ACOG recommendations

The latest ACOG guidelines recommend a longer span between testing, in contrast to the traditional annual test. In the absence of risk factors such as those previously mentioned, women are advised to be screened every 3 years until age 30, at which point CIN 3 changes are most likely to be found. After age 30, screening may occur every 3 years by cytology alone, or by coscreening with both cytology and HPV testing every 5 years. The longer period recommended between screening, when both Pap and HPV testing are performed, is due to the link between HPV and nearly all cases of cervical cancer.4 

An important exemption to the less frequent screening recommendations is for women who have had CIN 2 or higher levels of dysplasia. These patients need yearly screening for 20 years following dysplasia treatment or spontaneous regression.8 It is important to note that although Pap testing and HPV screening are invaluable tools in the detection of women at risk for cervical cancer, only a colposcopy procedure can identify the exact topography of cervical lesions.12


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Clinicians should educate patients that, although the recommended length of time between Pap tests has been widened, the ACOG does recommend yearly pelvic examinations in women aged 21 years and older to include an external visual, speculum, and bimanual examination.13 However, the ACOG states that clinical evidence of the value of this examination is lacking in healthy, asymptomatic women and that the decision to proceed with yearly pelvic examinations is best made by the healthcare provider and patient.13 In addition, clinical breast examinations are recommended for women age 20 to 39 every 1 to 3 years, and yearly examinations are recommended for women age 40 and older.

Healthcare providers must use their clinical judgment to adapt these guidelines to their patients, including risk factors in the patient’s history and behaviors that might warrant testing more frequently. In addition, with longer intervals between screenings, clinicians should educate themselves regarding symptoms of cervical cancer, and they should question patients during visits about the presence of any of these symptoms.

Poor clinician adherence to guidelines

Recommendations by women’s healthcare providers are among the strongest influences in convincing women to obtain Pap smear testing.14 Many clinicians report that guidelines by organizations such as the ACOG were influential in their recommendations to patients.5 However, recommendations to patients regarding intervals between testing and when to begin and end testing remain inconsistent among clinicians.15 

One study found that few clinicians’ screening practices were consistent with current recommendations.5 When tested on common patient scenarios to determine if Pap smear testing was warranted, many healthcare providers gave answers that conflicted with current guidelines; almost half of providers in the study indicated that they would recommend Pap smear testing on a teenager who had not yet had sexual intercourse.

Historically, changes in medical recommendations often take time to be accepted and implemented. This may be especially true when most insurance companies continue to pay for screening beyond the frequency of the recommendations.15 Loss of income due to less frequent testing is cited as a reason for clinicians’ resistance to recommended changes.16 

A survey of insurance coverage within my practice revealed coverage for Pap smears that are performed more frequently than current ACOG guidelines recommend. Medicare provides coverage for Pap smears every 2 years for women of nonchildbearing age and at low risk and coverage yearly for women of childbearing age and those considered at high risk.17 TRICARE, a part of the Military Health System that provides insurance for military families, covers Pap smear testing for sexually active patients age 18 and older, with the frequency to be determined by the clinician.18 Health insurance providers such as Cigna, Blue Cross Blue Shield Association, and Aetna also continue to provide coverage for yearly pap smears, per their customer service representatives. 

Effects of screening on patients

Other factors should be considered in screening women for cervical cancer more frequently than recommended. Women often report anxiety, embarrassment, and fear when facing Pap smear screening; these feelings are due both to apprehension regarding the test results and the invasive nature of the screening itself.19 In addition, women who have received abnormal Pap smear results report avoiding future visits due to fear.20 

Colposcopy with biopsy is the procedure performed to further evaluate abnormal Pap smear results. Being informed of abnormal Pap smear results and referred for a colposcopy is a great source of stress and anxiety for many women.21 Aside from the emotional effects, one study found that 39% of women reported pain following colposcopy, 47% reported bleeding, and 34% reported unusual discharge.7 

When biopsy results reveal a CIN 2 or higher level of dysplasia, current practice in the United States is to treat these lesions.22 The most common treatments in the United States for moderate and severe cervical dysplasia are cold-knife conization and LEEP; however, these treatments are not without risks.7 Cold-knife conization has been linked to higher risk of low-birth-weight babies, preterm premature rupture of membranes during pregnancy, and perinatal mortality.23 Women who have the LEEP, which can weaken the cervix, have twice the risk of giving birth prematurely.23 Patients often state that, along with anxiety, negative effects on their sex life persist long after these procedures.20 

The rising cost of health care is a concern to both patients and clinicians. Pap smear testing is frequently accompanied by HPV testing. The cost of these tests, along with common testing on specimens for infections that are often combined with Pap testing, can reach $1,000.24 In surveying my area by telephone, I found colposcopy costs, with biopsy and pathology, quoted in the range of $1,500 to $2,500. Over the course of a lifetime, in a low-risk woman, following the recommended guidelines for the length between testing could have a substantial financial effect on both the patient and the healthcare system. 

