Navigating the evidence about cancer screening

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Navigating the evidence about cancer screening
Navigating the evidence about cancer screening

At a glance

  • Numerous studies have affirmed that the usefulness of mammography increases with age.
  • While not flawless, mammography currently represents our best method for breast-cancer screening.
  • Data point heavily in favor or later initiation of Pap testing for women with normal Pap histories.
  • Women at heightened risk of cervical cancer should continue to undergo annual Pap screening.

As clinicians, we are dually blessed and burdened with a plethora of evidence and opinions regarding the tests and treatments that we recommend to our patients. In no field has this been more true recently than in women's health. Providers of preventive women's health care face the challenge of sifting through newly released data and analysis and then reconciling that information with our own experiences and the needs of our patients.

Recently the U.S. Preventive Services Task Force (USPSTF) updated its recommendations for breast-cancer screening in the general population.1 To much conversation and uproar, the USPSTF advocate:
  • Shifting the starting age for mammography from age 40 years to age 50 years
  • Scheduling mammograms biennially for women aged 50 to 74 years
  • Possibly ceasing screening mammography at age 75 years
  • Abandoning the routine teaching of breast self-examination to patients

Regarding clinical breast examination, the USPSTF found insufficient evidence to recommend for or against the practice in light of routine use of mammography.

In October 2011, the USPSTF proposed draft guidelines that would further the current trend toward less frequent, more targeted tests, suggesting that women younger than 65 years undergo Pap testing every three years, rather than annually as many clinicians continue to do, or even biannually, as current American College of Obstetrician and Gynecologist (ACOG) recommendations suggest.

Other proposed changes, suggest that screening be initiated at the age of 21 years in lieu of American College of Obstetrician and Gynecologist (ACOG) recommendations that state 21 years or within three years of initiating sexual activity as the criteria for Pap testing.

Currently, ACOG continues to call for Pap tests every two years for women aged 21 to 29 years, and every three years for women aged 30 to 65 years.

Both ACOG and USPSTF agree that women who have had previously normal Pap testing results and are not otherwise at risk should not continue to be tested after the age of 65 years. Cessation of Pap testing is also recommended after hysterectomy (with removal of the cervix) for benign disease. Women who have had abnormal Pap smears or who have other risk factors would have alternative schedules.

The public has endured a barrage of commentary on these topics during the past few years. Legislators, medical professionals, statisticians and health-care advocates have added their voices to the outcry. As clinicians, we have fielded countless questions from patients, colleagues, family and friends. Although most other professional societies have not adjusted their guidelines, all have issued responses, and speculation abounds that more change is ahead.

This article will explain the new recommendations and square them with current understandings of the state of the science, to help clinicians determine what is best for their patients.

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