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Pap smear guidelines may backfire for Some.

The recent guidelines on cervical cancer screening from the American College of Obstetricians and Gynecologists are well done. In general, the guidelines state that women should not have their first Pap smear before age 21, and that women aged 21-29 years can have Pap smears every 2 years. Women aged 30 and older who have had three consecutive negative cervical cytology test results may be screened once every 3 years with either a Pap smear or liquid-based cytology.

For the majority of the population, these are good guidelines. That's be cause most of the population--those who are insured and have access to the health care system--has an extremely low risk of cervical cancer. That's even more true if they have been exposed to the human papillomavirus vaccine.

In addition, there is a risk of overtreatment of dysplasia in younger women (under 30 years old), for whom most dysplasia resolves on its own. I recently saw published data linking surgical excision procedures to preterm delivery (Obstet. Gynecol. 2009;114:504-10; Am. J. Obstet. Gynecol. 2009;201:33.el-6). Therefore, in terms of reducing the number of procedures done on younger women, the guidelines are helpful.

The problem with these guidelines comes with the medically underserved population. That's because cervical cancer is really a disease of patients who don't have access to medical care. Of the 11,000 cervical cancer cases in this country every year, more than half of the patients either have never had a Pap smear or have not had one within the past 5 years. For the remaining patients who are at low risk anyway and have already been screened, these are probably good recommendations, but I'm worried that underscreened patients will hear these recommendations and think that they really don't need to worry about getting a Pap smear. This could potentially increase the disparity that already exists.

Another group that these recommendations may not be appropriate for is young women who are at high risk for dysplasia and cancer. For Pap smear screening to reach 90% sensitivity, you really need to have three negative Pap smears in a row, because there are a fair number of false negatives with this test. If a patient gets her first false negative at 21 and--following the new guidelines-gets the next false negative at 23, then by the time she is 25, a Pap smear could show advanced dysplasia or even cancer. So young women who are at high risk of cervical cancer, such as those who become sexually active at 11 or 12, should start their Pap smear earlier than the rest of the population, and have it done annually.

It is important to remember that there is still a large group of women that will require yearly Pap smears. These are women over age 30 with a history of dysplasia, a new sex partner, or a sex partner who's not monogamous with them. Also, women who are immunosuppressed by HIM, organ transplant, or chronic steroid use should be screened annually.

I am optimistic that the cervical cancer recommendations, along with new recommendations from the U.S. Preventive Services Task Force advising that certain women need fewer mammograms than they're currently being given, will not result in women visiting their ob.gyn, less often. Ob.gyns. are the primary providers to the majority of women under 40 who don't have an internist. For that population, the ob.gyn, is stall going to be their primary care physician.

I also am hopeful that there will be some changes coming in health care policy that will allow more people to have access to health care within the next few years. In cervical cancer, access is deftnitely the issue.

Dr. Temkin is assistant professor of obstetrics and gynecology in the division of gynecologic oncology at the University of Maryland, Baltimore.
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Author:Temkin, Sarah M.
Publication:Family Practice News
Article Type:Viewpoint essay
Geographic Code:1USA
Date:Dec 1, 2009
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