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U.S. Preventive Services Task Force
Cervical Cancer Screening Best Practices
Summary of Recommendations:
Women who have
been sexually active and have a cervix should be screened for cervical
cancer.
Women older than
age 65 should not be routinely screened for cervical cancer if they
have had an adequate recent screening with normal Pap smear and are
not otherwise at high risk for cervical cancer.
Women who have
had a total hysterectomy for benign disease should not have routine
Pap smear screening.
The evidence is
insufficient to recommend for or against the routine use of new technologies
to screen for cervical cancer.
The evidence is
insufficient to recommend for or against the routine use of HPV testing
as a primary screening test for cervical cancer.
Clinical Considerations:
The goal of cytologic
screening is to sample the transformation zone, the area where physiologic
transformation from columnar endocervical epithelium to squamous (ectocervical
epithelium takes place and where dysplasia and cancer arise. A
meta-analysis of randomized trials supports the combined use of an extended
tip spatula to sample the ectocervix and a cytobrush to sample the endocervix.
The optimal age
to begin screening is unknown. Data on natural history of HPV
infection and the incidence of high-grade lesions and cervical cancer
suggest that screening can safely be delayed until 3 years after onset
of sexual activity or until age 21, whichever comes first. Although
there is little value in screening women who have never been sexually
active, many U.S. organizations recommend routine screening by age 18
or 21 for all women, based on the generally high prevalence of sexual
activity by that age in the U.S. and concerns that clinicians may not
always obtain accurate sexual histories.
Discontinuation
of cervical cancer screening in older women is appropriate, provided
women have had adequate recent screening with normal Pap results.
The optimal age to discontinue screening is not clear, but risk of cervical
cancer and yield of screening decline steadily through middle age. New
American Cancer Society (ACS) recommendations suggest stopping cervical
cancer screening at age 70. Screening is recommended in older
women who have not been previously screened, when information about
previous screening is unavailable, or when screening is unlikely to
have occurred in the past. Evidence is limited to define "adequate
recent screening." The ACS guidelines recommend that older women
who have had three or more documented consecutive, technically satisfactory
normal/negative cervical cytology tests and who have had no abnormal/positive
cytology tests within the last 10 years can safely stop screening.
There is no direct
evidence that annual screening achieves better outcomes than screening
every 3 years. Modeling studies suggest little added benefit of
more frequent screening for most women. The majority of cervical
cancers in the United States occur in women who have never been screened
or who have not been screened within the past 5 years; additional cases
occur in women who do not receive appropriate follow-up after an abnormal
Pap smear. Because sensitivity of a singe Pap test for high-grade
lesions may only be 60-80%, however most organizations in the United
States recommend that annual Pap smears be performed until a specified
number (usually two or three) are cytologically normal before lengthening
the screening interval. The ACS guidelines suggest waiting until
age 30 before lengthening the screening interval; the American College
of Obstetricians and Gynecologists (ACOG) identifies additional risk
factors that might justify annual screening including a history of cervical
neoplasia, infection with HPV or other sexually transmitted diseases
(STDs) or high risk sexual behavior, but these data are limited to determine
the benefits of these strategies.
Discontinuation
of cytological screening after total hysterectomy for benign disease
(e.g., no evidence of cervical neoplasia or cancer) is appropriate given
the low yield of screening and the potential harms from false-positive
results in this population. Clinicians should confirm that a total
hysterectomy was performed (through surgical records or inspecting for
absence of a cervix; screening may be appropriate when the indications
for hysterectomy are uncertain. ACS and ACOG recommend continuing
cytologic screening after hysterectomy for women with a history of invasive
cervical cancer or EES exposure due to increased risk for vaginal neoplasms,
but data on the yield of such screening are sparse.
A majority of
cases of invasive cervical cancer occur in women who are not adequately
screened. Clinicians, hospitals, and health plans should develop
systems to identify and screen the subgroup of women who have had no
screening or who have had inadequate past screening.
Newer Food and
Drug Administration (FDA) approved technologies such as the liquid-based
cytology may have improved sensitivity over conventional Pap smear screening,
but at a considerably higher cost and possibly with lower specificity.
Even if sensitivity is improved modeling studies suggest these methods
are not likely to be cost-effective unless used with screening intervals
of 3 years or longer. Liquid-based cytology permits testing of
specimens for HPV, which may be useful in guiding management of women
whose Pap smear reveals atypical squamous cells. HPV DNA testing
for primary cancer screening has not been approved by the FDA and its
role in screening remains uncertain.
