Patient Care Hematology & Oncology - October 2007 - (Page 17)

Cervical cancer guidelines I known oncogenic HPV types and yet spontaneously regress.10,11 The ACS and ACOG both now recommend that cervical screening begin approximately 3 years after the onset of vaginal intercourse, but no later than age 21.1,2 To avoid potential denial of health insurance coverage for teens and young women who have their first Pap test before the suggested “3 years from first intercourse,” the guideline deliberately dances around an exact date that screening should begin.1,2 Intercourse is designated the hallmark event for determining the age of onset of cervical screening because the risk of HPV transmission to the cervix is low for other types of sexual activity.1 Even though the guideline calls for screening to start no later than age 21, the ACS supports a delay in cervical screening for any virgin who chooses not to be screened, provided that her clinician first counsels her about the reasons for screening and that she has no history of sexual abuse.1 This approach spares young women unnecessary anxiety over an abnormal Pap report and eliminates unnecessary colposcopies, biopsies, and cervical treatments for an infection that is typically transient.13 Moreover, CIN 3 that develops at this young age will invariably continue to be present, detectable, and just as treatable when screening begins. Perhaps, like many colleagues, you are understandably concerned that delaying the onset of Pap screening will put adolescents at risk for not getting other care important to their age-group. Of course, contraceptive counseling is critical for young sexually active women, as is screening for sexually transmitted infections (STIs) that are so common. For that reason, ACOG and the ACS both recommend that women who have started having sex should have contraceptive services, screening for STIs, and other indicated preventive health care regardless of their cervical screening status. In other words, the Pap should not be the sole reason for the onset of gynecologic care.1,2 With these recommendations in mind, how would you approach management in Cases 1 and 2 (pages 18 and 19)? Women who have started having sex should have contraceptive services, screening for STIs, and other indicated preventive health care regardless of their cervical screening status. “Low-risk”: A pointless way to gauge how often to screen? Controversy has long existed on whether “low-risk” women could, or should, be screened less frequently. The 1977 Walton Report recommended that women considered at low risk for cervical neoplasia and having three consecutive normal Paps could have their next Pap smear in 2 to 3 years.14 Prior to 2002, this formed the basis of the ACS and ACOG recommendations for extending screening intervals. Despite this stance, however, annual screening remained the norm for almost all women because clinicians felt uncomfortable increasing the screening interval on the basis of mostly nonverifiable patient parameters like age at first intercourse, history of monogamy, lifetime number of partners, and lack of history of STIs. Nor could the partner’s history ever be verified. Clearly, it was impossible to determine if anyone was really low risk. The major departure in screening recommendations from both organizations was eliminating the term low risk in assessing whether a woman could be screened less often.1,2 Now, screening frequency is to be based on objective factors that depend solely on age and on sensitivity of the test used for detecting CIN 2,3 and cancer. Base how often to screen on age and sensitivity of test used The median age for detection of CIN 3 is 29 years.11 For that reason, both organizations oppose strategies that would lengthen screening intervals to 3 OCTOBER 2007 PATIENT CARE HEMATOLOGY & ONCOLOGY 17

Table of Contents Feed for the Digital Edition of Patient Care Hematology & Oncology - October 2007

Patient Care - Hematology & Oncology - October 2007 Research Digest Contents Information for Authors Medicine in the News Strategies for Bridge Anticoagulation Therapy How to Integrate the New Cervical Cancer Guidelines into Practice Dermatology Case Challenge Clinical Clips Classified Advertising

Patient Care Hematology & Oncology - October 2007

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