Cutting cervical cancer: Organizations and researchers strive to improve screening, prevention

In 2012, the American Cancer Society (ACS) and US Preventive Services Task Force issued new cervical cancer screening guidelines stating that most women should not be screened more frequently than every 3 to 5 years. Some 25 other medical organizations, including the American Society for Colposcopy and Cervical Pathology and the American Congress of Obstetricians and Gynecologists (ACOG), agreed. Since that time, getting physicians and women to follow these and other cervical cancer prevention recommendations continues to pose challenges. For example, a study published last year found that 74% of 366 obstetrician-gynecologists surveyed continued to recommend annual Papanicolaou (Pap) testing for women aged 21 to 29 years, whereas 53% recommended them for women aged 30 years and older.1 Rebecca Perkins, MD, assistant professor of obstetrics and gynecology at Boston University in Massachusetts and coauthor of the study, notes that part of the reason for the lack of adherence to the new guidelines is because they keep changing. “They're a little bit confusing, and it always makes it harder to adapt to them if physicians and women are used to having a Pap exam every year,” she says. Some physicians may also worry that their patients will go elsewhere if they no longer offer them annual Pap tests; however, that assumption may be wrong, says Debbie Saslow, PhD, ACS director of breast and gynecologic cancer. “Some women may not come to their annual checkup because they hate the internal exam,” she says. “It may be that if fewer women have annual Pap tests and colposcopies for false-positives, more will actually come in.” She points to the fact that millions of women in the Kaiser Permanente system have undergone Pap tests every 3 years for the past 12 years. “It just took doctors answering their questions and explaining,” she says. The current cervical cancer screening guidelines are that women aged 30 to 65 years who have had negative test results should be screened with a Pap test combined with human papillomavirus (HPV) testing once every 5 years. A Pap test alone every 3 years is acceptable for women in this age group if HPV testing is not available. Meanwhile, women aged 21 to 29 years should receive cervical cancer screening once every 3 years with a Pap test; cotesting should not occur in this age group. The guidelines were developed based on input from a variety of medical groups and professionals who cited concerns about too many falsepositive findings and unnecessary and sometimes harmful medical procedures occurring as a result. Gynecologic oncologist Nadeem R. Abu-Rustum, MD, of Memorial Sloan-Kettering Cancer Center in New York City, notes that, “The recommendations are consistent with what many gynecologists were anticipating based on recent results from large clinical trials.” He adds that continued education and explanation of the rationale and evidence is needed to clarify the new guidelines. As with breast and prostate cancer, the pendulum is swinging toward less screening, Dr. Perkins says. “There has been a big push away from overscreening and screening too frequently toward getting more bang for your buck in the screening that you do,” she says. Toward that end, ACOG has joined a nationwide campaign known as “Choosing Wisely” to help educate both physicians and patients about choosing only necessary, evidence-based medical tests and procedures. They emphasize that women aged 30 years to 65 years should not undergo routine annual Pap tests but should still have annual well-woman visits with their practitioners. A still newer change in cervical cancer screening is the recent approval by the US Food and Drug Administration for the use of the cobas HPV test (Roche Molecular Systems Inc, Branchburg, NJ) as a primary screening tool for cervical cancer in women aged 25 years and older. The test was first approved by the FDA in 2011 for use in conjunction with or as a follow-up to a Pap test, but the recent approval expands the use of the test as a primary screening tool for the disease. The approval for the use of the HPV test alone does not change current guidelines for cervical cancer screening, according to the FDA. “The FDA panel was specifically asked whether this test is as good as the Pap test every 3 years, and the answer was yes, but it's up to medical organizations such as ACS or ACOG to issue guidelines about how often it should be used,” Dr. Perkins says. “I don't know when and if use of the HPV test alone will be incorporated into new guidelines.” Dr. Perkins recently coauthored a commentary published in Annals of Internal Medicine discussing the advantages, disadvantages, and questions related to the various screening tests for cervical cancer.2 “One of our main messages is that most women in the United States who develop cervical cancer haven't had recent screening with any test,” she says. “We need to make sure that all women are screened regularly with whatever test they have access to.” Dr. Saslow agrees. “Most women do get screened for cervical cancer—in fact, most get overscreened,” she says. “We should be targeting the 10% to 15% of women who don't get screened at all.” Both she and Dr. Perkins agree that more research needs to be done on how to reach underserved women of reproductive age who are at highest risk of cervical cancer. At the moment, there is no universal data set for this group. Dr. Perkins also is concerned about women “falling through the cracks” if screenings occur at longer intervals. Unlike the United Kingdom and Scandinavia, where all women receive a letter reminding them when their screenings are due, the United States does not have a national health system with these organized reminders. If women switch physicians or health systems, their records may not transfer, and they may not remember when they were last screened. “Having the Pap and HPV test is a wonderful way to reduce cervical cancer, but it only works if the woman shows up every 5 years to get screened,” she says. One way to ensure that patients do not miss their examinations is to link the examinations to age versus “every 5 years,” helping them to better remember when they need to get screened. For example, women would receive their first Pap and HPV examinations at age 30 years and then again at age 35 years, Dr. Perkins says. One of the most important elements of cervical cancer prevention is to continue to emphasize the importance of HPV vaccination, she and Dr. Saslow add. With no organized program of HPV vaccination, only approximately 30% of eligible young people are vaccinated in the United States versus approximately 70% to 85% in Australia, Canada, and the United Kingdom, says Dr. Saslow. Pediatricians are not recommending the vaccine with the same strength and urgency as they do other vaccines that are recommended for children at age 11 or 12 years, she notes. Dr. Perkins believes that is one of the most important messages physicians need to convey to their patients when they screen them for cervical cancer. “They need to explain that there is no question that HPV causes a lot of cancer and that they need to vaccinate their children against it,” she says. Most women do get screened for cervical cancer—in fact, most get overscreened. We should be targeting the 10% to 15% of women who don't get screened at all.—Debbie Saslow, PhD

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