Cervical Cancer Screening: Primum Non Nocere
Authors: Nora Kizer, Jeffrey F. Peipert
Journal: Annals of Internal Medicine (2012)

Editorials19 June 2012Cervical Cancer Screening: Primum Non NocereFREENora Kizer, MD, MSCI and Jeffrey F. Peipert, MD, PhDNora Kizer, MD, MSCIFrom Washington University in St. Louis School of Medicine, St. Louis, MO 63110.Search for more papers by this author and Jeffrey F. Peipert, MD, PhDFrom Washington University in St. Louis School of Medicine, St. Louis, MO 63110.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-156-12-201206190-00425 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail The Hippocratic Oath cautions us to abstain from doing harm. We must remember this basic tenet of our profession as we address new evidence and guidelines for cervical cancer screening. The purpose of screening is to identify at-risk individuals and to enable early intervention to reduce mortality and suffering. As such, screening should fit the ideal of doing no harm, yet providing substantial benefit.However, screening tests can unintentionally cause significant harm. False-positive test results can lead to overdiagnosis; misdiagnosis; and the potential for unnecessary diagnostic testing, procedures, and treatments and their inherent risks. For these reasons, screening tests, especially for a disease with a low incidence, must have high sensitivity in addition to acceptable specificity. Tradeoffs of increased sensitivity for decreased specificity can shift the balance of benefits and harms.It is important to consider these issues as one reads the U.S. Preventive Services Task Force (USPSTF) most current recommendations for cervical cancer screening in this issue (1). The American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology (ACS/ASCCP/ASCP) have also published new joint cervical cancer prevention guidelines based on a broadly attended consensus conference (2). These 2 sets of recommendations are largely congruent and are important steps forward to maximally efficient and effective cervical cancer screening. Health care providers should welcome these new recommendations with enthusiasm and incorporate them into routine clinical practice.The USPSTF and the ACS/ASCCP/ASCP guidelines agree that there are no clinically important differences between conventional and liquid-based cytology. Both guidelines state that cervical cancer screening should not begin until age 21 regardless of sexual activity. Women aged 21 to 29 years should be screened at 3-year intervals with cytology alone. Testing for human papillomavirus (HPV) should not be part of screening in this age group because the virus is highly prevalent and cytologic abnormalities are often transient. Only persistent oncogenic HPV infection increases the risk for cervical intraepithelial neoplasia (CIN) grade 3 and invasive cancer.However, the guidelines differ slightly in their recommendations for women aged 30 to 65 years. The ACS/ASCCP/ASCP recommendations state that the preferred method of screening is cytology with HPV testing (“cotesting”) at 5-year intervals. Use of cytology at 3-year intervals is also “acceptable,” especially if access to HPV testing is not practical. The USPSTF guidelines state that both methods provide similar benefits and advocate cotesting for women who desire to lengthen the screening interval. The ACS/ASCCP/ASCP guidelines also note that there is insufficient evidence to change screening intervals in this age group in women with a history of negative screenings.The guidelines concur that women aged 65 years or older who have been adequately screened and have no history of CIN2 or greater do not need to continue cervical cancer screening regardless of sexual activity. Adequate screening consists of negative results on 2 screenings in the past 10 years, with 1 screening occurring in the past 5 years. Women who have had a hysterectomy and do not have a history of CIN2 or greater should not have screening.Unlike the USPSTF recommendations, the ACS/ASCCP/ASCP guidelines address women who have received the HPV vaccine, recommending that they continue routine screening. Although evidence shows the vaccine to be highly effective at preventing HPV 16/18–associated CIN3+ lesions in individuals not infected with HPV, 30% of cases of cervical cancer are attributable to other HPV strains. In addition, the vaccine's true duration of coverage is unknown, which is of particular concern for women who received vaccination during early adolescence. Future evidence may show that less frequent screening is appropriate for vaccinated women, but given the limitations of current research and the low vaccination coverage among U.S. adolescents prior to first intercourse, the screening protocol should be the same for both vaccinated and unvaccinated women.In light of these new recommendations, it is worth highlighting several key public health messages. Although improved screening guidelines are commendable, approximately 50% of cases of cervical cancer are diagnosed in either the unscreened population or women who have not been screened for 5 or more years. Health care and public health professionals must place a high priority on increasing the proportion of women who receive appropriate screening. Strategies should include public education and awareness campaigns, programs to promote provider adherence to screening guidelines, and improved access to health care services. Reduction of cervical cancer morbidity and mortality will also require novel strategies for screening and treatment of identified abnormalities. Self-collected swabs for HPV testing in high-risk patients with subsequent cytology triage is one such strategy that holds promise for addressing the disparities in cervical cancer screening (3).Health care providers and patients may be reluctant to adopt the longer