Guidelines push back age for cervical cancer tests
New guidelines for cervical cancer screening say women should delay their first Pap test until age 21, and be screened less often than recommended in the past.
The advice, from the American College of Obstetricians and Gynecologists, is meant to decrease unnecessary testing and potentially harmful treatment, particularly in teenagers and young women. The group’s previous guidelines had recommended yearly testing for young women, starting within three years of their first sexual intercourse, but no later than age 21.
Arriving on the heels of hotly disputed guidelines calling for less use of mammography, the new recommendations might seem like part of a larger plan to slash cancer screening for women. But the timing was coincidental, said Dr. Cheryl B. Iglesia, the chairwoman of a panel in the obstetricians’ group that developed the Pap smear guidelines. The group updates its advice regularly based on new medical information, and Dr. Iglesia said the latest recommendations had been in the works for several years, “long before the Obama health plan came into existence.”
She called the timing crazy, uncanny and “an unfortunate perfect storm,” adding, “There’s no political agenda with regard to these recommendations.”
Dr. Iglesia said the argument for changing Pap screening was more compelling than that for cutting back on mammography — which the obstetricians’ group has staunchly opposed — because there is more potential for harm from the overuse of Pap tests. The reason is that young women are especially prone to develop abnormalities in the cervix that appear to be precancerous, but that will go away if left alone. But when Pap tests find the growths, doctors often remove them, with procedures that can injure the cervix and lead to problems later when a woman becomes pregnant, including premature birth and an increased risk of needing a Caesarean.
Still, the new recommendations for Pap tests are likely to feed a political debate in Washington over health care overhaul proposals. The mammogram advice led some Republicans to predict that such recommendations would lead to rationing.
Senator Tom Coburn, a Republican from Oklahoma who is also a physician, said in an interview that he would continue to offer Pap smears to sexually active young women. Democratic proposals to involve the government more deeply in the nation’s health care system, he said, would lead the new mammography, Pap smear and other guidelines to be adopted without regard to patient differences, hurting many people.
“These are going to be set in stone,” Mr. Coburn said.
Senator Arlen Specter, a Pennsylvania Democrat and longtime advocate for cancer screening, said in an interview: “And this Pap smear guideline is yet another cut back in screening? That is curious.” Mr. Specter, who was treated for Hodgkin’s lymphoma in 2005 and 2008, said Congress was committed to increasing cancer screenings, not limiting them.
Representative Rosa DeLauro, Democrat of Connecticut, said that the new guidelines would have no effect on federal policy and that “Republicans are using these new recommendations as a distraction.”
“Making such arguments, especially at this critical point in the debate, merely clouds the very simple issue that our health reform bill would increase access to care for millions of women across the country,” she said.
There are 11,270 new cases of cervical cancer and 4,070 deaths per year in the United States. One to 2 cases occur per 1,000,000 girls ages 15 to 19 — a low incidence that convinces many doctors that it is safe to wait until 21 to screen.
The doctors’ group also felt it was safe to test women less often because cervical cancer grows slowly, so there is time to catch precancerous growths. Cervical cancer is caused by a sexually transmitted virus, human papillomavirus, or HPV, that is practically ubiquitous. Only some people who are exposed to it develop cancer; in most, the immune system fights off the virus. If cancer does develop, it can take 10 to 20 years after exposure to the virus.
The new guidelines say women 30 and older who have three consecutive Pap tests that were normal, and who have no history of seriously abnormal findings, can stretch the interval between screenings to three years.
In addition, women who have a total hysterectomy (which removes the uterus and cervix) for a noncancerous condition, and who had no severe abnormalities on previous Pap tests, can quit having the tests entirely.
The guidelines also say that women can stop having Pap tests between 65 and 70 if they have three or more negative tests in a row and no abnormal test results in the last 10 years.
The changes do not apply to women with certain health problems that could make them more prone to aggressive cervical cancer, including H.I.V. infection or having an organ transplant or other condition that would lead to a suppressed immune system.
It is by no means clear that doctors or patients will follow the new guidelines. Medical groups, including the American Cancer Society, have been suggesting for years that women with repeated normal Pap tests could begin to have the test less frequently, but many have gone on to have them year after year anyway.
Debbie Saslow, director of breast and gynecologic cancer for the American Cancer Society, said professional groups were particularly concerned because many teenagers and young women were being tested and then needlessly subjected to invasive procedures.
In addition, Dr. Saslow said, doctors in this country have been performing 15 million Pap tests a year to look for cervical cancer in women who have no cervix, because they have had hysterectomies.
