Patient expectations
Another hurdle to embracing the guidelines is that of patient expectations. One of the big misunderstandings among patients of all ages is that they will skip all visits for 3 years because of the interval in Pap testing, Dr. Montgomery said. It is important to stress that “the Pap is just one of the services done during the visit, and a relatively small one when you look at all the other things that are part of a comprehensive well woman visit,” he said.
He further noted that both patient and physician age may be an important factor in acceptance of the guidelines and the changes in screening frequency.
As a physician with a large population of patients in their postreproductive years, and as one who trains young residents, he has noticed a generational difference: Younger patients and physicians are more accepting of the changes, but women who have spent 30 or 40 years coming in for an annual Pap smear equate that with health; they feel that they have done their part in staying healthy, and they have a greater sense of the value of the visit, he said.
Dr. Bohon predicted that both the advancing science and the concerns of patients and physicians will be considered when new guidelines are developed.
“My hope is that we have a realistic view of what the Pap can do,” Dr. Bohon said, adding that she expects that human papillomavirus (HPV) testing will get more and more reliable, and that clinicians will gain experience with following the HPV test and using that as a determining factor in patient care.
Guidelines at a glance
The USPSTF guidelines recommend screening with cytology every 3 years in women aged 21-29 years, and either screening with cytology every 3 years or cotesting using cytology and HPV testing every 5 years in those aged 30-65.
They also recommend against screening after hysterectomy with removal of the cervix in women with no history of high-grade precancer or cervical cancer, and against screening with HPV testing in women younger than age 30, either alone or with cytology.
The ACS/ASCP/ASCCP guidelines recommend a Pap test every 3 years in women aged 21-29 years, with HPV testing only if needed after an abnormal Pap test result. Those aged 30-65 years should have both a Pap test and an HPV test every 5 years, although a Pap test alone every 3 years is also acceptable. Women over age 65 years who have been screened regularly with normal results do not require screening, but those over age 65 years who are diagnosed with cervical precancer should continue to be screened, the guidelines say.
In April, the American College of Physicians in April released its own set of guidelines for screening average-risk women; these guidelines adhere closely to the USPSTF guidelines, and have been endorsed by the American Congress of Obstetricians and Gynecologists and the ASCP (Ann Intern Med. 2015;162[12]:851-9).