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In response to last week’s column on mammogram guidelines, I received an e-mail from a reader. She pointed out that while the new guidelines may decrease health care costs, “They are saying that too many mammograms (as well as other tests) are causing way too many people to be diagnosed and too many procedures being performed unnecessarily and harming people.”
She also notes that, “They are saying that the increased survival rates of many cancers are because we are treating people with stage 0 or 1 cancers who would never have had adverse reactions without treatment. And at times, we are actually causing harm to some of these people by treating them as chemo, surgery and radiation, which all have risks of their own.”
The reader also said, “This is also not a sexist issue as they have also begun to question too many diagnoses of prostrate cancer and too much treatment of it in early stages that would never have harmed anyone.”
The points are well made. In fact, I have previously discussed in this column the concerns regarding prostate cancer screening possibly causing more harm than good by detecting and treating prostate cancer that would never endanger the patient.
With all of this in mind, another recommendation was released recently by the American College of Obstetricians and Gynecologists (ACOG) regarding the timing and frequency of cervical cancer screening, which includes Pap smears and/or liquid-based cytology.
ACOG’s earlier recommendation was to begin cervical cancer screening three years after first sexual intercourse or by age 21 years, whichever occurred first. To avoid economic, emotional and future childbearing implications of unnecessary treatment of adolescents, ACOG has now moved the baseline cervical cancer screening to age 21 years.
Instead of annual screening, the ACOG now recommends that women aged 21 to 30 years who are not at high risk be screened every two years and that women 30 years and older may be screened once every three years if they have had three consecutive negative test results.
Risk factors that may indicate the need for more frequent screening include HIV infection, immune suppression, diethylstilbestrol (DES) exposure before birth, and previous treatment of abnormal Pap smears called cervical intraepithelial neoplasia (CIN) 2, CIN 3, or cervical cancer.
The thought behind the changed recommendations is that invasive cervical cancer is very rare in women younger than 21 years.
Although the rate of human papillomavirus (HPV) infection is high among sexually active teens, the immune system in most teenage women clears the HPV infection within one to two years. In addition, teens have a higher incidence of HPV-related precancerous changes because the cervix is immature, but most of these problems resolve spontaneously without treatment. On the other hand, women treated for these precancerous changes have recently been shown to have a significant increase in premature births, possibly creating more harm than good.
Regardless of age, women who have had a total hysterectomy for benign conditions and who have no history of high-grade CIN should stop all cervical cancer screening.
The upper age limit for discontinuing cervical screening remains the same in the revised ACOG guidelines, which recommend stopping cervical cancer screening at age 65 or 70 years for women who have at least three consecutive negative cytology results and no abnormal test results in the previous ten years.
Women vaccinated against HPV should follow the same screening guidelines as unvaccinated women, according to the revised guidelines.
Women previously treated for CIN 2, CIN 3, or cancer are still at risk for persistent or recurrent disease for at least 20 years after treatment. This group should therefore continue to be screened every year for at least 20 years.
With more information and experience regarding breast cancer and cervical cancer screening, we may be able decrease the cost of excellent health care by balancing the benefits against the risks of these tests. Perhaps, we will soon do the same for prostate cancer screening.
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