Though current cervical cancer screening guidelines generally recommend that women ages 30 and older get screened — either using a traditional pap smear or a complement of a pap smear and human papillomavirus testing — every 2 to 3 years instead of annually, a new survey published this week in the Archives of Internal Medicine finds that most physicians recommend screening far more frequently.
Cancer groups agree that high-risk women — such as those with a weakened immune system due to HIV or another condition, or who have had previous cervical abnormalities— should be screened more frequently, and for the most part there is consensus that women be screened less often after age 30. The American Cancer Society (ACS) recommends that women be screened annually throughout their 20s and should first be screened no later than age 21, but ideally within 3 years of first vaginal intercourse. At age 30, they suggest physicians incorporate both Pap smears and HPV testing for screening, and that women who have had 3 normal Pap results in a row delay screenings to once every 2 to 3 years. The American College of Obstetricians and Gynecologists (ACOG) recently changed its recommendations to suggest that young women begin cervical cancer screening at age 21, regardless of their age at first vaginal intercourse. ACOG also recommends that women ages 30 and older who have had 3 years of consecutive negative cervical cancer results delay screening to once every 3 years. Additionally, both ACS and ACOG have said that the addition of HPV co-testing strengthens the argument for less frequent screening. The U.S. Preventive Services Task Force has recommended screening once every three years for women ages 30 and older, and has not yet issued guidelines regarding the incorporation of HPV testing into cervical cancer screening protocol.
For the survey researchers from the Centers for Disease Control (CDC) and the National Cancer Institute asked more than 1,200 primary care physicians — including general practitioners, family medicine specialists, internists and obstetricians-gynecologists — what screening protocol they would recommend for 35-year-old patients with three different medical histories: a woman had had no new sex partners in the previous 5 years and had 3 normal Pap results in a row; a woman with no new sexual partners in the past 5 years and 1 normal Pap result; and a woman who’d had a negative HPV test and a normal Pap test result previously that year.
Despite current guidelines, however, researchers found that fewer than one third (31.8%) of physicians surveyed would delay screening to once every three years for a patient with no new sexual partners in the previous 5 years and 3 consecutive Pap results. For the scenario in which the patient had a similar sexual history but only 1 negative Pap result, the vast majority of physicians (81%) said they would recommend screening within a year of the last test. Additionally, researchers found that the tendency to recommend sooner screenings was most pronounced among obstetricians and gynecologists. In the scenario with 3 negative Pap tests in a row, 46.1% of Ob-Gyn doctors said they would recommend annual screening, compared to 30.7% of family physicians and 22.4% of internists. When the hypothetical patient history indicated just one negative Pap result, 89.1% of Ob-Gyn, 82.2% of family physicians and 72.% of internists said they would recommend screening no sooner than 3 years.
Incorporating HPV testing — which studies have suggested may be a more precise indicator of cervical cancer risk — into cervical cancer screening — didn’t dissuade doctors from recommending frequent screenings, the researchers found. For the scenario of a 35-year-old woman with a current normal Pap result and negative HPV test, fewer than 1 in 5 physicians (19%) surveyed said they conduct the next screening after at least 3 years. The majority of doctors surveyed (78%), said they would recommend another Pap again sooner.
The findings, the authors say, suggest that revised guidelines haven’t convinced physicians to spread out cervical cancer screenings when incorporating HPV tests or for patients with consistently negative Pap smears. Too often, they say, women are being screened too often — which can lead to more tests, unnecessary worry, and increased health care costs. They conclude that, extrapolating from the survey results:
“… the practice patterns we found in our study are likely to increase costs with little improvement in reducing cervical cancer incidence and increasing survival. Overuse of screening is expensive for the health care system and may result in unnecessary follow-up testing, increased risk of colposcopy-associated morbidities and adverse birth outcomes, and distress for patients. Evaluation of the cost-effectiveness of Pap and HPV cotesting strategies as implemented, along with other considerations, may be useful before resource-limited institutions choose one strategy over the other.”
In an accompanying editorial, Dr. George Sawaya, an associate professor of obstetrics, gynecology and reproductive sciences at the University of California, San Francisco, says that future study is needed to gain a more accurate picture of physicians’ adherence to screening guidelines, and that, ultimately, physicians need to be careful to find the right balance when it comes to fulfilling the oath to do no harm. To that end, he says longer intervals between screenings for low-risk women is a good place to start, and that this latest study should add to ongoing efforts to develop “rational approaches to screening.”