American College of Physicians Releases Best Practice Advice for Cervical Cancer Screening in Average-Risk Women

By Jo Cavallo
Posted: 5/1/2015 11:32:43 AM
Last Updated: 5/1/2015 11:32:43 AM

Key Points:
  • The American College of Physicians advises that physicians should start screening average-risk women for cervical cancer at age 21 and then once every 3 years with cytology tests alone.
  • Physicians should stop screening average-risk women 65 and older for cervical cancer if they have had three consecutive negative cytology results or two consecutive negative cytology plus HPV test results within 10 years, with the most recent test performed within 5 years.
  • Physicians should not perform HPV testing in average-risk women younger than age 30 or screen average-risk women of any age for cervical cancer if they have had a hysterectomy with removal of the cervix.
  • More In Depth

The American College of Physicians (ACP) released its clinical advice for cervical cancer screening in asymptomatic, average-risk women 21 years or older. Women at average risk are defined as those with no history of a precancerous lesion (cervical intraepithelial neoplasia grade 2 or a more severe lesion) or cervical cancer; those who are not immunocompromised, including being HIV infected; and those without in utero exposure to the synthetic estrogen diethylstilbestrol. The guideline covers seven areas, including when to start and stop screening, which screening tests to use, and at what screening interval. The clinical guideline is published in the Annals of Internal Medicine.

Methods

The Best Practice Advice guideline is based on a distillation of the best available evidence, including systematic reviews and recent guidelines, and is focused on primary screening rather than on management of abnormal screening test results. It is supported by the American Congress of Obstetricians and Gynecologists and endorsed by the American Society for Clinical Pathology.

Best Practice Advice Guideline

ey Points

  • The American College of Physicians advises that physicians should start screening average-risk women for cervical cancer at age 21 and then once every 3 years with cytology tests alone.
  • Physicians should stop screening average-risk women 65 and older for cervical cancer if they have had three consecutive negative cytology results or two consecutive negative cytology plus HPV test results within 10 years, with the most recent test performed within 5 years.
  • Physicians should not perform HPV testing in average-risk women younger than age 30 or screen average-risk women of any age for cervical cancer if they have had a hysterectomy with removal of the cervix.

The American College of Physicians (ACP) released its clinical advice for cervical cancer screening in asymptomatic, average-risk women 21 years or older. Women at average risk are defined as those with no history of a precancerous lesion (cervical intraepithelial neoplasia grade 2 or a more severe lesion) or cervical cancer; those who are not immunocompromised, including being HIV infected; and those without in utero exposure to the synthetic estrogen diethylstilbestrol. The guideline covers seven areas, including when to start and stop screening, which screening tests to use, and at what screening interval. The clinical guideline is published in the Annals of Internal Medicine.

Methods

The Best Practice Advice guideline is based on a distillation of the best available evidence, including systematic reviews and recent guidelines, and is focused on primary screening rather than on management of abnormal screening test results. It is supported by the American Congress of Obstetricians and Gynecologists and endorsed by the American Society for Clinical Pathology.

Best Practice Advice Guideline

  1. Clinicians should not screen average-risk women younger than 21 years for cervical cancer.
  2. Clinicians should start screening average-risk women for cervical cancer at age 21 once every 3 years with cytology (cytologic tests without human papillomavirus [HPV] tests).
  3. Clinicians should not screen average-risk women for cervical cancer with cytology more often than once every 3 years.
  4. Clinicians may use a combination of cytology and HPV testing once every 5 years in average-risk women aged 30 years or older who prefer screening less often than every 3 years.
  5. Clinicians should not perform HPV testing in average-risk women younger than 30 years.
  6. Clinicians should stop screening average-risk women older than 65 years for cervical cancer if they have had three consecutive negative cytology results or two consecutive negative cytology plus HPV test results within 10 years, with the most recent test performed within 5 years.
  7. Clinicians should not screen average-risk women of any age for cervical cancer if they have had a hysterectomy with removal of the cervix.

According to the Best Practice Advice article, the harms of screening for cervical cancer can occur at any point along the sequence of care, including the collection of cervical specimens, diagnostic evaluation, cervical treatments, and post-treatment surveillance. An abnormal screening test result can cause short-term anxiety, including concerns about sexually transmissible infections and their consequences, said the article’s authors.

Reducing Overuse of Cervical Cancer Screening

To reduce overuse of cervical cancer screening, the ACP article suggests that physicians and other health-care providers know current guidelines and understand the reasoning for the recommendation of less testing. “The desire to find the right balance between benefits and harms should be familiar to all physicians steeped in a tradition of doing no harm,” said the authors. “One way to explain these new guidelines to women reluctant to be screened less frequently is to be frank about the expected balance of benefits and harms.”

“ACP’s advice for cervical cancer screening is designed to maximize the benefits and minimize the harms of testing,” said David Fleming, MD, MACP, President of the ACP, in a statement. “Historically, physicians have low adherence to cervical cancer screening recommendations, beginning screening too early, performing screening too often, and continuing to screen women at low risk, either by age criteria or after hysterectomy with removal of the cervix.”

As clinicians adhere more strongly to cervical cancer screening guidelines, concluded the authors, it is anticipated that the harms and costs of cervical cancer screening will be minimized and the benefits will be maximized.

George F. Sawaya, MD, of the University of California San Francisco Helen Diller Family Comprehensive Cancer Center, is the corresponding author of this paper

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