Dr. Carol L. Brown, a gynecologic oncologist and surgeon at Memorial Sloan-Kettering Cancer Center, said the new guidelines should probably not be applied to all women, because there are some girls who begin having sex at 12 or 13 and may be prone to develop cervical cancer at an early age.
“I’m concerned that whenever you send a message out to the public to do less, the most vulnerable people at highest risk might take the message and not get screened at all,” Dr. Brown said.
Dr. Kevin M. Holcomb, an associate professor of clinical obstetrics and gynecology at NewYork-Presbyterian/Weill Cornell hospital, said that when he heard the advice to delay Pap testing until 21, “My emotional response is ‘Wow, that seems dangerous,’ and yet I know the chances of an adolescent getting cervical cancer are really low.”
As with the new mammogram recommendations, women may not readily give up a yearly cancer test.
“For people who’ve been having the testing regularly every year, it’s a big emotional change to test less frequently and there’s this fear of ‘Oh my gosh, I might be missing something,’ ” said Ivy Guetta, 49, of Westport, Conn., who plans to continue with annual Pap tests. Ms. Guetta has three daughters, ages 17, 14 and 8, and at the moment, she would not encourage them to wait until they turn 21.
Jen Jemison, 24, a legal assistant from Babylon, N.Y., said she thought she began getting Pap smears when she was about 18, but said that if she had been aware that the procedure for treating precancerous lesions could lead to premature births, she would have waited until she turned 21.
On the other hand, Ms. Jemison said that now that she is over 21, “I would still go every year” for the Pap test.
“One of my cousins had cervical cancer, so that’s in my head too,” she said. “I’d rather get it checked out regularly than have to worry about that.”
Panel urges mammograms at 50, not 40
Most women should start regular breast cancer screening at age 50, not 40, according to new guidelines released Monday by an influential group that provides guidance to doctors, insurance companies and policy makers.
The new recommendations, which do not apply to a small group of women with unusual risk factors for breast cancer, reverse longstanding guidelines and are aimed at reducing harm from overtreatment, the group says. It also says women age 50 to 74 should have mammograms less frequently — every two years, rather than every year. And it said doctors should stop teaching women to examine their breasts on a regular basis.
Just seven years ago, the same group, the United States Preventive Services Task Force, with different members, recommended that women have mammograms every one to two years starting at age 40. It found too little evidence to take a stand on breast self-examinations.
The task force is an independent panel of experts in prevention and primary care appointed by the federal Department of Health and Human Services.
Its new guidelines, which are different from those of some professional and advocacy organizations, are published online in The Annals of Internal Medicine. They are likely to touch off yet another round of controversy over the benefits of screening for breast cancer.
Dr. Diana Petitti, vice chairwoman of the task force and a professor of biomedical informatics at Arizona State University, said the guidelines were based on new data and analyses and were aimed at reducing the potential harm from overscreening.
While many women do not think a screening test can be harmful, medical experts say the risks are real. A test can trigger unnecessary further tests, like biopsies, that can create extreme anxiety. And mammograms can find cancers that grow so slowly that they never would be noticed in a woman’s lifetime, resulting in unnecessary treatment.
Over all, the report says, the modest benefit of mammograms — reducing the breast cancer death rate by 15 percent — must be weighed against the harms. And those harms loom larger for women in their 40s, who are 60 percent more likely to experience them than women 50 and older but are less likely to have breast cancer, skewing the risk-benefit equation. The task force concluded that one cancer death is prevented for every 1,904 women age 40 to 49 who are screened for 10 years, compared with one death for every 1,339 women age 50 to 59, and one death for every 377 women age 60 to 69.
The guidelines are not meant for women at increased risk for breast cancer because they have a gene mutation that makes the cancer more likely or because they had extensive chest radiation. The task force said there was not enough information to know whether those women would be helped by more frequent mammograms or by having the test in their 40s. Other experts said women with close relatives with breast cancer were also at high risk.
Dr. Petitti said she knew the new guidelines would be a shock for many women, but, she said, “we have to say what we see based on the science and the data.”
The National Cancer Institute said Monday that it was re-evaluating its guidelines in light of the task force’s report.
But the American Cancer Society and the American College of Radiology both said they were staying with their guidelines advising annual mammograms starting at age 40.
The cancer society, in a statement by Dr. Otis W. Brawley, its chief medical officer, agreed that mammography had risks as well as benefits but, he said, the society’s experts had looked at “virtually all” the task force and additional data and concluded that the benefits of annual mammograms starting at age 40 outweighed the risks.
