Patient Care Hematology & Oncology - October 2007 - (Page 19)

Cervical cancer guidelines I ing, genuine false-positive results are mostly from misinterpretation of normal cellular changes due to metaplasia, atrophy, inflammation, or repair as being possibly neoplastic (misclassified cytology). More important, the natural history of progression of CIN 2,3 to invasion is usually one of very long duration, with most early cytologic abnormalities spontaneously regressing. Women screened more frequently are most at risk both for misclassified results and for having transient unimportant cytologic changes detected. Both result in a high potential for anxiety, inconvenience, and increased costs. The ideal goal is to eliminate the risk of getting cervical cancer with the highest degree of reliability and the fewest screens.17 may lower this risk further, but it is unlikely to ever achieve 100% protection. What has driven annual screening is this concern about missing precancer until cancer occurs, regardless of how rarely that happens in well-screened Case 2: An abstinent 22-year-old A 22-year-old woman is in to renew the oral contraceptives that she has been on for 3 years to control acne. The patient states that she has never had intercourse and would prefer not to have a pelvic exam and does not feel she needs to have cervical screening. The American Cancer Society guidelines support this woman’s choice not to have a Pap if she clearly has no history of sexual activity (including sexual abuse) and chooses not to have cervical screening after you have counseled her that such screening and a pelvic exam are usually standard for women aged 21 and older, even when virginal. The visit does provide an opportunity to review her health history and medications, to counsel her on contraceptive options and protection from sexually transmitted infections were she to become sexually active, and to perform a general physical exam. Provider discretion and patient choice following counseling should be used to guide the initiation of cervical cytology screening in young women aged 21 and older who have never had vaginal intercourse and for whom the absence of a history of sexual abuse is certain.1 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. Extending the interval: Women having more than 3 consecutive normal Pap tests Three or more consecutive normal Paps reduce the risk of missed CIN 2,3+ to a level that’s acceptable in the public health arena.18,19 Whether this level of risk reduction is acceptable to clinicians and their patients is another story that has long been debated. True, the absolute risk of developing cervical cancer does diminish as the number of consecutively normal Pap results accrues: from 3.09/100,000 women within 18 months of a single normal Pap result, decreasing to 2.56 for 2 consecutive normal results and to 1.43 for 3.20 But while the absolute risk is low, the less good news is that these numbers are consistent with other studies that also demonstrate a doubling of the relative risk (RR) at 2-year screening intervals and a tripling of RR at 3-year intervals, when compared to annual screening.20 Even annual screening for life never achieves 100% protection. If all women in the United States were screened annually, it is estimated that there would still be 1.5 cases of cervical cancer per 100,000 women having at least 3 consecutive normal Paps prior to the diagnosis of cancer.1,20 Certainly screening with newer technologies that have higher sensitivity than conventional cytology OCTOBER 2007 PATIENT CARE HEMATOLOGY & ONCOLOGY 19

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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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