This U.S. Preventive Services
Task Force (USPSTF) recommendation was first published in: Ann Intern
Med. 2002;137 (Part 1):344-346.
References
Martin-Hirsch P,
Lilford R, Jarvis G, Kitchener HC. Efficacy of cervical-smear
collection devices: a systematic review ad meta-analysis. Lancet.
1999;354(9192):1763-1770.
Smith RA, Cokkinides
V, von Eschenbach AC, et al. American Cancer Society Guideline for the
Early Detection of Cervical Neoplasia and Cancer. CA Cancer J Clin.
2002;52(1):8-22.
Hildesheim A, Hadjimichael
O, Schwartz PE, et al. Risk factors for rapid-onset cervical cancer.
Am J Obstet Gynecol. 1999;180(3`Pt 1):571-577.
Janerich DT, Hadjimichael
O, Schwartz PE, et.al. The screening histories of women with invasive
cervical cancer, Connecticut. Am J Public
Health. 1995;85(6):791-794.
Harman KE, Hall
SA, Nanda K, Boggess JF, Zolnoun D. Screening for Cervical Cancer.
Systematic Evidence Review. No.25. (Prepared by the Research Triangle
Institute-University of North Carolina Evidence-based Practice Center
under contract No. 290-97-0011). Rockville, MD: Agency for healthcare
Research and Quality. January 2002. Available on the AHRQ Web site:
at: <a href=http://www.ahrq.gov/clinic/serfiles.htmwww.ahrq.gov/clinic/serfiles.htm.
American College
of Obstetricians and Gynecologists. Guidelines for Women's Health
Care. 2nd ed. Washington, DC: ACOG;2002:121-134, 140-141.
Mitchell HS, Giles
GG. Cancer diagnosis after a report of negative cervical cytology.
Med J Aust. 1996;164(5):270-273.
Sigurdsson K. Trends
in cervical intra-epithelial neoplasia in Iceland through 1995:evaluation
of targeted age groups and screening intervals. Acta Obstet Gynecol
Scand. 1999;78(6):486-492.
U.S. Preventive Services Task Force
Cervical Cancer Screening Best Practices
Summary of Recommendations:
Women who have
been sexually active and have a cervix should be screened for cervical
cancer.
Women older than
age 65 should not be routinely screened for cervical cancer if they
have had an adequate recent screening with normal Pap smear and are
not otherwise at high risk for cervical cancer.
Women who have
had a total hysterectomy for benign disease should not have routine
Pap smear screening.
The evidence is
insufficient to recommend for or against the routine use of new technologies
to screen for cervical cancer.
The evidence is
insufficient to recommend for or against the routine use of HPV testing
as a primary screening test for cervical cancer.
Clinical Considerations:
The goal of cytologic
screening is to sample the transformation zone, the area where physiologic
transformation from columnar endocervical epithelium to squamous (ectocervical
epithelium takes place and where dysplasia and cancer arise. A
meta-analysis of randomized trials supports the combined use of an extended
tip spatula to sample the ectocervix and a cytobrush to sample the endocervix.
The optimal age
to begin screening is unknown. Data on natural history of HPV
infection and the incidence of high-grade lesions and cervical cancer
suggest that screening can safely be delayed until 3 years after onset
of sexual activity or until age 21, whichever comes first. Although
there is little value in screening women who have never been sexually
active, many U.S. organizations recommend routine screening by age 18
or 21 for all women, based on the generally high prevalence of sexual
activity by that age in the U.S. and concerns that clinicians may not
always obtain accurate sexual histories.
Discontinuation
of cervical cancer screening in older women is appropriate, provided
women have had adequate recent screening with normal Pap results.
The optimal age to discontinue screening is not clear, but risk of cervical
cancer and yield of screening decline steadily through middle age. New
American Cancer Society (ACS) recommendations suggest stopping cervical
cancer screening at age 70. Screening is recommended in older
women who have not been previously screened, when information about
previous screening is unavailable, or when screening is unlikely to
have occurred in the past. Evidence is limited to define "adequate
recent screening." The ACS guidelines recommend that older women
who have had three or more documented consecutive, technically satisfactory
normal/negative cervical cytology tests and who have had no abnormal/positive
cytology tests within the last 10 years can safely stop screening.
