The American College of Physicians (ACP) today released clinical advice aimed at reducing overuse of cervical cancer screening in average risk women without symptoms. “Cervical Cancer Screening in Average Risk Women” is published in Annals of Internal Medicine and lists two concurring organizations: the American Congress of Obstetricians and Gynecologists and the American Society for Clinical Pathology.

“ACP’s advice for cervical cancer screening is designed to maximize the benefits and minimize the harms of testing,” said Dr. David Fleming, president. ACP. “Historically, physicians have low adherence to cervical cancer screening recommendations, beginning screening too early, performing screening too often, and continuing to screen women at low risk, either by age criteria or after hysterectomy with removal of cervix.”

ACP advises that physicians should start screening average risk women for cervical cancer at age 21 once every three years with cytology tests alone. Physicians may use a combination of cytology and HPV (human papillomavirus) testing once every five years in average risk women age 30 and older who prefer screening less often than every three years. Physicians should stop screening average risk women older than 65 years for cervical cancer who have had three consecutive negative cytology results or two consecutive negative cytology plus HPV test results within 10 years with the most recent test performed within five years.

ACP further advises that physicians should not screen average risk women younger than 21 years for cervical cancer or screen average risk women for cervical cancer with cytology more often than once every three years. Physicians should not perform HPV testing in average risk women younger than 30 years or screen average risk women of any age for cervical cancer who had a hysterectomy with removal of cervix.

The harms of screening average risk women without symptoms for cervical cancer include discomfort with speculum examinations and colposcopies, pain and bleeding with cervical biopsies and excisional treatments, prolonged surveillance, potential adverse obstetrical outcomes with some excisional treatments, and false positive testing.

“By following ACP’s Best Practice Advice, physicians can practice high value care by reducing over-screening, overtreatment, and unnecessarily higher costs,” said Dr. George F. Sawaya of the University of California, San Francisco Center for Healthcare Value.

Dr. Sawaya and Shalini Kulasingam, PhD, University of Minnesota, School of Public Health, Division of Epidemiology and Community Health co-authored the paper for ACP’s Clinical Guidelines Committee.

Cervical cancer is thought to be the long-delayed consequence of infection with high-risk types of HPV. The likelihood of a woman having abnormal test results varies by age and tests used.

About 30 percent of women aged 21-24 years, about 12 percent of women aged 30-34 years, and 5 percent of women aged 60-64 years will test positive for HPV. About 13 percent of women aged 21-24 years, about 7 percent of women aged 30-34 years, and 3 percent of women aged 60-64 years will have abnormal cytology. Cytological abnormalities are fairly common in women under age 21 yet clinically important cervical lesions are rare.

ACP’s Best Practice Advice is based on a distillation of relevant publications, including systematic reviews. ACP’s advice applies to women without symptoms who are at average risk, defined as those with no prior history of a precancerous lesion or cervical cancer, those who are not immune-compromised (including being HIV infected), and those without in utero exposure to diethylstilbestrol (a synthetic estrogen).

A summary for patients was also published in Annals.

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Steve Majewski
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American College of Physicians

Journal
  Annals of Internal Medicine