Cervical cancer screening and prevention 2016
COMMITTEE ON PRACTICE BULLETINS—Gynecology Practice Bulletin #157: Cervical Cancer Screening and Prevention (Replaces Practice Bulletin Number 131, November 2012). American College of Obstetricians and Gynecologists. Obstet Gynecol. 2016;127:e1–20. Full text of Practice Bulletin #168, an interim update of #157, is available to ACOG members at http://www.acog.org/Resources%20And%20Publications/Practice%20Bulletins/...
Cervical Cancer Screening and Prevention
The incidence of cervical cancer in the United States has decreased more than 50% in the past 30 years because of widespread screening. In 1975, the rate was 14.8 per 100,000 women. By 2011, it decreased to 6.7 per 100,000 women. Mortality from the disease has undergone a similar decrease from 5.55 per 100,000 women in 1975 to 2.3 per 100,000 women in 2011 (1). The American Cancer Society (ACS) estimated that there would be 12,900 new cases of cervical cancer in the United States in 2015, with 4,100 deaths from the disease (2). Cervical cancer is much more common worldwide, particularly in countries without screening programs, with an estimated 527,624 new cases of the disease and 265,672 resultant deaths each year (3). When cervical cancer screening programs have been introduced into communities, marked reductions in cervical cancer incidence have followed (4, 5).New technologies for cervical cancer screening continue to evolve, as do recommendations for managing the results. In addition, there are different risk–benefit considerations for women at different ages, as reflected in age-specific screening recommendations. In 2011, the ACS, the American Society for Colposcopy and Cervical Pathology (ASCCP), and the American Society for Clinical Pathology (ASCP) updated their joint guidelines for cervical cancer screening (6), as did the U.S. Preventive Services Task Force (USPSTF) (7). Subsequently, in 2015, ASCCP and the Society of Gynecologic Oncology (SGO) issued interim guidance for the use of a human papillomavirus (HPV) test for primary screening for cervical cancer that was approved in 2014 by the U.S. Food and Drug Administration (FDA) (8). The purpose of this document is to provide a review of the best available evidence regarding the prevention and early detection of cervical cancer.
Used with permission. Copyright the American College of Obstetricians and Gynecologists.
Cervical cancer screening and prevention 2016
By Ilana Cass, MD
Dr Cass is Vice Chair, Associate Clinical Professor, Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California. She is also a member of the Contemporary OB/GYN editorial board.
Practice Bulletin #157, published in January 2016, replaces Practice Bulletin #131 from November 2012. (Practice Bulletin #168 [October 2016] is an interim update of #157.) Practice Bulletin #157 summarized the Bethesda 2014 Classification system for reporting cervical cytology and corresponding consensus management guidelines, expanded upon recent data regarding HPV testing, both as an adjunct to conventional cervical cytology and as primary cervical cancer screening alone, and compared efficacy of the 3 available HPV vaccines. Level A evidence provides support for lengthening screening intervals based upon the powerful negative predictive value of HPV testing and the natural history of HPV infection.
Practice Bulletin #157 reflects the ongoing efforts to balance the benefits and harms of cervical cancer screening to identify the optimal screening tools and intervals for women.
The 2001 Bethesda system for reporting cervical cytology results and the seminal findings from the National Cancer Institute (NCI) ALTS trial for the triage of ASCUS and LSIL cytology paved the way for the creation of a standard management approach for women with abnormal cervical cytology. The American Society for Colposcopy and Cervical Pathology (ASCCP) developed evidence-based guidelines aligned with the Bethesda classification system to manage women with abnormal cervical cytology.1
In 2012, organizations including the American Cancer Society, the ASCCP, and the US Preventative Services Taskforce endorsed longer intervals between cervical cancer screening and delaying the onset of cervical cancer screening to age 21 for average-risk women. Cervical cancer screening further evolved with widespread adoption of co-testing as an alternative to cytology alone.2 A large clinical database at the Kaiser Permanente Medical Group Northern California provided evidence to guide management of abnormal cervical cancer screening tests including cytology and HPV co-testing.3,4 More than 900,000 women aged 30 to 64 were screened with co-testing between 2006 and 2010.
Analysis of data for 5-year CIN 3+ and cancer risks based upon HPV and cytology results are presented in the bulletin. The authors concluded that HPV status was a better predictor of CIN 3+ and cancer risk than cytology alone. Using the principle that women with similar risks of cervical neoplasia should be managed in similar ways, current consensus guidelines reflect estimated risks of CIN 3+ and cancer based upon patient age, cytology diagnosis, and HPV status, specifically infection with HPV-16 or 18.3,5 Co-testing in women over age 30 has led to the recommendation to further extend intervals between screening for low-risk women (HPV- and cytology-negative) and simplified surveillance for women who are HPV-positive but have normal cytology.