Cervical cancer screening used to be easy – they came once a year, I did a pap. High risk patients with abnormal paps stayed at the top of my radar because they came more frequently or had procedures. If they managed to slip under the radar, we caught them at their annual.
Now, with new consensus guidelines for pap smear screening, every patient is different. (Of course, they always were, but you get my point).
- Under age 21 – No pap. No HPV Testing. (That one’s easy…)
- Age 21-29 – Pap every 3 years. No HPV unless pap abnormal.
- Ages 30-65 – Pap every 3 years, or Pap + HPV every 5 years.
- Age 65 and older – If no history cervical pre-cancer, we can stop paps.
- Cervical pre-cancer at any age – Manage individually.
How I feel About the New Pap Smear Recommendations
Overall, I think we are moving in the right direction, but I must admit that I am not entirely comfortable with every aspect of the new guidelines.
I do like the “no paps before age 21” recommendation. Cervical cancer is exceedingly rare in this age group, and has not declined appreciably with increased screening. And there is nothing less fun for patient or doctor than a colposcopy in a teenager. Which does not mean I won’t slip in an occasional pap a year or two early in a young woman who initiated sexual activity at a very young age (like before age 16). These kids worry me.
I’m not so enamored with jumping right into every 3 year screening (as opposed to having three normal annual paps first) starting at age 21. That recommendation is based mostly on modeling and not real world results, and accepts a small increase in the number of cervical cancers in return for less colposcopies. I also worry that an every three year pap will turn into every five years, especially as we move towards longer acting contraceptives at the same time. This could increase the rates of cancers further in this group. Finally, I’d also argue that we’ve already made huge strides towards decreasing over-treatment by observing rather than treating low grade lesions in this age group. If it had been up to me I think I would have kept annual paps in this group, at least for three years before heading off to every three year paps.
This stands in contrast to the expected outcomes in women ages 30-65, where adding co-testing for HPV leads to better pre-cancer diagnosis and less cervical cancers – I like that a lot.
I also admit that I am having a bit of a problem thinking about stopping paps in healthy 65 year olds who are having new sexual partners and may be acquiring new HPV infections. The guidelines advise not to take sexual history into consideration in this age group, but I wonder if this is based on data from a world before the baby boomers found Match.com. In having discussions with such women about stopping paps, I find myself ordering an HPV test for reassurance before backing off. And thinking about readdressing the question in 5 years or so based on interval sexual history.
I’m still waiting to see what ACOG comes up with. They wrote in support for the new recommendations, but have yet to publish their own.
Doing less paps sounds simple, but the reality is that it takes more time
Not a lot of time, but in the era of the 15 minute office visit, every minute is precious.
Actually doing the pap takes a few seconds. But deciding whether or not to do the pap takes much longer. In order to determine which screening group a given patient falls into, I now have to go back and look at all her paps, review her history and figure out where we are in a given year on her screening scedule. That takes a few minutes.
Asking women to keep track is not always so helpful. You’d be surprised how many don’t know what their pap results were or how they may have been treated for abnormalities in the past. Getting old records is not always easy. The annual pap was always a great fallback position when there was uncertainty in the history.
At this point in time, my EMR has no ways of flagging the pap screening interval for me. (It still thinks I’m on an annual screening schedule with everyone.) So I’ve come up with little notes to myself in the assessment and plan – thinks like a macro that says “no hx abnormal paps, HPV neg, paps every 3-5 years”. Next visit I can see this and carry it forward. Or putting a pap flag in the problem list – though it really isn’t a problem, is it? Until I get off schedule because I’ve lost track, that is.
Patients have their own issues with the new recommendations
Some are thrilled to have one less test. Others, not so much. Needless to say, we’re having a lot of conversations during visits about the new guidelines, which takes – let’s say it shall we? – time.
I’m not arguing that we need to to go back to one size fits all annual screening
Every woman is an individual, and deserves to be treated as such. The new recommendations demand that we consider each woman’s risk of cervical cancer and weigh it against the harms of over-treatment in her age group. Overall, the risk-benefit ratio is favorable, but it does accept a small increase in cervical cancers in the age 21-29 age group, and a very very small number of expected cancers in the over 65 crowd without allowing for consideration of other risk factors such as sexual activity. I’m not convinced that’s a trade off worth making. Unlike mammograms, which have had a limited impact on breast cancer mortality and none on its incidence, pap smears actually prevent cancer. I wish we could have moved just a tad more slowly before making such sweeping changes.
How do you feel about the new pap recommendations?
If you’ve come up with any little tricks for using your EMR to track individualized pap intervals for your patients, let us know in the comments section.