BOSTON – New guidelines for cervical cancer screening in average-risk women issued today by the American College of Physicians are intended to standardize care and balance the harms and benefits of testing.
“Historically, physicians have initiated cervical cancer screening too early, and it is performed too frequently,” Dr. Tanveer P. Mir, chair-elect of the ACP’s Board of Regents, said during a media briefing. She noted that physicians also continue to screen patients at low or average risk, such as those who are older or who have had a hysterectomy. “There is much room for improvement.”
Terry Rudd/Frontline Medical News
From left: Dr. Robert M. Centor, Dr. Tanveer P. Mir, Dr. David A. Fleming
The ACP defines “average risk” as asymptomatic women with no prior history of precancerous lesions or cervical cancer, women who do not have HIV, and women who were not exposed in utero to certain synthetic estrogens.The potential harms of over testing range from false positives that require painful biopsies to unnecessary hysterectomies.
The American Congress of Obstetricians and Gynecologists and the American Society for Clinical Pathology have both endorsed the ACP’s new guidelines, which adhere closely to those released by the U.S. Preventive Services Task Force in 2012.
The ACP’s new guidelines advise that women at average risk for cervical cancer who are age 21 or older should undergo cytology testing every 3 years. For women age 30 and older who prefer less frequent screening, physicians should combine HPV (human papillomavirus) testing with the cytology tests every 5 years (Ann. Intern. Med. 2015 April 30 [doi:10.7326/M14-2426]).
Physicians should not screen women aged 65 years and older who have had three consecutive negative cytology results or two consecutive, combined negative cytology and HPV test results within 10 years, with the most recent test having been within 5 years, according to the new guidelines.
The guidelines also recommend that physicians should not screen average-risk women under 21 years of age for cervical cancer. For average-risk women who are 21 or older, cytology testing should not be done more than once every 3 years.
The ACP does not recommend screening in women at average risk who have had a hysterectomy with the removal of their cervix at any age.
“These are guidelines. It really is a clinical decision by the individual physician as to whether they’re going to follow guidelines, and which particular guidelines they’re going to follow,” ACP President David A. Fleming said.
Nearly one-third of all women aged 21-24 years will test positive for HPV, while 12% of women aged 30-34 years and 5% of women aged 60-64 years will also test positive, according to the ACP.
About 13% of all women aged 21-24 years, 7% of those aged 30-34 years, and 3% of women aged 60-64 years will have abnormal cytology. While cytologic abnormalities are common in female patients under 21 years of age, clinically important cervical lesions are not.
The paper’s release is part of the ACP’s effort to prepare its members for the transition from fee-for-service payment models to value-based ones that the U.S. Department of Health & Human Services has said will be the basis for at least 80% of all care by 2018.
“This is high-value care,” Dr. Robert M. Centor, chair of the ACP’s Board of Regents, said of the new guidelines. “Value is not merely cost. Some expensive tests and treatments have high value because they provide high benefit and low harm. Conversely, some inexpensive tests and treatments have low value because they do not have enough benefits to justify even their remote costs, and might even be harmful.”
More guidelines will follow as part of the ACP’s campaign to change what Dr. Centor called the “paradigm” of over treatment.
In anticipation of pushback from patients who would prefer to have the screening even if they are at low to average risk, Dr. Fleming said in an interview that the ACP will make educational materials available online for physicians to distribute to patients.
“I try to put it in human terms and explain the unintended consequences of [too much testing], and sometimes I do have a strong recommendation that we either do or do not do whatever the guideline is,” he said. “That’s where the trust relationship comes in.”
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