Source: USPSTF Website
The U.S. Preventive Services Task Force (USPSTF) is an organization which makes recommendations about preventive care services or screeing for patients who do not yet have symptoms of diseases. The USPSTF has now released the following Draft Recommendations for Cervical Cancer Screening in women.
Women between from 21 to 65 who have had vaginal intercourse should have a Pap smear every 3 years. The USPSTF recommends against screening for cervical cancer in women younger than age 21 years, regardless of their sexual history. The USPSTF also recommends against screening for cervical cancer in women older than age 65 years who have had adequate prior screening and are not otherwise at high risk for cervical cancer. Women who have had a total hysterectomy for benign disease are also exempted.
While there have been many studies recently regarding the link between cervical cancer and human paplillomavirus (HPV), the USPSTF recommends against screening for cervical cancer using human papillomavirus (HPV) testing, alone or in combination with cytology, in women younger than 30 years of age. The USPSTF also has concluded that the current evidence is insufficient to assess the balance of benefits and harms of HPV testing, alone or in combination with cytology, for screening for cervical cancer in women ages 30 years and older -calling into question the value of HPV testing as a screening tool. (This should not come as a big surprise to anyone given that the USPSTF also recommended against PSA testing for prostate cancer in men).
The average yearly rate of cervical cancer is 6.6 cases per 100,000 women (data from 2008). It is estimated that 4,210 women died from cervical cancer in the United States in 2010. Thankfuly, there has been a dramatic reduction in cervical cancer deaths in the US since widespread cervical cancer screening programs were introduced. Cervical cancer remains rare in women younger than age 21 and in those who have not had vaginal intercourse. Unfortunately, the majority of cervical cancer diagnoses occur in women who have never been screened or who have not been screened within the past 5 years.
So what’s the evidence that screening with Pap smears works for women? Women between 21 and 65 who had prior vaginal intercourse demonstrated a substantial reduction in cervical cancer incidence and mortality. There was, however, no reducting in the incidence and mortality (death from) cerival cancer in women younger than age 21.
So why not recommend HPV testing? According to the USPSTF, abnormal test results can lead to more frequent testing and invasive diagnostic procedures, such as colposcopy and cervical biopsy. Complications of these diagnostic procedures include vaginal bleeding, pain, infection, and failure to diagnose (inadequate sampling). Abnormal screening test results are also associated with mild psychological harms; short-term increases in anxiety, distress, and concern about health have been reported with cytology and HPV testing.
Also, many precancerous cervical lesions regress and that other lesions are so indolent (slow-growing) that they will not become clinically important over a woman’s lifetime. The identification and treatment of these lesions may actually constitute overdiagnosis, with unnecessary potential for treatment-related harms. It is difficult to estimate the precise magnitude of overdiagnosis associated with any screening or treatment program, but it is of concern since it leads to unnecessary surveillance, diagnostic tests, and treatments. Some treatments for precancerous lesions (e.g., cold knife conization, loop excision) are associated with adverse pregnancy outcomes, such as preterm delivery that can lead to low birth weight in infants and perinatal death.
In brief, the USPSTF Assessment Summary
The USPSTF concludes that for women ages 21 to 65 years, there is high certainty that the potential benefits of screening with cervical cytology substantially outweigh the potential harms. For women younger than age 21 years, regardless of sexual history, there is moderate certainty that the harms of screening outweigh the benefits. For women older than age 65 years who have had adequate prior screening and are not otherwise at high risk, there is moderate certainty that the benefits of screening do not outweigh the potential harms.
For women who have had a hysterectomy for benign disease, there is high certainty that the harms of cervical cancer screening outweigh the benefits.
For women younger than age 30 years, there is moderate certainty that the harms of HPV testing (alone or in combination with cytology) outweigh the benefits. For women ages 30 years and older, the evidence is insufficient concerning HPV testing (alone or in combination with cytology) and the balance of benefits and harms cannot be determined.
The recommendations of the USPTSF are one source of direction for doctors and for setting health care policies.
Posted by: David M. Schwadron, Esquire