Conclusions

Testing of cervical cells obtained via Pap smear screening has lowered the rate of cervical carcinomas. Research has shed light on the role that HPV plays in the development of cervical cancer and on the frequent remission of dysplasia and slow-moving and often predictable progress of the disease. Detection and treatment of cervical dysplasia before the onset of carcinoma is the goal of screening; however, it must be acknowledged that testing and treatment of cervical dysplasia is not without risk and negative effect. Analysis of this information led to changes in screening recommendations for women of all ages, both by raising the age at which screening should begin and by lengthening the interval between screenings for most women. 

The ACOG’s current recommendations—to begin screening with Pap testing at age 21, to screen every 3 years until age 30, and to screen every 3 years with Pap testing or every 5 years in combination with HPV testing thereafter—are the best evidence-based practice for patients, barring any of the previously mentioned risk factors. 

Kenda Harrison, MSN, FNP-C, is a family nurse practitioner in Shelbyville, Tennessee.

References

  1. Sherris J, Wittet S, Kleine A, et al. Evidence-based, alternative cervical cancer screening approaches in low-resource settings. Int Perspect Sex Reprod Health. 2009;35(3):147-154. 
  2. Schwaiger C, Aruda M, LaCoursiere S, Rubin R. Current guidelines for cervical cancer screening. J Am Acad Nurse Pract. 2012;24(7):417-424.
  3. Cervical cancer. National Institutes of Health Research Portfolio Online Reporting Tools (RePORT) website. http://www.report.nih.gov/nihfactsheets/viewfactsheet.aspx?csid=76. Updated March 29, 2013. 
  4. Cervical cancer screening. American Congress of Obstetricians and Gynecologists website. http://www.acog.org/Patients/FAQs/Cervical-Cancer-Screening 
  5. Benard VB, Saraiya M, Greek A, et al. Overview of the CDC Cervical Cancer (Cx3) Study: an educational intervention of HPV testing for cervical cancer screening. J Womens Health (Larchmt). 2014;23(3):197-203. 
  6. Vegunta S, Kransdorf LN, Mayer AP. Why more is not always better: new Pap smear guidelines. J Womens Health (Larchmt). 2014;23(1):105-106.
  7. Vesco KK, Whitlock EP, Eder M, et al. Risk factors and other epidemiologic considerations for cervical cancer screening: a narrative review for the US preventive services task force. Ann Intern Med. 2011;155(10):698-705.
  8. Randel A. ACOG releases guidelines on cervical cancer screening. Am Fam Physician. 2013;88(11):776-777.
  9. ACOG Committee on Practice Bulletins. ACOG Practice Bulletin Number 45, August 2003: Committee on Practice Bulletins-Gynecology. Cervical Cytology Screening. Obstetrics & Gynecology. 2003;102(2):417-427. 
  10. Cox JT. Update on cervical disease. OBG Management website.  http://www.obgmanagement.com/home/article/update-on-cervical-disease/720e926b6c5df4049d6dc75619088f24.html. Updated March 2012. 
  11. Morrison R, Moody P, Shelton M. Pap smear rates: predictor of cervical cancer mortality disparity? Online Journal of Rural Nursing & Health Care. 2010;10(2)21-27. 
  12. Petry KU. Management options for cervical intraepithelial neoplasia. Best Pract Res Clin Obstet Gynaecol. 2011;25(5):641-651.
  13. Well-woman recommendations. American Congress of Obstetricians and Gynecologists website. http://www.acog.org/About-ACOG/ACOG-Departments/Annual-Womens-Health-Care/Well-Woman-Recommendations 
  14. Linton DM. Cervical cancer screening interval. Clin J Oncol Nurs. 2009;13(2):235-237. 
  15. Almeida CM, Rodriguez MA, Skootsky S, et al. Cervical cancer screening overuse and underuse: patient and physician factors. Am J Manag Care. 2013;19(6):482-489.
  16. Saraiya M, Steben M, Watson M, Markowitz L. Evolution of cervical cancer screening and prevention in United States and Canada: implications for public health practitioners and clinicians. Prev Med. 2013;57(5):426-433. 
  17. Cervical & vaginal cancer screenings. Medicare website. https://www.medicare.gov/coverage/cervical-vaginal-cancer-screenings.html 
  18. Pelvic exams and Pap smears. TRICARE website. http://www.tricare.mil/CoveredServices/IsItCovered/PelvicExamsPapSmears.aspx. Updated June 5, 2015. 
  19. Oscarsson MG. Psychological adjustment of women in cervical cancer screening. Current Women’s Health Reviews. 2011;7(4):353-357. 
  20. Flanagan SM, Wilson S, Luesley D, et al. Adverse outcomes after colposcopy. BMC Womens Health. 2011;11:2.
  21. Kola S, Walsh JC. Determinants of pre-procedural state anxiety and negative affect in first-time colposcopy patients: implications for intervention. Eur J Cancer Care (Engl). 2012;21(4):469-476. 
  22. Pap and HPV testing. National Cancer Institute website. http://www.cancer.gov/cancertopics/factsheet/detection/Pap-test. Reviewed September 9, 2014. 
  23. Davisson L. Rational care or rationing care? Updates and controversies in women’s prevention. W V Med J. 2011;107(1):26-28, 30-32. 
  24. Bettigole C. The thousand-dollar Pap smear. N Engl J Med. 2013;369(16):1486-1487.

All electronic documents accessed December 10, 2015.