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.
Easy.
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.
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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.
Your blog posts are always wonderful, and they have been especially informative and well researched recently. Thanks!
The ACOG / USPSTF recommendations currently say not to do HPV testing under age 30, as far as I know, even if the cytology is abnormal: http://www.acog.org/About_ACOG/Announcements/New_Cervical_Cancer_Screening_Recommendations
Am I correct that the ACS recommendation are slightly different? (Which is not unheard of, they are different when it comes to mammography initiation and frequency, for example.)
If these ACS recommendations accept a higher rate of cervical cancer in the 20 – 29 group, I wonder what the effect of reflexive HPV testing will have on cancer detection in that age group.
What do you think of scheduling annual appointments for bimanual exams and counseling? I think bimanuals are still recommended yearly. How would that work, practically?
MomTFH –
USPSTF recs are for screening, not managing abnormal paps. HPV is not used for screening in the under 30 crowd, but still has a role in triaging abnormal pap smears in women over age 21. (Not in the under age 21 crowd)
Table 1 in the linked Oncology article is pretty clear on the role of HPV testing in management of abnl paps if you want a good reference. Also check out the ASCCP pap guidelines, which they referenced in the Oncology table.
http://download.journals.elsevierhealth.com/pdfs/journals/0002-9378/PIIS0002937807009301.pdf
ACOG has not come out with new recs, unless I missed something very recent.
There is no role for screening HPV testing in the under 30 crowd. They all have HPV and almost always will clear it. It would lead to much over diagnosis and over screening if HPV were added to routine screening.
As to how the annual exam will evolve over time, it will be interesting to see. I don’t know that there is anything magic about a 12 month interval. I do know I do a lot more than pap smears in my annual visits. But we will see.
Thanks for your comment.
MMP
Dr. P,
Thanks for the informative post, but I do have one small quibble — your comment that under-30s “all” have HPV. Although I am now 31, thus would escape this categorization, as a young woman wh was a virgin until a rape at 21, then abstained until marriage at 26. Going to the OB/GYN for check-ups was incredibly embarassing because of assumptions like yours about my behaviors and history. Especially after the rape, when I did know that I was at risk for STIs, I was humiliated by nurses and doctors who just assumed I had been sexually active in the past.
Certainly I understood that the doctor could not “take my word for it” in terms of skipping important tests or differential diagnoses, since that would open her up to potential liability, but the casual assumptions and stereotyping really put up barriers to my post-rape care. I was very devestated by the rape being my first sexual experience, and it contributed to my trauma to have the doctor dismiss that part of the trauma as irrelevant (and she made it clear she thought I was probably lying about my prior virginity, anyway).
Not all young people are sexually active or have multiple partners, and it can make an already traumatic situation even more difficult when there is that stereotyping going on.
Anyway, that’s my $.02 on the situation. Thanks for an interesting post.
Allison –
You are right – I should not have said “all”. “Most will acquire at least one HPV infection” would have been the correct way to state it. I was speaking about this age group on a population basis – not an individual one. It is on this population basis that the recommendations are made.
However, even virgins till marriage can acquire HPV. It does not require intercourse for transmission. Which brings up the important point that having HPV means absolutely nothing about a person’s morality or behavior. It is just a virus looking for a mucous membrane to infect. IN my opinion, having HPV says nothing more about a person that having a cold.
Which does not mean that one should not limit ones’s partners – that’s simple math.
Sorry for what you had to go through, both personally and with your docs.
Thanks for reading and for your comments.
Peggy
I wonder how it’s going to change women going into the doctor for regular check-ups. For me, the annual pap was the main reason I’d actually bother to make an appointment. Not that I wanted a pap, but that it served as a reminder kind of like getting a dental cleaning every 6 months.
NIcoleandmaggie –
It will be interesting to see how this plays out. I know this past week I saw a patient who had not been in for 5 years. “I heard you didn’t need a pap every year, but then I lost track” was her comment when she arrived.
I find with an every year policy, about half the folks come every 2 yrs or more.
Should be interesting…
Peggy
The OB/GYN I work with currently does annual paps on all women so I model that and do them annually even though I was taught and know other CNMs that follow the above guidelines. Not a single woman since I started working here a year ago has questioned it at all, which is interesting to me. Insurance companies pay for the pap annually and until that changes, what impetus do providers have to not do them, because it is, like you said, a whole lot easier just to do the pap than do an entire record review on every patient.
