ALBUQUERQUE, N.M. — Recent draft guidelines by two influential groups say healthy women should wait until they are 21 for their first Pap smear, stop at 65 after adequate screening and wait three years between tests.
Switching to Pap tests every three years – perhaps the biggest news for women – is actually not new advice at all.
Although many women still get annual Pap tests, which check for changes in the cells of the cervix, medical groups have recommended for years that healthy women get them every three years.
In October, draft guidelines by the U.S. Preventive Services Task Force and a group that included the American Cancer Society, the American Society for Colposcopy and Cervical Pathology and the American Society for Clinical Pathology, emphasized the benefits of Pap tests in reducing cervical cancer deaths and incidence, which dropped 50 percent since 1975.
Both groups say waiting three years does not find more cancer and that testing under 21 can lead to false positives and unnecessary surgeries. Final guidelines are expected this year.
If medical groups are in agreement, why do women still get annual tests?
Dr. Alan Waxman, a professor of obstetrics and gynecology at the University of New Mexico’s School of Medicine, puts it bluntly.
“The annual Pap test is dead,” says Waxman, lead author of the 2009 American College of Obstetrics and Gynecology guidelines on cervical cancer screening, which recommended Pap tests every two years. “Health care providers are reluctant to drop it. What we’re trying to do is use scientifically based recommendations that avoid over-screening and over-treatment.”
Almost all cervical cancers are caused by the human papillomavirus, or HPV. In 90 percent of cases, the body clears HPV on its own in two years, according to the Centers for Disease Control and Prevention. Precancerous cells take 10 to 15 years to become cervical cancer.
Most women who develop cervical cancer have never been screened or it has been more than five years since they were screened, says Dr. Susan Baum, medical director and epidemiologist with the New Mexico Department of Health’s Chronic Disease Prevention & Control Bureau.
Like new guidelines on breast and prostate cancer screening, cervical cancer screening guidelines may be hard to understand.
“None of us like to get mixed mesages,” Baum says. “For women who are told every year, to all of a sudden say every three years, that’s understandably confusing to people.”
Some doctors worry that women will skip annual check-ups if they don’t have an annual Pap test.
Dr. Kiley Manetta, an ob/gyn at Presbyterian Medical Group, suggests Pap tests after age 21 for most patients but still suggests annual tests for women between 20 and 30.
If a doctor is already doing a pelvic exam, Manetta says it is worth doing a Pap also. The test itself is not risky.
She prefers a case-by-case approach. Although cervical cancer is slow-growing, Manetta has had patients whose cancer develops quickly. One patient had a normal Pap test but returned two years later with a high-grade lesion.
If women forgo annual Paps they may also miss important care like thyroid or cholesterol checks.
“If their Pap smears are the sole driving force, then does their general health care kind of go out the window?” she says.
Moving away from annual Pap tests means reframing wellness visits, Baum says. Doctors can focus more on health concerns like contraception, sexually transmitted diseases and smoking or drinking.
“There are so many other ways you can use that time,” she says. “It’s not just about your breast and your cervix.”
There is more to a pelvic exam, in which doctors examine the vagina and cervix, than the Pap test, Waxman adds.
Unlike past years, recent draft guidelines are nearly identical, except when it comes to Pap and HPV tests at the same time, says Waxman. The U.S. Preventive Services Task Force says there is insufficient evidence to recommend co-testing. Other groups say women over 30 should have both tests every three to five years.
That difference could have a serious impact on cost. Under the Affordable Care Act, only “A” or “B” ratings by the task force are funded by Medicaid. Co-testing with HPV received an “I” for insufficient data.
Doing both tests provides extra assurance, Waxman says. If a woman has a normal Pap and is negative for HPV, her risk for cancer and precancer is extremely low over the next five to six years.
For women over 30 who have never had an abnormal Pap, Manetta tests for HPV. If both are negative, she tests again in three years.
One large European study found that if women had a normal Pap test, their risk of precancerous lesions or cancer in the next three years was about half of 1 percent. If an HPV test was also negative, the risk was about half of that, Waxman says.