September 14, 2017

Most women don't need both a Pap and an HPV test, USPSTF suggests

Daily Briefing

    The United States Preventative Services Task Force (USPSTF) on Tuesday released draft guidance on cervical cancer screenings, proposing for the first time that women ages 30 to 65 pick between either a Pap test or a human papillomavirus (HPV) test rather than receiving both.

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    USPSTF is accepting public comment on the proposed guidelines through Oct. 9.

    Background

    According to the American Cancer Society (ACS), nearly 13,000 U.S. women develop cervical cancer each year, and more than 4,000 die from the disease. However, cervical cancer screenings have drastically reduced the mortality rate of cervical cancer over the past 30 years, from 5.6 women per 100,000 in 1975 to 2.3 women per 100,000 in 2011.

    Overall, ACS estimates that cervical cancer screenings save over 4,000 lives each year.

    New recommendations

    USPSTF in the draft guidance recommended that otherwise healthy women ages 30 to 65 receive either a Pap test every three years or an HPV test every five years.

    The recommendation updates the panel's 2012 guidance, which recommended women ages 30 to 65 receive co-testing—both a Pap test and HPV test—every five years. According to the Associated Press, USPSTF proposed the new recommendations in light of research suggestion that the co-testing can lead to more false alarms than either test on its own, without any additional benefit for screened women.

    Aside from the new recommendations for women ages 30 to 65, the draft guidance affirms USPSTF's 2012 recommendations, NPR's "Shots" reports. Specifically, the guidance recommends that:

    • Women under age 21 do not receive cervical cancer screenings, unless they have an HIV infection or another condition that compromises her immune system;
    • Women ages 21 to 29 receive a Pap test every three years—but not an HPV test, which USPSTF said in that age group can lead to overtesting and overdiagnosis; and
    • Women over age 65 do not receive cervical cancer screenings unless they are deemed high-risk, such as those who do not have enough negative screenings in their medical history.

    According to "Shots," the new guidance—if confirmed—would more closely align USPSTF's stance on cervical cancer screening with guidance from the American College of Obstetricians and Gynecologists, the American College of Physicians, and other medical organizations, which recommend either the Pap smear every three years or both the Pap test and HPV test every five years. However, USPSTF's guidance marks the first that would recommend the HPV test without the Pap test.

    A harbinger of change, experts say

    Linus Chuang of the Icahn School of Medicine at Mount Sinai said the recommendations are "a big step forward" towards using HPV testing alone for cervical cancer screening, adding that "strategies such as self-collection of HPV DNA" should be looked at in the future.

    Kevin Ault, an assistant professor of OB-GYN at the University of Kansas Medical Center, explained, "Most of the value of co-testing is from the HPV test because it's specific—when it's negative, it's really negative—and it's very sensitive, so if you have a positive test, we're not going to miss people who have pre-cancer or cancer." He added that experts have "known for at least a couple decades that the Pap smear by itself misses some women with precancerous change. Some women have negative Pap smear but do have something, so we added the HPV test to catch it."

    That said, Ault cautioned that a positive HPV test doesn't guarantee that a woman will develop cervical cancer. Many cases of HPV clear on their own, particularly among younger women, Ault said, and an HPV infection takes between 10 and 30 years to develop into cancer—meaning that testing more frequently than every five years could lead to unnecessary treatment.

    While Ault said he believes the HPV test will become more routine over time, he cautioned that the rapidly evolving understanding of the disease has spurred a lot of clinical guidance updates, which can potentially confuse patients and deter adherence to the latest recommendations. "We still have to get women into these screens," Ault said. "We have to figure out how to reach [those with limited health literary or limited health care access] if we're really going to drive down cervical cancer rates in this country" (Walker, MedPage Today, 9/12; Haelle, "Shots," NPR, 9/12; AP/STAT News, 9/12).

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