What’s Going On With Cervical Cancer Screening in US?
Merck Education Created Confusion
Commenting specifically about the data on Pap tests done after hysterectomy, Dr. Harper puts some blame onto the Merck advertising/educational campaigns for Gardasil, which emphasize how human papilloma virus (HPV) is related to vaginal, vulvar, anal, and cervical cancers. These campaigns have “left most of the population and many ob/gyn as well as primary care doctors very confused about how to detect these increasingly more common HPV-related cancers,” she told Medscape Medical News.
“It does not surprise me that physicians have taken a woman’s risk for HPV exposure (number of sexual partners or past HPV infection) and stated that even with a hysterectomy for reasons other than HPV, there is no other way than a Pap test to determine if a vaginal cancer is beginning. There are a number of incorrect assumptions in that line of thinking, but that line of thinking has been spawned after the intense advertising campaign Merck undertook for their HPV vaccine,” she said.
In its report, the CDC also mentions vaginal cancer as a reason cited by proponents of continued screening after hysterectomy. “However, vaginal cancer is rare, and the value of cytology tests to detect vaginal cancer in the absence of a cervix is unknown,” the agency points out.
Unnecessary Testing in Other Groups
The CDC survey also highlighted several other groups of women who are undergoing cervical cancer screening unnecessarily and contrary to guidelines.
What to do if you are under 25 or over 64
The original cervical cancer screening programmes across the UK screened women from 20 to 64. The screening programme in England and Northern Ireland now starts at 25 because cervical cancer is very rare before this age. But changes in the cervix are quite common in younger women. So screening younger women can lead to unnecessary treatment and worry.
There is still more evidence coming in about the exact age groups we should screen. Wales and Scotland are still screening from age 20 until more evidence comes in, including from their own screening programmes. Another complication is that liquid based cytology has been introduced over the last few years. If you make more than one major change at a time to any health programme, you won’t necessarily know which change is responsible for improvements in your service. In Wales, for example, they decided to stick with the original screening age, and introduce LBC fully before making any more changes.
Make sure that you begin having regular cervical screening as soon as you are 25 if you are sexually active. If you are under 25 and are at all concerned, talk to your GP or go to a well woman clinic.
In England, Wales and Northern Ireland, the screening programme stops at 64. This is because women who have had normal cervical screening tests are very unlikely to go on to develop cervical cancer after this age. The NHS guidelines say that if your last 3 cervical screening tests were normal when you are 64, there is no need to have any more. But many older women have not had enough tests. The UK cervical screening programme has not cut the number of cases of cervical cancer as quickly as it hoped. One reason for this is because many older women have never had tests.
So, if you are over 64 and your last 3 tests were normal, you will not be asked to go to have any more. If you are over 64 and have had abnormal tests, you will continue to be invited for regular tests in the normal way. In Scotland, the screening programme stops at 60.
If you have never had a cervical screening test, you should have one done regardless of your age unless you have never been sexually active. Ask at your GP surgery or well woman clinic.
Remember that if you are over 64 and have not had 3 normal tests in a row, you should carry on having regular tests until you do. Make sure you ask at your GP or well woman clinic if you think you should continue to have regular screening tests.
Although there had been some variation in recommendations made by different organizations in the past, updated guidelines released last year saw a convergence of opinions and very similar recommendations issued by the American Cancer Society, the American College of Obstetricians and Gynecologists, and the US Preventive Services Task Force.
In the new guidelines, there were specific recommendations that cervical cancer screening should begin at age 21 years, and not before, and yet data from the CDC survey suggest that Pap testing is being carried out in 18- to 21-year-olds.
That may not be the case. Dr. Harper explained that what these young 18- to 21-year-old women were reporting as a Pap test may actually have been a test for chlamydia, “which is prime in this age group.”
Although it can be tested via urine, a chlamydia test is often done via a cervical sampling (ie, by a pelvic examination with a speculum), she explained. “Hence, a woman 18 to 21 who was being screened for chlamydia may have reported that she also had a Pap test done, not really knowing whether she did or not. Most of the time, the nurse practitioners or physicians who do the sample collection only report back that the results are ‘normal’ and not specifically that a chlamydia test was negative and a cytology test showed no abnormal cells.”