In April 2015, the American College of Physicians (ACP) released its clinical advice guideline, Cervical Cancer Screening in Average-Risk Women: Best Practice Advice From the Clinical Guidelines Committee of the American College of Physicians.1 The guideline aims to reduce the overuse of cervical cancer screening in asymptomatic, average-risk women 21 years of age or older and is supported by the American Congress of Obstetricians and Gynecologists and endorsed by the American Society for Clinical Pathology.
The guideline defines women at average risk as those with no history of a precancerous lesion (cervical intraepithelial neoplasia grade 2 or a more severe lesion) or cervical cancer; those who are not immunocompromised, including being HIV infected; and those without in utero exposure to the synthetic estrogen diethylstilbestrol.
The Best Practice Advice guideline is based on a distillation of the best available evidence, including systematic reviews and recent guidelines, and is focused on primary screening rather than on management of abnormal screening test results.
Best Practice Advice Guideline
The clinical guideline includes advice on when to start and stop screening, which screening tests to use, and at what screening interval.
- Clinicians should not screen average-risk women younger than age 21 for cervical cancer.
- Clinicians should start screening average-risk women for cervical cancer at age 21 once every 3 years with cytology (cytologic tests without human papillomavirus [HPV] tests).
- Clinicians should not screen average-risk women for cervical cancer with cytology more often than once every 3 years.
- Clinicians may use a combination of cytology and HPV testing once every 5 years in average-risk women aged 30 years or older who prefer screening less often than every 3 years.
- Clinicians should not perform HPV testing in average-risk women younger than age 30.
- Clinicians should stop screening average-risk women older than age 65 for cervical cancer if they have had three consecutive negative cytology results or two consecutive negative cytology plus HPV test results within 10 years, with the most recent test performed within 5 years.
- Clinicians should not screen average-risk women of any age for cervical cancer if they have had a hysterectomy with removal of the cervix.
Harms of Screening
According to the Best Practice Advice guideline, the harms of screening for cervical cancer can occur at any point along the sequence of care, including during the collection of cervical specimens, diagnostic evaluation, cervical treatments, and post-treatment surveillance. An abnormal screening test result can cause short-term anxiety, including concerns about sexually transmissible infections and their consequences, wrote the authors of the guideline.
Reducing Overuse of Screening
To reduce overuse of cervical cancer screening, the ACP clinical guideline suggests that physicians and other health-care providers know current guidelines and understand the reasoning behind the recommendation of less testing. “The desire to find the right balance between benefits and harms should be familiar to all physicians steeped in a tradition of doing no harm,” said the authors. “One way to explain these new guidelines to women reluctant to be screened less frequently is to be frank about the expected balance of benefits and harms.”
“ACP’s advice for cervical cancer screening is designed to maximize the benefits and minimize the harms of testing,” said David Fleming, MD, MACP, President of the ACP, in a statement. “Historically, physicians have low adherence to cervical cancer screening recommendations, beginning screening too early, performing screening too often, and continuing to screen women at low risk, either by age criteria or after hysterectomy with removal of the cervix.”
As clinicians adhere more strongly to cervical cancer screening guidelines, concluded the article, it is anticipated that the harms and costs of cervical cancer screening will be minimized, and the benefits will be maximized. ■
Disclosure: For full disclosures of the study authors, visit www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-2426.
Reference
1. Sawaya GF, Kulasingam S, Denberg T, et al: Cervical cancer screening in average-risk women. Ann Intern Med. April 30, 2015 (early release online).
