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New guidelines: Pap smears can start at 21

/ Source: news services

Most women in their 20s can have a Pap smear every two years instead of annually, say new guidelines that conclude that's enough to catch slow-growing cervical cancer.

The change by the American College of Obstetricians and Gynecologists comes amid a completely separate debate over when regular mammograms to detect breast cancer should begin. The timing of the Pap guidelines is coincidence, said ACOG, which began reviewing its recommendations in late 2007 and published the update Friday in the journal Obstetrics & Gynecology. There have been widespread concerns that the government is trying to cut health costs by limiting cancer screening for women.

However, the recommendations have been in development for the last several years and the announcement of the new guidelines was coincidental, Dr. Cheryl B. Iglesia, the chairwoman of a panel in the obstetricians’ group that developed the Pap smear guidelines, told The New York Times. The timing of the announcement was “an unfortunate perfect storm,” she told the newspaper, adding, “there’s no political agenda with regard to these recommendations.”

The recommendations are based on scientific evidence that suggests more frequent testing leads to overtreatment, which can harm a young woman's chances of carrying a child full term, according to Dr. Thomas Herzog of Columbia University in New York, who is chairman of an ACOG subcommittee on gynecologic cancers.

"Overtreatment of minor abnormal pap tests in young women and adolescents can lead to consequences such as preterm labor in some cases. It increases the risk," said Herzog.

Dr. Jennifer Milosavijevic, a specialist in obstetrics and gynecology at Henry Ford Health System in Detroit, supports the guideline changes. "Preterm delivery has become a huge problem in the United States that has potential serious consequences for the unborn fetus," she said.

The guidelines are unlikely to be met with the kind of rebellion that accompanied the mammogram guidelines this week, which were largely based on computer projections, Dr. Len Lichtenfeld, deputy chief medical officer of the American Cancer Society, said in a telephone interview.

"There is a lot more agreement about the science of cervical cancer screening," Lichtenfeld said.

Herzog said the new recommendations are based on studies that suggest starting screening earlier than age 21 causes more harm than benefit.

"We were overdiagnosing and overtreating adolescents and very young women," Herzog said in a telephone interview.

The guidelines also say:

  • Routine Paps should start at age 21. Previously, ACOG had urged a first Pap either within three years of first sexual intercourse or at age 21.
  • Women 30 and older should wait three years between Paps once they've had three consecutive clear tests. Other national guidelines have long recommended the three-year interval; ACOG had previously backed a two- to three-year wait.
  • Women with HIV, other immune-weakening conditions or previous cervical abnormalities may need more frequent screening.

Paps can spot pre-cancerous changes in the cervix in time to prevent invasive cancer, and widespread use has halved cervical cancer rates in the U.S. in recent decades. About 11,270 new cases will be diagnosed this year, and about 4,070 women will die from it, according to American Cancer Society estimates. Half of women diagnosed with cervical cancer have never had a Pap, and another 10 percent haven't had one in five years.

Cervical cancer is caused by certain strains of the extremely common sexually transmitted virus called HPV, for human papillomavirus. There is a new HPV vaccine that should cut cervical cancer in the future; ACOG's guidelines say for now vaccinated women should follow the same Pap guidelines as the unvaccinated.

Moreover, ACOG cited studies showing no increased risk of cancer developing in women in their 20s if they extended Pap screening from every year to every two years.

As for adolescents, ACOG said cervical cancer in teens is rare — one or two cases per million 15- to 19-year-olds — while HPV-caused cervical abnormalities usually go away on their own, and unnecessary treatment increases the girls' risk of premature labor years later.