Screening young women before the age of 21 doesn't reduce cervical cancer rates, according to an opinion from the American College of Obstetricians and Gynecologists' Committee on Adolescent Health Care. Because of this, the committee recommended for the first time that cervical cancer screening start at age 21, except in situations that warrant earlier testing.
“The vast majority of adolescent girls should wait until they turn 21 before they have their first Pap test,” Dr. Cheryl B. Iglesia, chair of ACOG's Committee on Gynecologic Practice, said in a statement. “Our guidelines now specify the exceptions to this recommendation,” which include adolescents whose immune systems are compromised by HIV, prior organ transplants, or long-term steroid treatment.
Young women with HIV should get Pap tests twice in the year following their diagnosis with the virus and annually after that. Those with a history of an organ transplant or long-term steroid treatment should be tested every 6 months in the year after they start having sex, followed by annual screening.
Dr. Veronica Gomez-Lobo, director of pediatric and adolescent gynecology at Washington Hospital Center and Children's National Medical Center, also in Washington, said she appreciates that the committee paid particular attention to how to handle adolescents with compromised immune systems—her area of specialty. “I think it makes it very clear for us as clinicians as to what we should be doing,” she said.
Dr. Gomez-Lobo said that waiting until age 21 to screen young women makes sense, given how rare cervical cancer is in that age group. “When we did screen a lot of teenagers, we were not preventing the few cancers that do happen in adolescents,” she said. “Ultimately, many were having excisional procedures that put them at risk for preterm labor in the future.”
The guidelines also specify how physicians should manage women younger than age 21 years who have already had Pap tests and who were found to have dysplasia. Periodic observation is generally safe for those with low- to high-grade precancerous lesions (Obstet. Gynecol. 2010;116:469-72).
For those women whose Pap smear results showed improvement in dysplasia, it's acceptable to wait to rescreen until age 21, although annual screening is also okay.
In those younger women who were found to have cervical intraepithelial neoplasia 3 (CIN 3), however, treatment with cryotherapy, laser therapy, or loop electrosurgical excision is warranted as the natural history of CIN 3 has not been determined.
Adolescents should not be tested for human papillomavirus because the infection tends to resolve on is own most of the time, according to the guidelines. Pregnancy in young women does not alter the recommendations, nor does a diagnosis of a sexually transmitted infection other than HIV.
“While some clinicians will prefer to wait for updated guidelines produced by the U.S. Preventive Services Task Force or the American Cancer Society before changing their practices, it is clear that the momentum of the evolutionary changes will continue in the direction that ACOG has taken,” said Dr. Michael S. Policar, clinical professor of obstetrics and gynecology and reproductive sciences at the University of California, San Francisco.
“The bottom line is that by continuing to screen adolescents for cervical cancer, including those who are pregnant, we risk harming our patients rather than helping them. It's time to abandon this unnecessary practice,” he said.
Disclosures: Dr. Gomez-Lobo reported that she has received an investigator-initiated grant from Merck and is studying the use of Gardasil in transplant patients. Dr. Policar reported having no conflicts of interest.