PAP/NGC Program Review
Cervical cancer screening guidelines—then and now
Dina R. Mody, MD
all cervical cancers contain human papillomavirus, and a
persistent infection with high-risk HPV is a major risk factor.
High-grade squamous intraepithelial lesions, or HSIL, are considered
significant precancerous lesions. Most HPV infections are transient,
however, and regress spontaneously.1,2 Such transient
HPV infections may be asymptomatic or produce low-grade cytologic changes.
In 2001 and
2002, the American Cancer Society convened an expert panel that
was divided into working groups to review evidence and formulate
recommendations about when to start screening, when to discontinue
it, screening of women with hysterectomy, screening intervals, and
screening tests. The ACS published the revised cervical cancer screening
guidelines in late 2002.3 The new guidelines take into
account new technologies for cervical cytology screening and the
current state of knowledge of the underlying etiology for cervical
cancers and intraepithelial lesions. Click
here for a comparison of the guidelines published in 19884
and the new 2002 guidelines and the rationale behind the recommendations.
CAP policy on cervical cancer screening
The CAP’s policy on screening for cervical cancer was revised
earlier this year. It reads as follows: “The College of American
Pathologists encourages annual pelvic exams and regular cervical
cancer screening for all women. Regular cervical cancer screening
should begin three years after women become sexually active or by
the age of 21. Current data indicate that most women under the age
of 30 will benefit from annual cervical cancer screening. Lengthened
intervals of cervical cancer screening may be appropriate for some
women, depending upon specific clinical circumstances.
of age, the appropriate screening interval should be determined
by each patient in consultation with her physician, taking into
account detailed patient history and risk factors. A woman’s
human papillomavirus status may be a contributing factor in determining
cervical cancer screening frequency. When accuracy or completeness
of the historical record is in doubt, annual screening should be
the default screening interval.”
adenocarcinomas and screening
The incidence of cervical adenocarcinomas has been increasing. There
is little data on the efficacy of cervical cytology as a screening
and detection tool for adenocarcinomas. Use of the endocervical
brush and new liquid-based technologies may increase the sensitivity.
Whether better endocervical sampling devices or new liquid-based
technologies actually increase detection of cervical adenocarcinomas
and precursor lesions is not yet known.
For a perspective on the process the ACS used to formulate the new guidelines and
on the recommendations themselves, see “Too
much emphasis on screening interval, too little on safety,”
by R. Marshall Austin, MD, PhD.
- Moscicki AB, Shiboski S, Broering J, et al. The natural history of human
papillomavirus infection as measured by repeated DNA testing in
adolescent and young women. J Pediatr. 1998;132: 277-284.
- Ho GY, Bierman
R, Beardsley L, et al. Natural history of cervicovaginal papillomavirus
infection in young women. N Engl J Med. 1998;338:423-428.
- Saslow D, Runowicz C, Solomon D, et al. American Cancer Society Guidelines
for the early detection of cervical neoplasia and cancer. CA
Cancer J Clin. 2002;52:342-362.
- Fink DJ. Change in American Cancer Society checkup guidelines for detection
of cervical cancer. CA Cancer J Clin. 1988;38:127-128.
- Centers for Disease Control. CDC Guideline for Immunocompromised Individuals;
USPHS/IDSA guidelines for the prevention of opportunistic infections
in persons infected with HIV: a summary. MMWR Morb Mortal
Wkly Rep. 1995; 44(rr-8):1-34.
- Wiener JJ, Sweetnam PM, Jones JM. Long-term follow-up of women after hysterectomy
with a history of preinvasive cancer of the cervix. BR J Obstet
- Kim JJ, Wright TC, Goldie SJ. Cost effectiveness of alternative triage
strategies for atypical squamous cells of undetermined significance.
- Goldie SJ, Kim JJ, Wright TC. Decision analytic modeling to inform U.S. national
health policy: new guidelines for cervical screening. Oral presentation
at the national SMDM meeting 2002.
- Sherman ME, Lorincz AT, Scott DR, et al. Baseline cytology and HPV testing
and risk for cervical neoplasia: a ten year cohort analysis of
20810 women. J Natl Cancer Inst. 2003;95:46-52.
- Lorincz AT, Richart RM. HPV DNA testing as an adjunct to cytology in cervical
screening programs. Arch Pathol Lab Med, in press.
chair of the CAP Cytopathology Committee, is professor of pathology,
Baylor College of Medicine, Houston, and director of cytopathology
at Baylor and Methodist Hospital, Houston.