New cervical Ca screening guidelines recommend less frequent assessment
Annual assessment increases the harms of cervical cancer screening, compared with longer intervals, according to updated guidelines
IN THIS ARTICLE
What is the likely overall impact of new guidelines recommending less screening for cervical cancer?
We put this question—and others—to public health expert Neal M. Lonky, MD, MPH, clinical professor of obstetrics and gynecology at the University of California–Irvine and a member of the board of directors of Southern California Permanente Medical Group. Dr. Lonky serves as an OBG Management contributing editor. His responses offer a thoughtful commentary on the pressing issue of reducing the rate of cervical cancer in the United States.
“We have no evidence that any screening strategy will lower the cancer rate with any combination of cytology innovation or HPV test innovation,” he says. “These guidelines purely focus on ‘holding the gains’ on the current cancer incidence in the United States.”
OBG Management: Could you elaborate?
Dr. Lonky: The guidelines ask, “Are we wasting money?” and “Are we putting more women at risk with frequent testing?” They also go on to suggest that extra screening is prone to false-positive work-ups. They state that only CIN 3 is the true cancer precursor and that it should be the sole target of screening.
OBG Management: Do you think screening should be more frequent than the guidelines recommend?
Dr. Lonky: No, less screening is still safe—the extra cancer burden will be marginal, and some women who are not going to develop cervical cancer will be found to have CIN and treated unnecessarily. I think the common-sense response is: If we can prevent the same number of cancers with less use of screening resources and colposcopy, that is a good thing. We can use the savings to reach out to more women and increase the screening rate overall in the unscreened and under-screened populations.
OBG Management: Do you think the new guidelines fully address the issue of preventing cervical cancer?
Dr. Lonky: No, I don’t. What bothers me terribly is the fact that the focus is more on the resources and not on the cancer rate. We had wanted to address that rate with vaccination, but, due to low utilization of the vaccine, that strategy is unlikely to eradicate cervical cancer.
Until we create a therapy that is effective in altering the natural history of all CIN in any grade that it is detected, we will be unable to eradicate cervical cancer. Early CIN or HPV infection should be the target. Regrettably, research on an effective therapy is only beginning, and liberal, inappropriate use of destructive therapies increases the harms of finding early disease—and, therefore, the harms far exceed the benefits. The presumption that we can detect and treat CIN 3 just before it invades is woefully inadequate as a “screening” or “secondary prevention” strategy. We need to put more effort into finding an effective topical or oral therapy that will reverse the neoplastic progression of CIN 1+. If we had that, we could target early HPV infection or CIN 1 instead of CIN 3.
OBG Management: What do you make of the fact that about 50% of the cervical cancers that are diagnosed in the United States occur in women who have never been screened—and another 10% occur in women who have not been screened within the past 5 years?
Dr. Lonky: That means that 40% of the cancers in this country occur in women who are regularly screened—and the new guidelines do nothing to reduce that rate overall. If the argument is that society as a whole should re-invest the extra, ineffective dollars tied to screening women who are already well screened and shift those dollars to outreach to and screening of the under-screened or unscreened, I laud that, but I think that is an idealistic—not realistic—goal. Health care delivery and health- seeking behavior are tied to so many variables, such as insurance and employment, that this public health care goal cannot be guaranteed or the money easily redistributed. With these new guidelines, the overall cost of screening for cervical cancer should decrease, with little or no loss in effectiveness to prevent cervical cancer. Our next job is to find the better screening method or strategy and migrate to it, to lower the cancer rate.
Dr. Kaunitz also believes the updated guidelines could have an impact on women’s health-care–seeking behavior.
“Many ObGyns may be concerned that longer screening intervals may translate into fewer patient visits. As we implement these new guidelines in our practices, our challenge as women’s health clinicians will include educating our patients not only that cervical cancer screening can be performed less frequently without placing them at risk, but also that well-woman visits and pelvic examinations provide health benefits above and beyond early detection of cervical cancer,” he says.
