Multiple options for cervical cancer screening

August 23, 2018 9:13 AM | Anonymous

August 23, 2018, MedPage Today 

Routine screening for cervical cancer substantially reduces disease incidence and mortality for average-risk women ages 21 to 65, and the benefits outweigh the harms, the U.S. Preventive Services Task Force (USPSTF) concluded in a final guidance statement on the issue.

The recommendations encompassed multiple screening strategies. The task force concluded "with high certainty" that the benefits of screening women ages 21 to 29 every 3 years with cytology alone (Pap test) "substantially outweigh the harms." The USPSTF panel also concluded that screening every 3 years with a Pap test alone, every 5 years with high-risk human papillomavirus (hrHPV) DNA testing alone, or every 5 years with both tests (cotesting) provides benefits that outweigh the harms for women ages 30 to 65.

The final recommendations differed from the draft guidance, published in September 2017, by recognizing cotesting as an acceptable screening option. However, cotesting every 5 years for women 30 to 65 is identified as an "alternative" to the "preferred" strategies of cervical cytology or hrHPV testing alone.

"Women should choose which strategy is right for them after a discussion with their clinician," according to a statement from the USPSTF.

The task force's review of evidence showed that women younger than 21 or older than 65 do not benefit from screening, provided that women at the upper end of the age range were adequately screened in the past.

The recommendations, published in JAMA, apply to women with an intact cervix, irrespective of sexual history, but do not apply to women with a history of cervical cancer or precancerous cervical lesions.

"Screening for cervical cancer saves lives and identifies the condition early when it is treatable," said task force member Carol Mangione, MD, of UCLA. "There are several effective screening strategies available, so women should talk to their doctor about which one is right for them."

Added panelist Melissa Simon, MD, of Northwestern University's Feinberg School of Medicine in Chicago: "Most cases of cervical cancer occur in women who have not been regularly screened or appropriately treated. That's why it's important for women to be screened regularly throughout their lifetime and receive follow-up and treatment when needed."

The authors of an accompanying editorial lauded the USPSTF for including cotesting as an option for cervical cancer screening.

"The USPSTF has shown a high degree of responsiveness to the concerns of clinicians and patients about cotesting," wrote Lee Learman, MD, PhD, of Florida Atlantic University in Boca Raton, and Francisco Garcia, MD, of the University of Arizona in Tucson.

"The current USPSTF recommendation statement preserves the greatest range of choices for practitioners and patients; in that sense, both will benefit," the editorial added.

The recommendations have the effect of achieving "an unprecedented degree of concordance across recommendations from a variety of professional organizations," Learman and Garcia continued. The USPSTF, American College of Obstetricians and Gynecologists (ACOG), American Cancer Society/American Society for Colposcopy and Cervical Pathology (ASCCP)/American Society for Clinical Pathology, and (to a lesser extent) the Women's Preventive Services Task Force of the Institute of Medicine "all arrived at very similar recommendations."

The author of a second editorial appearing in JAMA Internal Medicine noted that the USPSTF did not include cost-effectiveness in the review that led to the recommendations. "Although the USPSTF sets the standard for evidence-based recommendations and acknowledges the critical value of high-quality evidence in making recommendations, it might reasonably be asked, where is the evidence of value in cervical cancer screening?" wrote George Sawaya, MD, of the University of California San Francisco.

Sawaya pointed out that he is leading an ongoing evaluation of cost-effectiveness analyses "to determine the range of reasonable options for cervical cancer screening. Such analyses may inform future screening recommendations."

He also noted that the USPSTF recommendations differ in two ways from the Society of Gynecologic Oncology (SGO) guidance on the issue: (1) Starting hrHPV testing at age 30, rather than 25, as supported by SGO; and (2) testing at 5-year intervals and not more frequently.

ACOG, ASCCP, and SGO issued a joint statement, thanking the USPSTF for including multiple screening options in the recommendations and describing the task force guidance as "largely in line" with their own recommendations.

One or more members of the task force disclosed relationships with Healthwise, the National Area Health Education Center Organization, and the Merck Foundation.

Sawaya reporting having no relevant relationships with industry.

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