The American College of Obstetricians and Gynecologists issued new guidelines for cervical cancer screening, delaying the start of Pap smears for young women and cutting back on the frequency of the tests.
Only days ago, the U.S. Preventive Services Task Force caused a furor by recommending that women wait until they're 50 to start getting mammograms. But, "It's just pure coincidence that these guidelines have been released now," says Dr. David Soper, the chairman of ACOG's Gynecology Practice Bulletin Committee.
The organization is recommending that young women begin being screened every two years for cervical cancer between the ages of 21 and 29. Previous recommendations called for annual Pap smears three years after the onset of sexual activity or 21 years of age. ACOG was concerned that starting earlier would lead to harmful tests for women who are at a low risk of cancer.
The human papillomavirus, or HPV, that causes cervical cancer is common in sexually active young girls. Invasive cervical cancer in that age group, however, is rare. According to the National Institutes of Health, just one in a million girls is likely to develop cervical cancer between the ages of 15 and 19. The vast majority of the abnormalities that are detected on a Pap smear clear up on their own.
Dr. Alan Waxman, who wrote the guidelines for ACOG, says there was recognition that this is a sensitive period in a young girl's life. A Pap test can be very uncomfortable for the girl and sometimes for the physician doing the test.
"She's very, very sensitive to her body image," Waxman says. "She goes and gets her first Pap smear. It comes back abnormal."
Now she's confronted with the question of whether she has cancer, and she'll have to undergo additional tests that are intrusive and may be uncomfortable, he says.
The main reason for the change in the guidelines is the possible harm that may be done to young women who have an abnormal Pap smear and have to undergo repeated tests and treatment for cervical cancer. There's growing evidence that the treatment contributes to premature births in about 1 in 18 young women who have been treated for precancerous lesions.
It is too early to know what impact the HPV vaccine will have on screening, so ACOG recommends that women who have been vaccinated follow the same guidelines as women who have not been vaccinated.
Once a woman reaches age 30 and has had three normal Pap test results, the committee recommends that she be screened every three years. It is also reasonable, they say, to discontinue cervical cancer screening for women ages 65 to 70 who have three or more normal tests in a row — and have had no abnormal test results in the past 10 years.
What has happened is that the recommendations have caught up with the science, says ACOG's Soper. Most cervical cancer is caused by the HPV type 16 and HPV type 18. It can take five to 10 or 20 years for the HPV infection to cause premalignant changes in the cervix. So it is possible to detect as many cancers with less frequent screenings.
"You don't improve cancer detection by doing annual smears in women in the different age groups," Soper says. Doing the test every other year in women ages 21 to 29, and every three years in women older than 30, is just as good as doing the test annually. "There's no danger in this new guidance," Soper adds.
The American Cancer Society concurs, though it has yet to change its guidelines, which are currently under review, says Len Lichtenfeld, deputy chief medical officer. "There's a consensus building among experts," he says, "that starting before age 21 may not be appropriate."
Cervical cancer experts have been working together, so disputes like the one that arose over breast cancer screening have not arisen. Lichtenfeld says that's good news because it sends a straightforward message to women.
There are women who do need more frequent Pap smears: Women who are infected with HIV, who are immuno compromised, who have had a previous abnormal Pap smear, or who were exposed to diethylstilbestrol in utero should continue to be screened every year for cervical cancer.
ACOG still recommends that women visit the gynecologist annually, whether or not they're going to get a Pap smear.