Pap guidelines changed

Low-risk, healthy women don't need a yearly screening

Heidi Hagemeier / The Bulletin /

Published Feb 14, 2013 at 04:00AM

For many women, getting a Pap smear is an annual health care ritual. Yet new recommendations say women with consistently normal test results don’t need a yearly screening for cervical cancer.

Last year, several medical organizations, including the U.S. Preventive Services Task Force and the American College of Obstetricians and Gynecologists, changed their guidelines on annual cervical cancer screenings. The updates cover when women should start getting Pap smears, how often they should have them and when to stop.

“Everybody agrees now,” said Dr. Janey Purvis, a Bend Memorial Clinic family practice physician who specializes in women’s health. “The evidence is pretty clear.”

Physicians emphasize, however, that women should still get an annual checkup.

“The annual well-woman exam is not only about Pap smears,” Purvis said. “It’s so important. It’s about breast cancer screening, it’s about cholesterol, it’s about diet and exercise, it’s about blood pressure, it’s about colonoscopy screening. It’s really your wellness exam for the year.”

Under the new guidelines, women need not start getting Pap smears until age 21. Between 21 and 29, the guidelines recommend screening every three years.

Then at age 30, if they have had consecutive, normal Pap smear results, there are two options. One is to continue getting Pap smears every three years until age 65.

The other is to administer a relatively new DNA test for the virus that causes cervical cancer, human papillomavirus, or HPV, on the Pap smear cell sample. If it comes back negative, then women need only be screened once every five years.

“The evidence is clear that if you’ve had all negative, consecutive Pap smears and a negative HPV test that you have very, very little risk of developing cancerous cells in the next five years,” Purvis said.

Then, at 65, women without abnormal Pap results in their past can stop screening.

Also, women who undergo a hysterectomy for benign reasons and who have always had normal screenings can forgo the test.

Research backs switch

Cervical cancer used to be one of the leading causes of death for women in the U.S., according to the Centers for Disease Control and Prevention. It’s caused by certain strains of HPV, a common sexually transmitted disease that also causes genital warts and other, rarer cancers.

But the incidence of cervical cancer has dropped significantly in the past 40 years, the CDC says, in large part due to Pap screening.

The Pap smear is a cytology test, meaning a tissue sample is taken and the cell structure is examined in a lab, said Dr. Ann-Bridget Bird, a gynecologist for St. Charles Ob/Gyn-Redmond.

One of the prime reasons for the changes is that research showed that the screenings were unnecessary in some age groups and increased the risk of overtreatment.

Bird said the immune systems of women younger than 21 usually manage on their own to clear HPV.

“What we were doing for so many years was doing lots of screenings and finding and treating minor abnormalities,” Purvis said. “And really they would have gone away on their own most of the time. So we may have been doing procedures that they didn’t need to have.”

The HPV test need not be administered before age 30 for the same reasons, Bird said.

The test, which detects several high-risk HPV strains, started becoming available in 2009. Purvis said it’s more sensitive than a Pap smear and therefore might indicate when a woman has precancerous changes before the Pap smear shows them. But it doesn’t test for all high-risk strains, making a Pap essential.

Not all women qualify

Not all women are candidates for the new recommendations. It’s a discussion they should have with their doctors, Bird said. A woman who has had abnormal Pap results will likely need annual screening.

Women also aren’t always aware of when they were last screened, Bird said. Sometimes they don’t know if a pelvic exam included a Pap.

“These recommendations make sense from a basic science perspective and from a perspective of having a long-term relationship between one patient and one physician,” she said. “But that’s not necessarily reality.”

Women may move or switch insurance carriers and go to a new doctor. The records don’t always follow.

“If she’s not there with her records,” Bird said, “it’s hard to follow those guidelines.”

Purvis emphasized that women who have had the HPV vaccine, which starting in 2006 became recommended for young women, still need to get a cervical cancer screening. The vaccine doesn’t cover every strain of cancer-causing HPV, and it isn’t administered widely yet in the population.

She added that women shouldn’t take the new recommendations as a reason to skip their annual visit.

“The fear is if we say five years, they come back in 10,” she said. “And by then they might have cervical cancer.”

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