screening intervals recommended in the new guidelines. We believe that it is paramount for health care providers to take the initiative in fostering this change and acceptance. More frequent screening than recommended not only offers no benefit but can cause harm. Both the USPSTF and ACS/ASCCP/ASCP clearly state that more frequent screening causes significant harm in terms of short-term psychological stress, vaginal bleeding and infection, and potential adverse pregnancy outcomes. These harms come at little to no benefit in reduction of CIN3 and cervical cancer. Screening is unnecessary and can cause harm in women younger than 21 years of age. Annual cytologic testing is no longer recommended. Again, the harms outweigh the benefits. Adhering to these recommendations will require a change in thinking as we move past annual Papanicolaou (Pap) testing from very young to very old ages to longer screening intervals that incorporate use of HPV testing where indicated. As many women have used the annual Pap test screening visit as an opportunity to address and discuss other health problems and receive other preventive measures, it will be important for clinicians and health care systems to devise methods to ensure continued care for other primary care concerns appropriate to each age group.Promotion of the HPV vaccine before first intercourse, when prophylactic vaccination is most beneficial, is another important prevention message. The United States lags far behind other health care systems, such as those in Australia and the United Kingdom, with only 32% of eligible women who have received the complete HPV 16/18 vaccine (4). Vaccinating young women before the onset of sexual activity should be encouraged (5).Future work should focus on appropriately acknowledged research gaps. These include the following: identifying novel strategies to increase screening coverage in unscreened and underscreened women; evaluating how to modify screening practices among HPV-vaccinated women and women of different risk groups (e.g., number of sexual partners); assessment of the role of HPV testing alone compared with cotesting; and additional longitudinal studies of older women to determine the optimal age to stop screening women who test negative for HPV. Because the new guidelines require clinician acceptance and subsequent changes in behavior, it will be useful to follow the degree to which health care providers follow the guidelines and the reasons for noncompliance, especially short-interval screening.Overall, the new recommendations from the USPSTF and ACS/ASCCP/ASCP are compatible and appropriate. They reflect well-thought-out decision-making based on new, increased understanding of the natural history of HPV infection and cervical carcinogenesis. We should embrace the guidelines and strive to incorporate them into routine practice. Promotion of HPV vaccination before first intercourse and expanding screening to reach the most vulnerable populations at highest risk for cervical cancer should be public health priorities.Nora Kizer, MD, MSCIJeffrey F. Peipert, MD, PhDWashington University in St. Louis School of MedicineSt. Louis, MO 63110References1. Moyer VA; U.S. Preventive Services Task Force. Screening for cervical cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012;156:880-91. LinkGoogle Scholar2. Saslow DS, Solomon D, Lawson HW, Killackey M, Kulasingam SL, Cain J, et al. American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer. CA Cancer J Clin. 2012. [Forthcoming]. Google Scholar3. Castle PE, Rausa A, Walls T, Gravitt PE, Partridge EE, Olivo V, et al. Comparative community outreach to increase cervical cancer screening in the Mississippi Delta. Prev Med. 2011;52:452-5. [PMID: 21497619] CrossrefMedlineGoogle Scholar4. Centers for Disease Control and Prevention (CDC). National and state vaccination coverage among adolescents aged 13 through 17 years—United States, 2010. MMWR Morb Mortal Wkly Rep. 2011;60:1117-23. [PMID: 21866084] MedlineGoogle Scholar5. Castellsagué X, Díaz M, de Sanjosé S, Muñoz N, Herrero R, Franceschi S, et al; International Agency for Research on Cancer Multicenter Cervical Cancer Study Group. Worldwide human papillomavirus etiology of cervical adenocarcinoma and its cofactors: implications for screening and prevention. J Natl Cancer Inst. 2006;98:303-15. [PMID: 16507827] CrossrefMedlineGoogle Scholar Comments 0 Comments Sign In to Submit A Comment Author, Article, and Disclosure InformationAuthors: Nora Kizer, MD, MSCI; Jeffrey F. Peipert, MD, PhDAffiliations: From Washington University in St. Louis School of Medicine, St. Louis, MO 63110.Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M12-0639.Corresponding Author: Jeffrey F. Peipert, MD, PhD, Washington University in St. Louis School of Medicine, 4533 Clayton Avenue, Campus Box 8219, St. Louis, MO 63110; e-mail, peipertj@wustl.edu.Current Author Addresses: Drs. Kizer and Peipert: Washington University in St. Louis School of Medicine, 4533 Clayton Avenue, Campus Box 8219, St. Louis, MO 63110. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoScreening for Cervical Cancer: U.S. Preventive Services Task Force Recommendation Statement Virginia A. Moyer , on behalf of the U.S. Preventive Services Task Force* Metrics Cited byRationale and design of the research project of the South Florida Center for the Reduction of Cancer Health Disparities (SUCCESS): study protocol for a randomized controlled trial 19 June 2012Volume 156, Issue 12 Page: 896-897 Keywords Age groups Cell biology Cervical cancer Cervical cancer screening Health care Health care providers Human papillomavirus Human sexual behavior Prevention, policy, and public health Vaccines ePublished: 19 June 2012 Issue Published: 19 June 2012 Copyright & PermissionsCopyright © 2012 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...