The 411 on the Potential New Cervical Screening Schedule
Visiting the gynecologist for regular check-ups isn’t likely on your list of favorite things, but it’s a necessary part of being female. For those hoping for fewer tests and potentially lower costs, good news may be on the horizon.
Gynecologists recommend well-woman exams every year to promote prevention, identify disease risk factors and check for medical problems. Cervical cancer screenings such as a Pap test (cytology) or human papillomavirus (HPV) test are done less frequently depending on a patient’s age.
Since 2012, the U.S. Preventive Services Task Force (an independent, volunteer panel of experts in prevention and evidence-based medicine) has suggested a Pap test every three years for women ages 21 to 65, or co-testing, meaning both a Pap and HPV test, every five years for women ages 30 to 65. This year, however, the panel is considering changing their recommendation based on clinical trials and computer modeling to allow for either the Pap test every three years (same as before) or the HPV test only every five years.
The panel’s Draft Recommendation Statement includes information on the harms of screening and treatment, which provides the rationale for the potential change. According to their research, both Pap and HPV tests can lead to increased follow-up tests, invasive diagnostic procedures and unnecessary treatment in the case of women with false-positive results.
Diagnostic procedures can be physically harmful, leading to possible vaginal bleeding, pain, infection and failure to diagnose, as well as psychologically harmful, especially in the case of women receiving positive HPV results. Issues can also arise during treatment, potentially leading to adverse outcomes during pregnancy, including preterm delivery and related complications.
Darren Tate, M.D., OBGYN and physician on the medical staff at Texas Health Fort Worth, says he understands the reasoning behind the proposed change.
“It is important to eliminate some of those false positives which lead to unnecessary colposcopies and cryotherapy,” he says. “I think we’ve all been on a learning curve when it comes to that. Earlier in my career, I did more biopsies because I was scared to miss something. Looking back, I’m sure some of those could have been avoided, but you have to balance that with the 12,000 women diagnosed with cervical cancer every year.
“More than half of those women have never had a Pap test, so we can’t totally eliminate screening. We can do better though, both by lowering costs and potential harm by doing too many unnecessary procedures.”
Through their research, members of the panel discovered that many precancerous cervical lesions will either regress or grow so slowly that they fail to become a problem during a woman’s life. As such, identification and treatment of these lesions are considered overdiagnosis, which is problematic because it leads to avoidable surveillance, diagnostic tests and treatments.
In the draft statement, the section on clinical considerations explains that evidence suggests that while both Pap and HPV tests do a good job of detecting abnormal cells (CIN 2/3) on the surface of the cervix, there are pluses and minuses to both tests. Pap tests performed every three years are marginally less sensitive for detecting abnormal cells than an HPV test done every five years.
While the higher sensitivity of HPV tests translates to a slightly lower mortality rate, HPV results often lead to more diagnostic tests, which may or may not be necessary or beneficial.
Additionally, when both Pap and HPV tests are done together, additional testing is performed twice as often than when only HPV tests are done.
Tate says that the conversation about the frequency of cervical cancer testing could take a backseat if vaccinations became more mainstream.
“Less than half of girls between the ages of 14 and 18 in the U.S. receive the cervical cancer vaccine at all and many others drop out before they have all three shots that are necessary to be fully protected,” he explains. “I’d be more comfortable reducing the frequency of screening if we could increase vaccinations. Then we might be able to do just HPV testing since it causes the vast majority of cervical cancer, particularly in women over 30.
“Right now, five years between tests seems a little long, but in other countries where everybody is vaccinated, they are able to go that long safely. Vaccinations are our primary prevention, and screening is our second, but ideally, both things should happen.”
Once the panel makes a final decision on whether to change their screening schedule recommendation, gynecologists will then weigh the pros and cons of such a change for their patients. Gynecological health needs and risk factors will differ from patient to patient, so don’t be afraid to talk to your doctor about why a new screening schedule may or may not be right for you.