No Yearly PAP? How to Interpret Changing Guidelines

By Gretchen Fermann, MD

You may have heard about changing guidelines for how often cervical cancer screening tests should be done. Or you may just have heard that women don’t need a PAP yearly anymore. I’m sure you were rejoicing, as this tops the list of least-liked activities among women, followed closely by getting a root canal.

Here is the reasoning behind the change and a summary of the guidelines:

HPV is a common viral infection than can cause genital warts (low risk types) or cervical cancer (high risk types). This is most commonly a sexually transmitted virus. Eighty percent of women will be exposed to HPV at some point in their life but rarely will they develop cervical cancer. Most women who get exposed to HPV also get rid of it in one or two years thereby making it a rather transient infection.

Co-testing is the name for the screening tool that combines the PAP, looking at the cells under a microscope, with a DNA test for the presence of High Risk (HR) HPV. The increased likelihood that a person with an abnormality will be picked up by co-testing compared to that of a PAP alone has allowed spacing out of the screening interval. Additionally, the combination of a negative PAP with a NEG HR HPV test gives nearly 100% assurance of no high-grade pre-cancer nor cervical cancer in the subsequent 3 years.

PAP smear screening now begins at age 21 and is done every 3 years. At age 30, the HR HPV test is added to the PAP, and co-testing continues every three to five years until age 65. This protocol is used as long as testing remains NEGATIVE. More frequent testing or other tests (such as a colposcopy) may be recommended if testing is abnormal.

Just because a PAP smear isn’t recommended yearly doesn’t mean you can skip your annual exam! There are many reasons to continue with annual exams, which are opportunities for education, screening, and preventative healthcare.

Though co-testing will reduce the cost of cervical cancer screening, that was not the motivation for the change. The benefit to women who co-test negative is that they have better reassurance that they won’t be diagnosed with cancer in the next three years. They can also avoid having minor abnormalities detected from transient HPV infections that will likely resolve on their own, and so avoid unnecessary visits, biopsies, and procedures.

The benefit to women who co-test PAP-negative but HR HPV-positive is that their health care providers can recognize that they are the group at risk for subsequent diagnoses of a high-grade pre-cancer or cancer, and provide intensified follow-up. Prior to co-testing, about 30 percent of cervical cancers were preceded by only negative PAPs in the three years prior to diagnosis.

So, let’s usher in this new era of cervical cancer screening with gratitude to the HPV researchers who have allowed us to have our cake and eat it, too; we can have improved cervical cancer detection AND reduced frequency of testing.

Gretchen Fermann, MD, is a board-certified gynecologist practicing with Seven Hills Women’s Health Centers in Cincinnati, OH.

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