There is no direct
evidence that annual screening achieves better outcomes than screening
every 3 years. Modeling studies suggest little added benefit of
more frequent screening for most women. The majority of cervical
cancers in the United States occur in women who have never been screened
or who have not been screened within the past 5 years; additional cases
occur in women who do not receive appropriate follow-up after an abnormal
Pap smear. Because sensitivity of a singe Pap test for high-grade
lesions may only be 60-80%, however most organizations in the United
States recommend that annual Pap smears be performed until a specified
number (usually two or three) are cytologically normal before lengthening
the screening interval. The ACS guidelines suggest waiting until
age 30 before lengthening the screening interval; the American College
of Obstetricians and Gynecologists (ACOG) identifies additional risk
factors that might justify annual screening including a history of cervical
neoplasia, infection with HPV or other sexually transmitted diseases
(STDs) or high risk sexual behavior, but these data are limited to determine
the benefits of these strategies.
Discontinuation
of cytological screening after total hysterectomy for benign disease
(e.g., no evidence of cervical neoplasia or cancer) is appropriate given
the low yield of screening and the potential harms from false-positive
results in this population. Clinicians should confirm that a total
hysterectomy was performed (through surgical records or inspecting for
absence of a cervix; screening may be appropriate when the indications
for hysterectomy are uncertain. ACS and ACOG recommend continuing
cytologic screening after hysterectomy for women with a history of invasive
cervical cancer or EES exposure due to increased risk for vaginal neoplasms,
but data on the yield of such screening are sparse.
A majority of
cases of invasive cervical cancer occur in women who are not adequately
screened. Clinicians, hospitals, and health plans should develop
systems to identify and screen the subgroup of women who have had no
screening or who have had inadequate past screening.
Newer Food and
Drug Administration (FDA) approved technologies such as the liquid-based
cytology may have improved sensitivity over conventional Pap smear screening,
but at a considerably higher cost and possibly with lower specificity.
Even if sensitivity is improved modeling studies suggest these methods
are not likely to be cost-effective unless used with screening intervals
of 3 years or longer. Liquid-based cytology permits testing of
specimens for HPV, which may be useful in guiding management of women
whose Pap smear reveals atypical squamous cells. HPV DNA testing
for primary cancer screening has not been approved by the FDA and its
role in screening remains uncertain.
This U.S. Preventive Services
Task Force (USPSTF) recommendation was first published in: Ann Intern
Med. 2002;137 (Part 1):344-346.
References
Martin-Hirsch P,
Lilford R, Jarvis G, Kitchener HC. Efficacy of cervical-smear
collection devices: a systematic review ad meta-analysis. Lancet.
1999;354(9192):1763-1770.
Smith RA, Cokkinides
V, von Eschenbach AC, et al. American Cancer Society Guideline for the
Early Detection of Cervical Neoplasia and Cancer. CA Cancer J Clin.
2002;52(1):8-22.
Hildesheim A, Hadjimichael
O, Schwartz PE, et al. Risk factors for rapid-onset cervical cancer.
Am J Obstet Gynecol. 1999;180(3`Pt 1):571-577.
Janerich DT, Hadjimichael
O, Schwartz PE, et.al. The screening histories of women with invasive
cervical cancer, Connecticut. Am J Public
Health. 1995;85(6):791-794.
Harman KE, Hall
SA, Nanda K, Boggess JF, Zolnoun D. Screening for Cervical Cancer.
Systematic Evidence Review. No.25. (Prepared by the Research Triangle
Institute-University of North Carolina Evidence-based Practice Center
under contract No. 290-97-0011). Rockville, MD: Agency for healthcare
Research and Quality. January 2002. Available on the AHRQ Web site:
at: <a href=http://www.ahrq.gov/clinic/serfiles.htmwww.ahrq.gov/clinic/serfiles.htm.
American College
of Obstetricians and Gynecologists. Guidelines for Women's Health
Care. 2nd ed. Washington, DC: ACOG;2002:121-134, 140-141.
Mitchell HS, Giles
GG. Cancer diagnosis after a report of negative cervical cytology.
Med J Aust. 1996;164(5):270-273.
Sigurdsson K. Trends
in cervical intra-epithelial neoplasia in Iceland through 1995:evaluation
of targeted age groups and screening intervals. Acta Obstet Gynecol
Scand. 1999;78(6):486-492.