Joshua Strauss, MD
In the second decision of its kind and magnitude in a matter of days, a major medical group has again recommended cutting back on cancer screening for women. On the heels of Monday’s USPSTF release on reducing mammography, newly revised evidence-based guidelines regarding cervical cancer screening were issued today by The American College of Obstetricians and Gynecologists (ACOG) and published in the December issue of Obstetrics & Gynecology.
The new guidelines, “based on good and consistent scientific evidence,” recommend beginning cervical cancer screening at 21 years of age. ACOG’s previous guidelines published in 2006 had advised yearly screens 3 years after the initiation of sexual intercourse, but no later than 21 years. The rationale for changing course, according to the group, is the mounting evidence that the vast majority of precancerous cervical lesions in adolescents and young women are likely to spontaneously resolve. Thus, the bulletin argues, screening this age group leads to “unnecessary and harmful evaluation and treatment in women at very low risk of cancer.”
Another major guideline revision relates to women ages 21 to 29: Recommendations for annual screens have been changed to biennial testing for this population. However, screening recommendations for women 30 years and older will remain the same: “Women aged 30 years and older who have had three consecutive negative cervical cytology screening test results and who have no history of CIN 2 or CIN 3, are not HIV infected, are not immunocompromised, and were not exposed to diethylstilbestrol in utero may extend the interval between cervical cytology examinations to every 3 years.”
Media and other public reaction to these latest guidelines have been understandably received in the context of the recent revision of the breast cancer screening guidelines earlier this week, as well as the ongoing national healthcare debate. Skeptics may see these latest recommendations as an effort to reduce healthcare costs by rationing cancer screenings to smaller groups of individuals. However, others will argue that the medical community is undergoing an appropriate revision of its screening process. This opinion is most clearly articulated by Dr. H. Gilbert Welch, a professor of medicine at Dartmouth, in an interview in the New York Times. He notes that “the efforts to detect cancer early can be a two-edged sword. Yes, it helps some people, but it harms others… we’re trying to negotiate that balance,” he said. “There’s no right answer, but I can tell you that the right answer is not always to start earlier, look harder and look more frequently.”
Image of high grade dysplasia (carcinoma in situ) in the uterine cervix courtesy Wikimedia Commons
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Grady, Denise. “Guidelines Push Back Age for Cervical Cancer Tests.” 20 November 2009. The New York Times.
Ho GY, Bierman R, Beardsley L, Chang CJ, Burk RD. Natural history of cervicovaginal papillomavirus infection in young women. N Engl J Med 1998;338:423-8. (Level II-2)
Primary and preventive care: periodic assessments. ACOG Committee Opinion No. 357. American College of Obstetricians and Gynecologists. Obstet Gynecol 2006;108:1615-22.
Sack, Kevin. “Screening Debate Reveals Culture Clash in Medicine.” 20 November 2009. The New York Times.