I personally, went to every 3 year paps when I turned 30 and had a negative HPV result at that pap, and I still feel a bit “short-changed” when I go in for my annual pelvic and a pap isn’t done. It’s a change in mind-set that is difficult to feel comfortable with after it being drilled into my head that I needed a pap smear every year.
I have many patients who are less willing to change that I am. So we discuss it and settle on a mutually agreeable screening plan for each woman.
Once the insurers step in and stop paying for annual paps in all women I think we will see a faster change.
Thanks for reading.
Peggy
Once insurers quit paying the demand for annual PAPs will stop on a dime. I’m using the sticky-notes section in our EMR to indicate when the next one is due.
mamadoc –
Ah sticky notes – my long lost friend. Will ask our IT guys if EPIC has a sticky note function yet – I haven’t seen it.
Have a great evening.
Peggy
I have to admit, I’m always surprised when I hear that some women really want a yearly pap. I was so happy when my doctor told me about the move to three year intervals for women such as myself.
I do wonder, though, about the need for a yearly physical for someone who’s basically healthy. If you’re ever looking for something to write about, explaining that might be interesting for some of your readers.
Bardiac –
There is noting magic about 12 months, and we are rapidly moving away form the annual physical concept towards periodic screening. Problem is, that without touchstone points, we lose opportunity to identify and address so many health issues. And as I stated above, 12m month usually becomes 1-2 years, and 3 years may become 5 and now we’re playing catch up and fix instead of prepare and prevent.
Read Dinosaur docs rants on what medicine hs evolved from and to on this issue. It’s a great argument against the whole “wellness ” idea –
http://dinosaurmusings.wordpress.com/2012/03/18/reclaiming-medical-care/
Best,
Peggy
This is a great post. I appreciate the ultra-concise summary of the recommendations, followed by the expansive discussion of nuance. All these screening protocols, including the PSA quandry, are not one size fits all by any means.
Thanks.
Thanks, Dr. Charles – Writing this post actually clarified how I am going to practice in this era of less testing. THat’s what I love about blogging – it’s often an opportunity to do the kind of thinking that we don’t have time for at the office.
Thanks for reading.
Peggy
I think you raise a really interesting point about the women >65 years of age. I too wonder if that is based on assumptions that older adults are not finding new sexual partners or simply aren’t having sex. In a medical librarian capacity, I have previously tried to explain to at least one person why it’s important to have information on HIV/AIDS in older adults, but some people really cannot wrap their minds around the idea that older adults ever have sex.
Rachel –
I think it’s based more on data on incidence of cervical ca and age. My concern is how old that data is and if it reflects a population with as many different sexual partners over time as current folks have. I don’t know the answer, – haven’t investigated the literature to that depth. Hoping we may get a little guidance form COG on this when they publish their guidelines.
Thanks for your comment.
Pegg
Could be a combination of both – people may not do much current research into that based on assumptions about people’s sex lives. If you do get into the literature on that, I’d love to hear what you find.
EEW –
Your comments makes me suspect you are marketing the product you speak of. I therefore deleted your comment. If I am in error, kindly identify yourself and let me know. At this point, I do not accept advertising on this blog, paid, unpaid or stealth.
THanks
Peggy
I am a second year medical student, and I have mixed feelings about the new pap smears too. It’s good to cut down on unnecessary expenses, but is it worth it when it leads to more cancer? And last I heard, STDs were on the rise in nursing homes more than anywhere else! Then again, if so many people have acquired HPV in their early life, maybe less change is to be expected if they’ve made it to their 60s untouched by cervical precancer.
I was wondering: do the new regulations affect reimbursement? For example, if you decide to do non-recommended pap smears for your patients who are older than 65, or if you do paps more frequently for high-risk young women, will you only be reimbursed for the recommended ones?
Hi Sarah –
Thanks for your comments.
At this point, the new guidelines do not seem to have impacted reimbursement, at least among the payors in my practice. Medicare, as you may know, for some years has only paid for routine screening pap smears every other year. However, patients at increased risk can have paps yearly. – I posted about this a few years back.
http://www.tbtam.com/2007/12/medicare-and-the-annual-gyn-exam-2.html
Good luck to you in med school !
Peggy