Patient Care Hematology & Oncology - October 2007 - (Page 18)

I Cervical cancer guidelines Case 1: A sexually active 16-year-old A 16-year-old girl who first had intercourse at age 13 is in the office for contraception. Contraceptive and sexually transmitted infection (STI) counseling, standard physical examination, speculum examination, Pap test, chlamydia testing, and pelvic examination were performed as per recommended guidelines that women have their first Pap test approximately 3 years from first intercourse or by age 21.1,2 The patient has declined testing for gonorrhea, HIV, and syphilis. But what if the patient had started intercourse only 2 years ago? In this circumstance a Pap test would not be preferred, but under the current guidelines you could elect to do a Pap. The adolescent may have a fairly high likelihood of unimportant transient human papillomavirus (HPV) cellular changes that might place her in an abnormal Pap management protocol, but patient choice and provider discretion are always protected. The other tests would remain the same. It is important to remember that for most young women contraceptive care and STI screening, and not cervical screening, are the primary reason for their visit. If having a Pap (“My mother told me it’s time for me to have my first Pap”) is the primary reason for the visit, a simple discussion of the reasoning behind the new guidelines suffices for most, and the visit provides the opportunity to explore the need for these and other preventive health care options. 1. Saslow D, Runowicz CD, Solomon D, et al. American Cancer Society guideline for the early detection of cervical neoplasia and cancer. CA Cancer J Clin. 2002;52:342-362. 2. American College of Obstetricians and Gynecologists. Cervical Cytology Screening. ACOG Practice Bulletin Number 45. Washington, DC; August 2003. years until age 30, to maximize detection and treatment of high-grade precancer before it has the opportunity to progress to invasion.1,2 The ACS— having become convinced that liquid-based cytology (LBC) is more sensitive for CIN 2,3+ than the conventional Pap smear—made a major departure from its previous screening recommendations by supporting 2-year screening intervals for women younger than age 30 only if they are screened with LBC. But, as mentioned, the group still recommends annual cytology for women in this age-group screened with the conventional Pap smear.1 In contrast, ACOG recommends annual screening regardless of the technology used.2 Both organizations recommend that screening intervals can be widened to 2 to 3 years for women aged 30 and older having 3 consecutive satisfactory normal Pap results, as these women are at less risk for subsequent detection of CIN 2,3+.1,2 The second option both organizations now give for extending the screening interval for women older than 30 is to screen with both a Pap (conventional or LBC) and a HPV test (combined testing), with women negative on both tests needing subsequent screening with this combination no more often than every 3 years.1,2 But always keep in mind that these screening recommendations apply only to women with normal immunity. Women with HIV should be followed at CDC-recommended intervals, and women with a history of in utero diethylstilbestrol exposure require annual screening.1,2,15 No other risk factors are considered important because adherence to these new screening recommendations prevents most cervical cancers irrespective of whether a woman has recently acquired a new partner or partners or has numerous sexual partners, a history of early sexual debut, or smokes.16 Importance of extending screening intervals With any screening test, the more frequently the test is done, the greater the likelihood over time that false-positive results will occur. In cervical screen- 18 PATIENT CARE HEMATOLOGY & ONCOLOGY www.patientcareonline.com http://www.patientcareonline.com

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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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