May 1, 2015 — Many women were raised on the mantra "Pap smear once a year."
But for women 21 years and older at average risk for cervical cancer, getting screened once every 3 years should be enough, according to advice from the American College of Physicians (ACP).
There is also a recommendation against screening women younger than 21 for cervical cancer. Also, doctors should not test for human papillomavirus (HPV) infections in women younger than 30, the group says.
The advice was released at the ACP’s internal medicine conference and published online in the Annals of Internal Medicine.
Do No Harm
Screening can lower the frequency, severity, and death rate from cervical cancer by spotting precancerous lesions, and it can catch the disease at early stages before symptoms appear. But there are also risks involved with testing and treatment, the authors of the new recommendations say.
Doctors also don’t always follow guidelines, the authors say. They begin screening too early and use it too often, even in women judged to be at low risk because of their age or because they’ve had a hysterectomy.
Although women under 21 commonly have unusual features in the cervix, these are rarely a sign of problems, the authors say. If screened, though, many of these women have procedures including biopsies, and some may be treated even if the unusual features are likely to go away on their own.
Annual screening is no longer recommended because of the high rate of false-positive results -- when a Pap smear result is abnormal -- tied to frequent screening. There is a long lag time between the development of precancerous lesions and invasive cervical cancer -- about 10 years -- so less-frequent screening should still be able to spot the disease in time, the authors explain.
For average-risk women 30 years and older who would rather not get tested every 3 years, doctors can offer "cotesting" -- a combination of Pap smear and HPV testing -- once every 5 years, the authors say.
Women older than 65 who’ve had no abnormal Pap smears in the previous 5 years are unlikely to get cervical cancer. But they’re at higher risk than younger women of being subjected to unnecessary procedures on the basis of false-positive results, the authors say.
Old Habits Die Hard
Doctors should take the lead in cracking down on unnecessary screening of women at average risk for cervical cancer, says ACP President David Fleming, MD.
"Often times our practices become a habit,” he told reporters at a news conference. “It's an expectation not only of the physician, but also of the patient. And I have had patients who had hysterectomies where the advice had been that screening was no longer indicated, but they still want it, for reassurance.”
"The challenge here is to change habits," says Robert Centor, MD, chair of the ACP’s Board of Regents.
The authors estimate that about 60% of women are screened for cervical cancer before the age of 21. And they think that about 53% of women ages 75 to 79 years and 38% of those 80 and older have been screened recently.
Marcela del Carmen, MD, from Massachusetts General Hospital, was not involved in coming up with the recommendations, but she says they’re sound.
"We know that the risk of having cervical cancer in women younger than 21 is exceedingly small, so there's really not much benefit in screening somebody in that population," she says.
"A lot of young women are HPV-positive,” she says. While HPV can cause cervical cancer, many HPV infections clear over time and don’t result in a health issue.
Some of the authors report receiving fees from the ACP.