown University agreed, and argued that the HPV vaccine will further decrease the transmission of the virus that is responsible for up to 70 percent of cancers in the coming years.

Below is a timeline of changes to cervical cancer screenings over the years, according to Waxman:

1957 -- The American Cancer Society runs a nationwide campaign for women to get a Pap test every year.

1976 -- Canadian health leaders examine data and recommend a woman get a Pap smear every two years, after a woman has three consecutive normal Pap smears.

1980 -- The American Cancer Society follows Canadian guidelines recommending a woman get a Pap smear every two years after three consecutive normal Pap smears.

1988 -- The American College of Obstetricians and Gynecologists recommends starting screening at 18, or with the onset of sexual activity and getting a Pap test every year. But after three negative Pap tests, women should be screened less often.

2003 -- ACOG guidelines shift from recommending the first Pap smear at age 18 or the onset of intercourse to age 21 or three years after the onset of intercourse.

2008 -- The American College of Obstetricians and Gynecologists guidelines shift to recommend adolescents who have a minor abnormality on a Pap test wait to get biopsies and a diagnostic test called a colposcopy.

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