New guidelines on cervical cancer screening: more than just the end of annual Pap testing.

T guidelines on cervical cancer screening published jointly in this Journal [1], in CA: A Cancer Journal for Clinicians, and in the American Journal of Clinical Pathology represent a tremendous policy shift in cancer prevention in the United States. Previous disparate guidelines from the American Cancer Society (ACS), the American College of Obstetricians and Gynecologists (ACOG), and others presented expert consensus that, each hoped, reflected best science. Unfortunately, each was imbued with biases based on experts’ personal experiences and professional interests. Although most had common components, clinicians and women were easily confused by disparities among guidelines. Noncompliance was rampant [2]. The current guidelines are an attempt by national societies and federal agencies to address these defects by developing common guidelines incorporating best evidence through a defined process. The result is a remarkable step forward that nevertheless reflects the conflicts and compromises that accompanied its creation. Dogmatic advocates of evidence-based medicine may be disappointed, but clinicians should celebrate. The guideline development process was complicated. The steering committee was created by leaders in the American Society for Colposcopy and Cervical Pathology, the ACS, and the American Society for Clinical Pathology; membership in the steering committee changed during the roughly 2 years that the group was active. Six working groups assessed relevant screening issues. Literature review followed, supported by reviews from the leading evidence-based practice centers developed by the federal Agency for Health Care Research and Quality in preparation for the March 2011 US Preventive Services Task Force (USPSTF) meeting. Identified relevant articles were graded using standardized criteria under the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system for guideline development [3]. Draft guidelines were posted to the World Wide Web and revised after a comment period. After several delays, revised guidelines were presented at a consensus meeting in Rockville, Maryland, held on November 17 to 19, 2011, which included representatives from the 3 sponsoring organizations and 24 participating organizations. All accepted guidelines were approved by at least 66% of those attending. Approved guidelines were refined by a central writing group for publication. To summarize the recommendations, screening should begin at age 21 years with cytology, continuing at 3-year intervals through age 29 years. For women ages 30 to 65 years, cotesting every 5 years using both cytology and a test for DNA from carcinogenic human papillomavirus (HPV) is preferred, although cytology at 3-year intervals remains acceptable. Primary screening with HPV DNA testing alone is attractive but not yet ready for use in the US. Screening should stop at the time of hysterectomy for benign disease or at age 65 years for adequately screened women. Reprint requests to: L. Stewart Massad, MD, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, School of Medicine, Washington University, 4911 Barnes-Jewish Hospital Plaza, St Louis, MO 63110. E-mail: massadl@wudosis.wustl. edu