New Recommendations: Less Frequent Pap Testing!
Consistently (and sheepishly) I reveal to my patients the ever-changing landscape of recommended testing and screening. Immunization guidelines are updated frequently, always heralding more shots. For instance, new goals for cholesterol mean more testing and more medication prescribed. There seems to be more, more, and more intervention. And so, it is with pleasure, that I highlight new, more "hands-off" recommendations for pap testing.
History and Progress
The pap test has been performed since the 1950's as a means to screen for cervical cancer and it has proven to be extremely effective. Once one of the most frequent causes of death in women, cervical cancer has been pushed toward the bottom of the list thanks to pap testing. Since the pap's inception, science has advanced our knowledge of cervical cancer.
We know the following:
- Human Papilloma Virus (HPV) is the only cause of cervical cancer
- Genital HPV is contracted via skin to skin contact
- Most HPV infections are transient, lasting 1-2 years. In other words, the body eventually fights off the virus.
- Pre-cancerous changes usually peak in a population a few years after the median age of first sexual contact (17 years of age in the U.S.).
The goal in screening is to prevent death and sickness from cervical cancer. With the pap test, this has been achieved. We are now facing a secondary goal: to hone treatment, minimizing unnecessary treatment, without sacrificing the efficacy of the pap. The culmination of recent research accomplishes this goal.
Screening should begin at age 21 in sexually active women, regardless of when sexual activity begins. The rationale behind this is that most all HPV infections clear spontaneously in young, healthy women.When screened at age 21, those who do not clear the infection will be far enough along in the process (although not yet progressed to cancer) to warrant treatment. My personal policy is to not perform a pap on a woman who has not had sexual relations - no exposure means no risk.
Subsequent Pap Testing
If a previous test was normal, pap testing should occur every 3 years between the ages of 21 and 30. In this age group, the pap test only should be done without testing for HPV.
With pap testing, the cells are examined for abnormalities. In addition, there is an option to perform HPV testing on the specimen. In this 21-30 age group, only the pap test (without HPV testing) is necessary. After the age of 30, if the previous test was normal, subsequent testing should occur within 5 years. In this age group, both a pap test and HPV testing should occur on the swab specimen of the cervix.
The rationale for this is based on demographics and occurrence, along with rates of HPV progression. Again, most HPV infections are transient in these age groups.
Cessation of Pap Testing
Guidelines now call for no further pap testing after the age of 65 regardless of sexual activity. Although, an important note needs to be made that these pap guidelines are for women with previously normal pap testing. If a woman has an abnormal pap and has been shown to have cleared the infection with a normal pap and HPV test, she is back into the guidelines for previously negative pap testing as outlined above.
These days, life is a little bit easier for women in regards to cervical cancer screening. At the outset, given the timing of the recommendations with "Obamacare" and major overhauls in healthcare, it's seems as though screening is being dangerously watered down. However, after reviewing the research, I can say that these new guidelines are a sound balance of good care without too much in the form of unnecessary pap testing.
Keep in mind that these guidelines are new. Many doctors have not embraced or been exposed to them. Arm yourself with knowledge if you are due for annual exam.
Saslow, D.; et al. "American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology Screening Guidelines for the Prevention and Early Detection of Cervical Cancer." Journal of Lower Genital Tract Disease, 16.3 (2012) : 175-204. Print.