American cancer cincinnati society

The American Cancer Society has issued new guidelines that call for young women to begin cervical cancer screening by age 21 and give selected older women the option of stopping screening at age 70.

The guidelines, issued last month by an expert panel convened by the ACS, state that adolescents should be screened no later than 3 years after they first become sexually active or at age 21, whichever comes first. Earlier ACS guidelines suggested that they should be screened by age 18.

Addressing older women, the guidelines recommend that those who are at least 70 years of age and have had at least three normal Pap test results and no abnormal results in the last 10 years may choose to stop cervical cancer screening. In addition, the ACS now recommends that healthy women over the age of 30 who have had three normal Pap smear results in a row can be screened every 2-3 years.

The guidelines have garnered support from several medical groups, including the American College of Obstetricians and Gynecologists and the Society of Gynecologic Oncologists.

The following points are some of the guideline highlights:

* Screening in young women. The move to begin screening by age 21 instead of 18 should encourage more adolescents to get proper gynecologic care, Dr. Debbie Saslow, director of breast and gynecologic cancer at the ACS in Atlanta, said.

"So many adolescents have mild changes [in the appearance of the cervix] that are going to go away on their own," she said. "But although somewhere between 70% and 90% of changes will disappear, once doctors find them, it's very tough to say, 'Let's wait and see.' So you get all these adolescents who get repeatedly screened and sent for colposcopies and biopsies. They may end up not being able to get pregnant or not being able to complete a pregnancy and they get turned off Pap screening."

The new guidelines may help prevent such scenarios from occurring, she said.

Physician groups that had been following the previous ACS guidelines said they would have to rethink their own position in light of the change in adolescent screening recommendations.

"Since we accepted the last ones, we'll need to look at these and adjust our current recommendations," said Dr. Debbie Allen, a member of the Commission on Clinical Policies and Research at the American Academy of Family Physicians. "I think it's very sound reasoning for why we should not begin Pap tests until 21."

Still, physicians will need to make sure adolescents continue to get annual checkups even when a Pap smear isn't needed, said Dr. Allen of Indiana University in Indianapolis.

"We've got to be careful that the lay public [doesn't] think, 'Adolescents don't need to be checked,'" she said. For instance, adolescents will still need to be tested for sexually transmitted diseases during the first few years of sexual activity, and they will also need to come in for contraception.

Dr. Paula Hillard, who served as a liaison to the ACS for the American College of Obstetricians and Gynecologists, agreed. "Age 18 is tricky because the potential need for the Pap smear is what the mom could tell her daughter or vice versa" to get her in for an office visit, she said. "That's good because she needs advice about contraceptives. So we're not saying 'Don't come see us,' but we are saying that the Pap smear shouldn't drive the visit."

Dr. Hillard is a professor of pediatrics and of obstetrics and gynecology at the University of Cincinnati and was a member of an ACS guidelines subcommittee that discussed when to initiate Pap smears.

ACOG will review its own guidelines in light of the ACS guidelines, Dr. Hillard said, noting that ACOG has endorsed the ACS guidelines in principle.

* Screening in older women. Under the guidelines, women 70 years of age and older with an intact cervix who have had three or more normal Pap tests and no abnormal Pap tests in the last 10 years may choose to stop cervical cancer screening.

Women in this age group who have a history of cervical cancer, in utero exposure to diethylstilbestrol (DES), or who are immunocompromised should continue screening as long as they are in "reasonably good health and do not have a life-limiting chronic condition," the guidelines say.

* Screening frequency. After screening has been initiated, it should be done annually with conventional cervical cytology smears or every 2 years using liquid-based cytology. "If you screen every year with a liquid-based Pap test, you're going to have more false positives and all those added costs," Dr. Saslow said.

It's true that a very few cancers may be missed by screening every 2-3 years, but the risk of that happening is extremely low, she said. "It's the difference between a one-ma-million [chance] and two-in-a-million, and how many people would you need to give unnecessary follow-up to, to find that second one? Most women who have cervical cancer are either not screened at all or haven't been screened in the last 5 years."

Still, there will probably be ob.gyns. who continue to screen women each year regardless of how many normal Pap test results they have, Dr. Saslow said. "We know from limited focus groups that doctors say 'Women come in to get their Pap smear, and when they do that, they can get other things too.' But the women say 'If you told me that I didn't need a Pap smear every year, I'd be more likely to come in and get my blood pressure checked."'

* Women who have had a hysterectomy. Screening after total hysterectomy for benign conditions is not indicated unless the cervix removal was done to treat cancer or precancer. Women who have had a subtotal hysterectomy should continue screening until at least age 70.

The guidelines, "Early Detection of Cervical Neoplasia and Cancer," were published in CA: A Cancer Journal for Clinicians (52[6]:342-62, 2002). The guidelines are also available online at http://CAonline.AmCancerSoc.org.