A board-certified obstetrician and gynecologist expresses his concerns about the new ACS cervical cancer screening guidelines.

By Michael D. Randell, MD, FACOG

Recently the American Cancer Society (ACS) updated its screening guidelines for cervical cancer to advocate a human papillomavirus (HPV) test every 5 years for women between the ages of 25 and 65 years.1 The new guideline raises the minimum screening age, and it represents a shift away from cotesting that combines the HPV with a Papanicolaou (Pap) test. These changes are a drastic departure from the guidelines of medical institutions including the American College of Obstetricians and Gynecologists (ACOG).2-4 By prioritizing HPV testing alone over cotesting, I believe we are taking a step backward in the standard of care provided to women and limiting the opportunities for women and their healthcare providers to make choices together on the method and frequency of cervical cancer screening. 

Photo RandellMichael-cropped

Michael D. Randell, MD, FACOG

The primary purpose of cervical cancer screening is the detection of cancerous and precancerous lesions (CIN3/AIS). Several studies5-7 have shown that screening with cotesting detects more cancerous and precancerous lesions than either Pap or HPV alone, which is why this approach is trusted and used by the majority of healthcare providers.8 A paper from Quest Diagnostics showed that cotesting (vs HPV testing) was more effective at diagnosing CIN3/AIS precancer and that HPV testing alone missed twice as many cervical cancer cases compared to cotesting.5 These data highlight the importance of considering real-world data, with a nationally representative population and screening practices, when determining guidelines.   

The new ACS guidelines also now state that testing should begin at the age of 25 years, compared to previous recommendations that screening begin at age 21. While a low percentage (about 0.5%) of women under the age of 25 years die from cervical cancer,1 these are young women who could be saved by testing earlier with the Pap test.  Based on the evidence provided in the guideline, it is difficult to understand what convinced the ACS that changes needed to be made or that delaying care and performing HPV testing alone would provide better care in the United States.

The model that informed the ACS guidelines indicated that cotesting identifies more CIN2 and CIN3 than HPV testing alone (while requiring fewer colposcopies), which is at odds with another output from their model showing that cotesting would lead to higher rates of cervical cancer incidence and death.7 The modeling data1,9 behind changes to HPV testing from cotesting do not incorporate the opportunistic nature of screening (without adequate primary or secondary prevention uptake) in the United States compared with other countries.10 Public access to all inputs and assumptions of this model is a crucial next step for clinical understanding and transparency.  Since the introduction of Pap testing, great strides have been made in reducing the mortality rate of cervical cancer,11,12 which was once the leading cause of cancer death in US women.13

Recently, data indicate that cervical cancer rates are becoming stagnant and even rising in some areas.14,15 These guidelines are moving us further away from our goal of providing the optimal health services to our patients, and it is difficult to understand why. All women should have the opportunity for early and accurate diagnostic testing that has been proven to save lives, which is why healthcare providers should continue to follow the guidelines of the ACOG and others that call for the initiation of cervical cancer screening with a Pap test at age 21 and for cotesting starting at age 30. This will allow healthcare providers to best safeguard their patients’ health. 

Michael D. Randell, MD, FACOG, is a board-certified obstetrician and gynecologist in private practice in Atlanta, and he is on staff at Emory Saint Joseph’s Hospital. He is a Diplomate of the American Board of Obstetrics and Gynecology and the National Board of Medical Examiners, and he is a Fellow of the American College of Obstetricians and Gynecologists.

References  

1. Fontham ETH, et al. Cervical cancer screening for individuals at average risk: 2020 guideline update from the American Cancer Society. CA Cancer J Clin. 2020. (In press).

2. American College of Obstetricians and Gynecologists. Cervical cancer screening (update). https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/2018/08/cervical-cancer-screening-update. Accessed June 18, 2020.

3. US Preventive Services Task Force. Screening for cervical cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2018;320:674-686.

4. Women’s Preventive Services Guidelines. www.hrsa.gov/womens-guidelines-2016/index.html. Accessed July 29, 2020.

5. Kaufman H, et al. Contributions of Liquid-Based (Papanicolaou) cytology and human papillomavirus testing in cotesting for detection of cervical cancer and precancer in the United States. Am J Clin Pathol. July 8, 2020.

6. Austin RM, et al. Enhanced detection of cervical cancer and precancer through use of imaged liquid-based cytology in routine cytology and HPV co-testing. Am J Clin Pathol. 2018;150:385-392.

7. Schiffman M, et al. Relative performance of HPV and cytology components of cotesting in cervical screening. J Natl Cancer Inst. 2018;110:501-508. 

8. Albright DM, Rawlins S, Wu JS. Cervical cancer today: survey of screening behaviors and attitudes. Women’s Healthcare. 2020;8:41-46.

9. Kim JJ, Burger EA, Regan,C, et al. Screening for cervical cancer in primary care: a decision analysis for the US Preventive Services Task Force. JAMA. 2018; 320(7): 706-714.

10. Nayar R, Goulart RA, Davey DD. Primary HPV cervical cancer screening in the United States: Are we ready? J Am Soc Cytopathol. 2018;7:50-55.

11. National Cancer Institute. SEER Stat Fact Sheets: Cervix Cancer. http://seer.cancer.gov/statfacts/html/cervix.html. Accessed August 6, 2020.

12. Centers for Disease Control and Prevention. Cervical Cancer Is Preventable. https://www.cdc.gov/vitalsigns/cervical-cancer/index.html. Updated November 5, 2014. Accessed July 29, 2020.

13. American Cancer Society. Cancer Facts and Figures 2020. https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2020/cancer-facts-and-figures-2020.pdf. Accessed July 29, 2020.

14. North American Association of Central Cancer Registries. Fast Stats https://faststats.naaccr.org/selections.php?#Output Accessed May 20, 2020.

15. Surveillance, Epidemiology, and End Results (SEER) Program (www.seer.cancer.gov) SEER*Stat Database: Incidence – SEER Research Data, 9 Registries, Nov 2019 Sub (1975-2017) – Linked To County Attributes – Time Dependent (1990-2017) Income/Rurality, 1969-2017 Counties, National Cancer Institute, DCCPS, Surveillance Research Program, released April 2020, based on the November 2019 submission.

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