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  PAP/NGC Program Review

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cap today

May 2003
Special Section:
PAP/NGC Program Review

Cervical cancer screening guidelines—then and now

Dina R. Mody, MD

Nearly 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.

“Regardless 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.”

Cervical 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.

References

  1. 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.
  2. 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.
  3. 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.
  4. Fink DJ. Change in American Cancer Society checkup guidelines for detection of cervical cancer. CA Cancer J Clin. 1988;38:127-128.
  5. 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.
  6. 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 Gynaecol. 1992;99:907-910.
  7. Kim JJ, Wright TC, Goldie SJ. Cost effectiveness of alternative triage strategies for atypical squamous cells of undetermined significance. JAMA. 2002;287:2382-2390.
  8. 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.
  9. 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.
  10. Lorincz AT, Richart RM. HPV DNA testing as an adjunct to cytology in cervical screening programs. Arch Pathol Lab Med, in press.

Dr. Mody, 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.