1. Update:Pap Smear Guidelines
Anoop Agrawal, M.D.

2. Pap Smear Guidelines
American College of Obstetrics and Gynecology (ACOG) – released new guidelines in November 2009
U.S. Preventative Services Task Force (USPSTF) – last published in 2003
American Cancer Society (ACS) – last published in 2002.
Guidelines in this review based upon the ACOG revision.

3. Cervical Cancer Trends
Rate of cancer has decreased by more than 50% in past 30 years
1975 – incidence was 14.8 per 100,000
2006 – incidence was 6.5 per 100,000
Estimates for 2009
11,270 new cases with 4,070 deaths in U.S.
500,000 new cases with 240,000 worldwide
Women who are immigrants to the US are especially high- risk group due to variable screening in their country of origin.

4. HPV and Cervical Neoplasia
The HPV type and persistence of HPV infection are the main determinants of cervical neoplasia.
There are “high-risk” types of HPV confirmed to be oncogenic agents.
Other factors that may play a role are smoking and immunosuppression.
Adolescents and young women with normal immune systems will likely clear the infection within 8-24 months.
In this group, HPV infections and dysplasia will likely resolve spontaneously.

5. Paps in the era of HPV Vaccination
Theoretically, a reduction in cervical cancer will not begin to be seen for another years following a widely implemented vaccination program.
Women who have been vaccinated should be screened by the same regimen as non-immunized women. (Level C)

6. Pap Smear Techniques Two techniques:
Liquid-based
Conventional method
Majority of screening in U.S. is now liquid-based.
Studies have found no significant difference in sensitivity or specificity between the two techniques.
Lubricant may be used on the speculum however... lubricant on the cervix will interfere with the transfer of cells and lead to false results.

7. Case One
An 18 yo hispanic female presents with vaginal discharge. She has a history of chlamydia and reports ‘37’ sexual partners. You plan to perform a pelvic exam and obtain samples for STDs. When should she begin cervical cancer screening?
Cervical cancer screening should begin at age 21 years. (Level A)

8. Why wait till 21 years old?
Sexually active adolescents have a high rate of infection with HPV, but…
Invasive cervical cancer is very rare in women younger than 21 years.
0.1% of cases occur before 21 years.
Data from CDC from ‘98-’03 found 14 cases/yr in females aged years.
Surveillance Epidemiology and End Results (SEER) data from ‘02-’06 shows incidence rate of 1-2 cervical cancer cases per 1,000,000 females aged years

9. Why wait till 21 years old?
Recommendation to wait till 21 also based on potential for adverse effects associated with follow-up interventions
Recent studies have documented a significant increase in premature births in women previously treated with excisional procedures for dysplasia.
Earlier onset of screening may increase anxiety, morbidity and expense from the test itself and overuse of follow-up
These patients should still have testing for STDs. In asymptomatic patients, can be done without use of a speculum.

10. Case Two
A 25 yo white female presents for her annual physical exam. She reports a history of ASCUS in the past. Her last pap smear was one year ago and was normal. Should you perform her pap smear today?
No. Cervical cancer screening is recommended every 2 years for women aged years. (Level A)

11. Frequency of Cervical Screening
Screening every 2 years for women aged years.
Women aged 30 years and older who have had 3 consecutive negatives may be screened every 3 years.
Exceptions are:
HIV
Immunosuppressed
Exposed to diethylstilbesterol in utero
Previously treated for CIN 2, CIN 3, or cancer
All of the above recommendations are Level A.

12. Data for Cervical Cancer Screening
National Breast and Cervical Cancer Early Detection Program:
In 31,728 women aged years found prevalence of CIN 2 and 3 of 0.028% and 0.019% in those who had three annual negative Pap tests in a row.
No cases of invasive cancer in this group.
The calculated risk based on computer models with this data estimate 4 women with cancer per 100,000 over the next 3 years with annual screening.
With triennial screening, estimate 8 per 100,000.
Though this is a doubling, the absolute number of cases is small and the estimated cost of finding each additional case of cancer was large.

13. Case Three
A 57 yo African-American female is here for her annual check-up. She reports having had a hysterectomy ‘some years ago’ for ‘pre-cancerous lesions.’ Does she still need cervical cancer screening?
Yes. Women who have had a hysterectomy and due to a history of CIN 2 or CIN 3 need continued ANNUAL screening. (Level B)

14. Woman with Hysterectomy
Women who have had a total hysterectomy for benign indications and have no prior history of high-grade CIN should discontinue screening. (Level A)
Primary vaginal cancer is very rare.
Of 6,543 women with hysterectomies for benign reasons, only 1.8% had an abnormal cytology and 0.12% had vaginal intraepithelial neoplasia on biopsy.

15. Case Four
A 67 yo female presents for annual physical. She is wondering when she can stop having Pap smears performed. She has had regular screening throughout her life. What do you advise?
You may discontinue screening at either 65 or 70 years of age in women who have had three or more negative cytologic test results in a row and no abnormal test results in past 10 years. (Level B)
Risk factors should be reassessed during the annual exam to determine if reinitiating screening is appropriate.

16. Case Five
A 17 yo female had a Pap smear performed at another facility. The results showed ASC-US with positive reflex HPV testing. She has come in for follow-up. What do you recommend for further management?
Ignore the results and resume cervical cancer screening at age 21 years.
HPV testing should not be used in women younger than 21 years. If inadvertently performed, a positive result should no influence management.

17. HPV Testing
Reflex HPV DNA testing serves as a useful triage test to stratify risk to women
aged 21 years and older with a ASC-US
postmenopausal women with LSIL
Also has proven role in primary screening in women older than 30 years.
Women with both negative cervical cytology and HPV DNA testing are extremely low risk for CIN 2 or CIN 3 during the next 4-6 years.
This is lower risk than women who have only had a negative cytology.
Women over 30 years with negative cytology and HPV should be rescreened no sooner than 3 years. (Level A)

18. Conclusions
New guidelines are designed to better balance the risks and benefits of screening based on newer data.
Cervical cytology screening should begin after age 21 years.
For women between age years with average risk, cervical cytology screening should be every 2 years.
For women 30 years and older, screening may be every 3 years if they have had at least 3 negative screens prior.
Women with total hysterectomies for benign reasons do not need any further screening.

19. References
American College of Obstetrics and Gynecology. ACOG Practice Bulletin 109, December 2009: cervical cytology screening. Obstet Gynecol 2009;114:
Sawaya GF. Cervical Cancer Screening – New guidelines and the balance between benefits and harms. N Eng J Med 2009;361: