BOSTON -- The American College of Physicians (ACP) said Pap smears should be the mainstay of cervical cancer screening in normal-risk women younger than 30, with molecular testing for human papilloma virus (HPV) reserved for older patients only.
The recommendation was part of a new clinical practice guideline for cervical cancer screening in asymptomatic, average-risk women aged 21 years or older.
The guidelines aim to reduce the overuse of screening in women who do not have an increased risk of cervical cancer, wrote George Sawaya, MD, an obstetrician-gynecologist at the University of California San Francisco and director of of San Francisco General Hospitals' Colposcopy and Cervical Dysplasia Clinic, and colleagues.
Average-risk was defined as those with no history of a precancerous lesions or cervical cancer, those who are not immunocompromised, and those without in utero exposure to diethylstilbestrol.
Historically, physicians often ignore official recommendations on cervical cancer screening, said Tanveer Mir, MD, a palliative care specialist and chair-elect of the ACP's Board of Regents Clinicians, at a press conference here. They often begin screening too early, perform it too often, and do not end screening in elderly women at low risk.
"This is high value care," said Robert Centor, MD, an internist at the University of Alabama School of Medicine at Birmingham and chair of the ACP's Board of Regents.
Value does not only mean cost, Centor added. Physicians also must think about the benefits and harms of a particular screening test.
The guidelines were published concurrently in the Annals of Internal Medicine and are supported by the American Congress of Obstetricians and Gynecologists (ACOG) and the American Society for Clinical Pathology (ASCP).
Backing Off HPV Testing in Younger Women
For women younger than 30 years, clinicians should not perform HPV testing at all because of the high prevalence of HPV infection in this age group, wrote authors.
False positives in this age group could lead to downstream harms such unnecessary biopsies and hysterectomies, said Centor.
Cervical cone biopsies could result in subsequent childbirth complications, added Mir.
The guidelines echo those set by the U.S. Preventive Services Task Force (USPSTF), which state that co-testing is not preferred. It issued a grade D recommendation for this practice, discouraging the use of it.
The ACP has a history of endorsing the USPSTF guideline, Debbie Saslow, PhD, director of the Breast and Gynecologic Cancer of the American Cancer Society (ACS), told MedPage Today.
But the ACP is "basically restating the guideline from 3 years ago without really adding anything new to it," she added. "I wish people would understand how powerful having HPV testing is."
In January 2015, an interim guidance report that included representatives from ACS, ASCC, ASCP, and ACOG stated that primary HPV testing at age 25 continuing at 3-year intervals was a reasonable alternative to cytology or co-testing for HPV.
The report voiced support for HPV testing alone as the primary screen for cervical cancer, given evidence that HPV testing is more reproducible and more sensitive at detecting precancerous lesions.
In April 2014, the FDA approved Roche Diagnostics' cobas HPV test as a primary screening test for cervical cancer in women at least 25 years old for infection with 14 high-risk HPV strains, including HPV 16 and 18.
This followed a unanimous vote by an FDA advisory committee to recommend that Pap smears be replaced by HPV testing for first-line cervical cancer screening.
For women at least 30 years old who prefer less frequent screening, ACP guidelines state that clinicians may use a combination of cytology and testing for high-risk HPV types once every 5 years.
This differs from two sets of guidelines released in 2012, which stated that co-testing for HPV in women aged 30 to 65 years was preferable, given improved detection of adenocarcinoma.
The guidelines were released by ACOG and by the American Cancer Society (ACS), in collaboration with the American Society of Colposcopy and Cervical Pathology (ASCCP) and the American Society of Clinical Pathology (ASCP).
Notably, the ASCP supported both the interim ACS/ASCCP guidelines and the current ACP recommendation.
When to Start, When to Stop
Clinicians should not screen average-risk women younger than 21 regardless of sexual history, authors wrote.
Clinically important cervical lesions are rare in this age group, though cytologic abnormalities are common. Screening could lead to colposcopy, biopsy, or treatment for lesions that will likely regress. According to self-reports, about 60% of women have been screened by age 21.
Screening should stop when average-risk women are older than 65. The women must have had three consecutive negative cytology results or two consecutive negative cytology and human papilloma virus (HPV) test results within 10 years, with the most recent test performed within 5 years.
Cervical cancer is uncommon in women of this age with a negative screening history, and the harms from false positive results may outweigh the benefits of screening, authors wrote.
Similarly, women who have had a total hysterectomy should not receive screening for cervical cancer.
The risk of cervical cancer after total hysterectomy is zero, said Centor.
Once screening begins at age 21, clinicians should screen once every 3 years -- but no more frequently than that -- with cytology.
Disclosures
Funding for the paper was provided exclusively by the ACP.
Kulasingam reported personal fees from the ACP.
Barry reported outside grants, personal fees, and nonfinancial support from the Informed Medical Decisions Foundation/Healthwise and personal fees and nonfinancial support from Massachusetts General Hospital/Harvard Medical School.
Schünemann reported that he played a critical role in the World Health Organization cervical cancer screening and treatment guidelines for low- and middle-income countries.
Primary Source
Annals of Internal Medicine
Source Reference: Sawaya GF, et al "Cervical cancer screening in average-risk women: Best practice advice from the clinical guidelines committee of the American College of Physicians" Ann Int Med 2015; DOI: 10.7326/M14-2426.