For the first time in more than a decade, the American College of Obstetricians and Gynecologists (ACOG) has issued important new recommendations concerning the Pap smear, the screening for cervical cancer.
The gist of the new changes: Fewer screenings across the board for women of most age groups, and a later starting date for screenings to begin.
Better understanding of cervical cancer
Many of these changes have come about not only because of the technological changes in cancer screening over the years, but also because scientists now have a better understanding of the development of cervical cancer, says Dr Stanley Zinberg, ACOG's vice president for Practice Activities.
While the guidelines, issued in August, are expected to affect gynaecology practices in the US, not all physicians agree they will ultimately have a woman's best interests in mind.
The issue at stake here is the annual gynaecologic examination - a necessary and important clinical evaluation that, in the minds of many women and even some doctors, has always been intimately linked to the Pap smear, says Dr Steven Goldstein, a professor of obstetrics and gynaecology at New York University School of Medicine.
Pros and cons of new guidelines
By reducing the number of necessary Pap smears, particularly in older women, Goldstein says it's likely the number of annual gynaecological examinations will drop as well. And that, he says, could be highly detrimental to the future of women's health care.
While the new guidelines might result in only a small increase in the number of cervical cancers which go undetected, my fear is that other gynaecological problems, including uterine and ovarian cancer, as well as breast cancer, could suffer much bigger increases when women stop going for their annual examination, which they are likely to do if they no longer need a Pap smear, Goldstein says.
Although ACOG continues to advise women to have an annual pelvic examination, even if a Pap smear is not part of the work-up, Goldstein and others remain wary that the opposite message will be heard.
Back to square one?
It took several decades to get the message out that you need an annual Pap smear before we could get women in for yearly pelvic examinations. And I'm concerned these changes will put us back at square one in terms of protecting women's health, Goldstein says.
Cervical cancer remains among the leading causes of gynaecologic surgery. After breast cancer, cervical cancer is the most common type of cancer among South African women. It is also the most common cause of death from a gynaecologic cancer.
Because cervical cancer is generally slow growing, pre-cancerous changes in the cells can often be identified via a Pap smear. When those cells are treated, says Goldstein, actual cancer rarely develops - one reason a Pap smear is the key to protection.
Past and present recommendations
In the past, yearly Pap smears were recommended, particularly for sexually active women. That's because some strains of the sexually transmitted disease HPV, or human papilloma virus, can cause the cell changes that lead to cervical cancer.
Now, however, ACOG says that, based on new testing for HPV, along with newer, more accurate ways of reading a Pap smear, the annual screening may no longer be necessary.
To help you know what to expect from your doctor - and your examination - here are some of the key ACOG recommendations likely to be implemented by your gynaecologist in the near future:
- First Pap smear: Approximately three years after first sexual encounter, or by age 21, whichever comes first. (Previous recommendation: Age 18).
- Women up to age 30: Annual Pap smear. Because this group has the greatest risk of HPV, yearly testing is still recommended.
- Women over age 30: A negative Pap smear for three consecutive years means future testing is only necessary every two to three years.
- One negative test result using a combined Pap smear and specific HPV test means future screening is necessary every three years thereafter. If one of the two tests is positive, more frequent screening may be necessary.
- Exceptions: Women who are HIV positive, were exposed to DES in utero, or have suppressed immune systems still need yearly testing.
- Women with a hysterectomy: If the cervix is removed, and there is no evidence of malignancy, and no history of abnormal cancerous cell growth, Pap smears can be discontinued.
- If there is a previous history of abnormal cervical cell growth, annual screening is recommended until there are three consecutive negative tests, after which screening can be discontinued.
The new guidelines also stress more individualised treatment of women, with doctors determining on a case-by-case basis who can stop having cervical cancer screenings, and at what age. Important factors to consider include the woman's age, her medical history and health care. This recommendation departs only slightly from that of the American Cancer Society, which calls for stopping screenings in non-high risk women by age 70, and that of the US Preventative Service Task Force, which suggests dropping testing for most women at age 65. - (HealthDayNews)
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