When the Canadian Medical Association recommendations on new guidelines for screening for cervical cancer came out recently several of my sexual health colleagues were aghast. They asked me if it was part of an austerity program—cutbacks on screening programs. In my opinion, not this time.
Women and health-care providers are well aware that regular Pap testing is essential to women’s health. Pap screening has reduced deaths from cervical cancer by 70 per cent. The reason it has been so effective is that when irregular cells are detected, a woman can be followed and treated when necessary to prevent these cells from becoming cancer. Cervical cancer is very slow growing (10 to 20 years).
Until recently, most women were told they needed an annual Pap test. It was often done at the annual health exam. Some clinics tied it to birth control pill renewal to ensure that women were screened.
The most notable changes from the CMA are the recommended age to begin testing and the interval between tests.
According to the CMA, testing should begin at age 25. Regular screening should take place at three-year intervals until age 70. There are, of course, exceptions, in particular for women with symptoms of cervical cancer or previous abnormal test results on cervical screening; and for immunosuppressed women (e.g., women with HIV/AIDS).
The CMA’s reasoning is that while there is strong evidence for screening women 30 to 69, the value of screening and the balance of benefits and harms for women outside this age group is unclear. That is why the recommendation for routine screening for women 25 to 29 is weaker; and the recommendation for women 20 to 24 is for not routinely screening for cervical cancer; the CMA also recommends ending screening at the age of 70.
Two fundamental developments motivated the new guidelines.
We have known for more than a decade that cervical cancer is caused by persistent Human Papillomavirus (HPV) infection, combined with other factors such as smoking. What we have learned since then is how the body deals with the virus. Not only do most people clear HPV from their bodies without medical intervention, but the majority of women under the age of 30 (especially if they do not smoke) will have a normal result after a finding of Atypical Squamous Cells of Undetermined Significance (ASCUS), a Low-Grade Intraepithelial Lesion (LSIL) and even, in some cases, after a high-grade lesion is found. Current management of irregular results (recalls for Pap testing and repeated colposcopy) was deemed to cause more harm than good. Like breast self-examination, what appeared to be abnormalities, resulted in over-testing and anxiety for the women being tested, without reducing sickness and death.
The second change was the advent of HPV testing. Because there are certain strains associated with cervical cancer, it began to make sense to limit further testing like colposcopy to the women who had these strains. For over a decade, panels of researchers have been trying to decide how to integrate HPV testing into Pap screening. In some provinces, women over 30 are offered HPV testing following a specific abnormal result.
As the research evolved, the management of abnormal results in the sexual health clinic where I worked also evolved. Sending women for colposcopy became more selective depending on the result, as did the frequency of recall for abnormal Pap tests.
While I consider the new recommended guidelines to be a step in the right direction, my only disappointment is the lack of discussion about risky sexual activity and sexually transmitted infections (STIs). In my experience, women often think they are being tested for STIs when they have a Pap test; and think that when they have a Pap test, they are also being tested for STIs. This is not necessarily the case.
Women under 25 may or may not be having sexual activity. For that reason the CMA acknowledges that a woman who has not had had oral, vaginal, or digital sexual activity before age 25 need not start Pap screening.
However, women who have had unprotected sexual activity need to be tested for Chlamydia, gonorrhea and HIV. Women who share needles or crack pipes need to be tested for Hepatitis C. Women who notice unusual symptoms (or whose partner has unusual symptoms) need to see their health-care provider. While a Pap test may uncover HPV or herpes on the cervix, it is not an STI test.
So here are the take home messages:
Anyone with a cervix needs Pap testing. If you have sex with women or if you are a trans man with a cervix, this includes you.
Get tested for STIs as necessary—new partner, unusual symptoms, broken condom…
Information changes practice. Rightly so.