Other advocacy groups, like the National Breast Cancer Coalition, Breast Cancer Action, and the National Women’s Health Network, welcomed the new guidelines.
“This is our opportunity to look beyond emotions,” said Fran Visco, president of the National Breast Cancer Coalition. The task force “is an independent body of experts that took an objective look at the data,” Ms. Visco said. “These are the people we should be listening to when it comes to public health messages.”
Some women, though, were not pleased. “I know so many people who had breast cancer and survived, and what saved their lives was early detection,” Janet Doughty, 44, of San Clemente, Calif., said in a telephone interview. She said she had had an annual mammogram since her late 30s and would not stop now.
The guidelines are not expected to have an immediate effect on insurance coverage but should make health plans less likely to aggressively prompt women in their 40s to have mammograms and older women to have the test annually.
Congress requires Medicare to pay for annual mammograms. Medicare can change its rules to pay for less frequent tests if federal officials direct it to.
Private insurers are required by law in every state except Utah to pay for mammograms for women in their 40s.
But the new guidelines are expected to alter the grading system for health plans, which are used as a marketing tool. Grades are issued by the National Committee for Quality Assurance, a private nonprofit organization, and one measure is the percentage of patients getting mammograms every one to two years starting at age 40.
That will change, said Margaret E. O’Kane, the group’s president, who said it would start grading plans on the number of women over 50 getting mammograms every two years.
The message for most women, said Dr. Karla Kerlikowske, a professor in the department of medicine, epidemiology and biostatistics at the University of California, San Francisco, is to forgo routine mammograms if they are in their 40s.
Starting at age 50, Dr. Kerlikowske said, “the message is to get 10 mammograms in a lifetime, one every two years.” That way they get the most benefit and the least harm from the test. If women are healthy, she added, they might consider having mammograms every two years until age 74.
Nearly two-thirds of all women in their 40s had mammograms within the last two years, as did 72 percent of women age 50 to 65, according to an editorial by Dr. Kerlikowske that accompanies the report.
In order to formulate its guidelines, the task force used new data from mammography studies in England and Sweden and also commissioned six groups to make statistical models to analyze the aggregate data. The models were the only way to answer questions like how much extra benefit do women get if they are screened every year, said Donald A. Berry, a statistician at the University of Texas M. D. Anderson Cancer Center and head of one of the modeling groups.
“We said, essentially with one voice, very little,” Dr. Berry said. “So little as to make the harms of additional screening come screaming to the top.”
The harms are nearly cut in half when women have mammograms every other year instead of every year. But the benefits are almost unchanged.
The last time the task force issued guidelines for mammograms, in 2002, the reportwas announced by Tommy G. Thompson, the secretary of health and human services. When the group recommended mammograms for women in their 40s, some charged the report was politically motivated. But Dr. Alfred Berg of the University of Washington, who was the task force chairman at the time, said “there was absolutely zero political influence on what the task force did.”
It was still a tough call to make, Dr. Berg said, adding that “we pointed out that the benefit will be quite small.” In fact, he added, even though mammograms are of greater benefit to older women, they still prevent only a small fraction of breast cancer deaths.
Different women will weigh the harms and benefits differently, Dr. Berg noted, but added that even for women 50 and older, “it would be perfectly rational for a woman to decide she didn’t want to do it.”
Researchers worry the new report will be interpreted as a political effort by the Obama administration to save money on health care costs.
Of course, Dr. Berry noted, if the new guidelines are followed, billions of dollars will be saved.
“But the money was buying something of net negative value,” he said. “This decision is a no-brainer. The economy benefits, but women are the major beneficiaries.”
Roni Caryn Rabin contributed reporting.
This article has been revised to reflect the following correction:
Correction: November 19, 2009
An article on Tuesday about revised guidelines on breast cancer screening misstated a statistic from the United States Preventive Services Task Force, which released the recommendations. The task force concluded that one cancer death was prevented for every 1,339 women aged 50 to 59 who were screened for 10 years — not 50 to 74.
I don't know what to think. I've heard some women say that these changes are purely to minimize costs to insurance companies. This makes a lot of sense to me. However, the Times reports on this as though the benefit to women actually does outweigh the potential risks. What does VP think?
Complete with the new "Female Sexual Dysfunction", I just wish that I could trust that someone out there had my best interests at heart. It gets so tiresome to have to constantly be on top of issues like this to make sure that I'm not getting scammed, or duped by my insurance company into reducing costs to them.