Women have a new set of guidelines to consider when deciding whether to get screened for cervical cancer, a disease that will strike more than 13,000 people in the United States this year, including more than 200 in Kentucky.
The U.S. Preventive Services Task Force, an independent panel of experts, issued guidelines recently that vary by age group but mainly recommend screening every three to five years, beginning at age 21, and include an alternative to the Pap smear for women ages 30-65.
“These are the overall recommendations, but they may have to be modified for some women,” said Dr. Miriam Krause, a Louisville gynecologist and partner at Fertility and Endocrine Associates.
For example, the guidelines aren’t for high-risk women nor people who have a compromised immune system, such as women with HIV, nor are they for people displaying possible signs of cervical cancer, such as abnormal bleeding or discharge that can occur in advanced cases.
“If anybody has symptoms, then they should always see their doctor for that, even if they had a normal Pap smear three years ago,” said Krause, who’s board certified in obstetrics and gynecology, reproductive endocrinology and fertility.
Although the guidelines don’t call for getting a Pap smear every year, Krause said there’s still value in receiving an annual pelvic exam to do other things, such as checking for fibroids or ovarian cysts. Annual visits also give patients a chance to receive a breast exam and to talk with their health care provider about other topics, such as depression, libido, pain, pregnancy planning and overall wellness, she said.
Some people don’t know which kind of testing they’ve received in the past, so that’s another reason for women to talk with their health care provider, said Dr. Daniel Metzinger, a gynecologic oncologist with the James Graham Brown Cancer Center and University of Louisville Physicians.
Both the Pap smear and the high-risk HPV test, which can be done at the same time, require lying on an exam table, and the task force says women shouldn’t get hung up on which type of test to undergo once they reach their 30s.
“Participation in regular screening has a far greater effect on cervical cancer morbidity and mortality than which of the 3 recommended screening strategies is chosen for women ages 30 to 65 years,” the task force noted. “Implementation should therefore focus on ensuring that women receive adequate screening, regardless of which strategy is used.”
Here are the recommendations:
- Women ages 30-65 have these recommended options: Getting screened every five years solely with a test for high-risk HPV, the sexually transmitted human papillomavirus; relying on a Pap smear alone every three years; or getting both tests every five years, which is called co-testing.
- The task force recommends that women ages 21 to 29 get tested every three years with the Pap test.
- No screening is recommended for women younger than 21. The same goes for women older than 65 if they’ve been adequately screened in the past and have a history of repeated normal screening results.
The guidelines are targeted at women who have a cervix, regardless of the patient’s sexual history or whether she’s received HPV vaccination, which is given to children, starting as young as 9, and young adults to prevent cervical and other HPV-related cancers.
The goal of getting screened is to save lives and to identify cervical cancer early when it is treatable, said task force member Dr. Carole Mangione in a news release. “There are several effective screening strategies available, so women should talk to their doctor about which is right for them.”
Cervical cancer is a condition that will be diagnosed in an estimated 13,240 U.S. women this year and lead to around 4,170 deaths, according to the American Cancer Society. On a more positive note, incidence rates declined by half between 1975 and 2014 due to widespread screening, the society noted.
But “there needs to be a continued effort to ensure all women are adequately screened because a significant number of women in the country are not,” according to a joint statement by the American College of Obstetricians and Gynecologists (ACOG), the Society of Gynecologic Oncology (SGO) and ASCCP, a professional society for an interdisciplinary group of health care professionals. “It’s also essential for women to have access to all of the tests and that they are appropriately covered by insurance companies.”
Kentucky’s incidence and mortality rates for cervical cancer were higher than the nation’s for the period 2011-2015, with about 72 women a year dying, according to the government’s State Cancer Profiles website. The Bluegrass State’s age-adjusted incidence rate was 8.8 per 100,000 people during that time, compared to the U.S. rate of 7.5, but in southeastern Kentucky the rate was as high as 12.2 in Laurel County.
Kentucky also ranked among the top 10 worst states for cervical cancer incidence and mortality but could improve by embracing HPV vaccination, said Thomas C. Tucker, associate director for cancer prevention and control at the University of Kentucky Markey Cancer Center. This cancer is “one that we’re concerned about because it’s one that we can virtually eliminate,” he said, noting that “every year we have 200 new cases. … This is something we can fix.”
Almost all cervical cancers are caused by persistent infection with certain types of HPV, according to the American Cancer Society.
Some strains are more aggressive than others “in regard to causing cervical cancer and now potentially also anal cancer and like throat cancer,” Krause said. “The low-risk HPV types cause things like genital warts.”
In general, HPV is thought to be responsible for about 91 percent of cervical cancers, 75 percent of vaginal cancers, 69 percent of vulvar cancers, 63 percent of penile cancers, 91 percent of anal cancers, and 70 percent of oropharyngeal cancers, according to the U.S. Centers for Disease Control and Prevention.
During the period 2010 to 2014, HPV-associated cancer incidence rates in the United States ranged by state from a low of 7.9 per 100,000 people for Utah to a high of 15.3 per 100,000 people for Kentucky, according to a CDC brief from March 2018.
“A high percentage of young women become infected with HPV as they initiate sexual activity,” said David Doering, a gynecologic oncologist with the Norton Cancer Institute who cares for women with cancers of the reproductive tract.
However, many of the cases resolve spontaneously. If you initiate screening too early, you’ll find abnormalities, “but the vast majority of those go on to resolve (on their own) and so that’s a reason for not screening below age 21,” Doering said. “You’ll find abnormalities that then almost force you to act and you end up doing” various procedures that aren’t necessary.
The task force examines the evidence of both the benefits and harms of screening services and assesses the balance before making its recommendations.
It noted that cervical cancer is rare before age 21 and does not progress quickly.
“Because of the slow progression of disease and the high likelihood of regression in this age group, evidence suggests that screening earlier than age 21 years, regardless of sexual history, would lead to more harm than benefit,” according to the task force. The task panel also noted that treatment of certain kinds of cervical dysplasia (abnormal growth of cells on the surface of the cervix) “among women younger than 21 years may increase risk for adverse pregnancy outcomes.”
However, the task force found that the three recommended screening options for women in the age 30-65 category “offer a reasonable balance between benefits and harms,” adding that “women in this age group should discuss with their health care professional which testing strategy is best for them.”
Women also can discuss the pros and cons of the testing methods with their health care provider and the fact that guidelines vary from organization to organization, so your doctor may favor co-testing instead of solely relying on the HPV test at an appropriate age.