The American Congress of Obstetricians and Gynecologists issues new cervical cancer screening guidelines
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Cervical cancer used to be the leading cause of cancer death among women. The Pap smear — a swab to evaluate the cells of the cervix (the bottom of the uterus) to look for cancerous changes — is now widely used to test for cancer and, as a result, the incidence of cervical cancer deaths has fallen. Still, in the United States in 2009 (the last year for which statistics are available), 12,357 women were diagnosed with cervical cancer, and 3,909 women died of the disease, according to the federal government’s Centers for Disease Control and Prevention.
The HPV Virus
According to the Centers for Disease Control, almost all cervical cancer is caused by the human papillomavirus, or HPV. There are more than 100 types of HPV; some cause warts on the skin (genital and non-genital), others cause cancer of the throat. There are types of HPV that affect the skin of the cervix and anus, and these types of HPV are transmitted during genital-to-genital contact.
Most individuals will have an HPV infection at least once in their lifetime, but most of these types of HPV can be cleared by the body’s immune system. Some types of HPV are called “persistent.” This means they are more likely to remain in the body and cause changes to the cells, eventually resulting in cancer. HPV must be present in the cervix for many years to cause cervical cancer.
Younger Women and HPV
It is known that younger women have more rapid turnover of the cells of the cervix. This means that even if they have changes that appear to be cancerous on a Pap smear, their cells may become normal again over time. If a Pap smear shows abnormal changes of the cervical cells, it is necessary to do additional testing, such as a colposcopy (a procedure in which the cervix is viewed under magnification to evaluate the appearance of the cervix) or a biopsy (in which a tiny portion of the cervix that looks abnormal is removed for further testing).
Other procedures that remove larger portions of abnormal cervical cells are sometimes required. In addition to the emotional strain associated with needing these procedures, in rare cases, procedures that remove large areas of the cervix can actually shorten the length of the cervix. It is possible that a shorter cervix may not be as strong, and in rare instances women who are pregnant may be at risk for an early delivery. In order to decrease the risk of unnecessarily treating young women of childbearing age, many professional organizations in the United States now recommend that Pap smears begin at age 21.
The American Congress of Obstetricians and Gynecologists (ACOG) offers the following age-related guidelines:
Young women between 21 and 30 years of age
• Generally only have the Pap test to look for abnormal cervical cells (cytology testing)
• New guidelines indicate that in this age group, women who have never had an abnormal Pap smear and are asymptomatic (no abnormal bleeding, no pain with sexual activity) can have Pap testing every three years.
Women over age 30
• The risk of HPV becoming “persistent” increases for women over age 30. For these women, there are two options for testing (again in women with no history of abnormal Pap testing and no symptoms):
• Option 1: continue cytology testing every 3 years. For these women, we will often ask the lab to look for the presence of HPV if the cells appear abnormal.
• Option 2: do cytology testing with HPV co-testing. For these women, we check the cytology and request an HPV test every time they have a Pap smear; with this option, testing may be done as little as every 5 years.
Women age 65 years and older
• Generally, if a woman has had many years of normal Pap smears, these can be discontinued at age 65 years, or after a woman has had a hysterectomy (removal of the uterus) for a reason other than cancer.
Reduce Your Risk of HPV
There are several things that you can do to reduce your risk of getting HPV or of having the HPV remain in your body. Condom use is recommended with all sexual activity. Although HPV can still be spread by the genital skin not covered by a condom, the use of male or female condoms does reduce the risk of transmission. Smokers tend to have a higher rate of cervical cancer; smoking cessation could reduce that risk.
HPV vaccines can reduce the risk of cervical cancer and/or genital warts. These vaccines work best when they are administered prior to the onset of sexual activity and are approved for females age 9-26 and males age 11-21. Unfortunately, there is no HPV testing available to see if men are infected if they do not have symptoms.
Many of us grew up having yearly Pap smears and for some of us it is a big shift to feel comfortable having this testing less frequently. Now, professional organizations believe that by using these new methods of testing we will continue to diagnose cervical cancer but avoid the adverse effects associated with testing more frequently (unnecessary procedures, worry about those procedures and possible shortening of the cervix). It is still recommended that you have an annual visit with your provider. Please discuss these recommendations with your health care provider and have a conversation to determine the screening plans that best fit your unique history and concerns.
Chalice Santorelli is a nurse practitioner at Southampton Medical Associates.