The new guidelines say most women in their 20s can have a pap smear every two years, instead of annually, to catch slow-growing cervical cancer.
“Much like the recently released mammogram screening guidelines, these new measures have been based on statistical analysis that screening tools sometimes lead to unnecessary and extensive evaluation and treatment of the masses to find the rare exception to the rule,” said Dr. Joel Puleo of the Pinehurst Women’s Clinic in Rockingham. “These new guidelines are meant to be just that — guidelines — and should not replace common sense of the patient and health care provider. The College (ACOG) continues to recommend the annual well-women exam where age appropriate health issues are reviewed and health dialogue with testing may occur.”
Puleo said the most important changes in the revised guidelines include the new guideline that cervical cancer cytology screening (pap smears) should begin at age 21, regardless of sexual history.
The College argues screening before age 21 should be avoided because women younger than 21- years-old are at very low risk of cancer, and screening these women may lead to unnecessary and harmful evaluation and treatment.
The guidelines also recommend a pap smear every two years for women between the ages of 21 and 29, rather than annually, because evidence shows that screening women every year has little benefit over screening every other year, according to the ACOG.
Puleo said there’s always an exception to the rule when it comes to screening patients.
“I’ve got two patients under 50 with breast cancer, a mother and a daughter, and if they’d followed the new guidelines, they could have had a major problem,” Puleo said. The new guidelines say only women 50 and older should receive mammograms, and receive them every other year, instead of annually from age 40 and up.
“Screening is different than diagnostic testing,” Puleo said. “If you see something, common sense should prevail. If young women are sexually active you should absolutely get them in for wellness checks, safe sex talks, birth control practices, etc. But these new guidelines put the emphasis on the heightened sense of awareness.”
Puleo said the problem with annual screenings and follow-ups is that it’s a hard concept to get people compliant because cancer doesn’t really hurt.
“If I call a patient and tell her that her pap smear was abnormal, they almost don’t believe me,” Puleo said. “We have two or three people in my practice that have severely abnormal paps and with these guidelines we’re going to closely follow these people. In the past we would have done biopsies which could be harmful.”
But Puleo said the problem isn’t with these patients, it’s with those that are non compliant.
Puleo explained he had one patient he tried to call in for a follow-up for an abnormal pap result for two years. Finally the health department intervened and told the patient she couldn’t receive more birth control without first visiting Puleo for her follow-up, which ended up in an extensive biopsy where a large amount of her cervical tissue was removed.
“These guidelines leave it up to the discretion of the patient. If they’re non compliant or at high risk, it’s better to err on the side of being conservative. A majority of people don’t take their health seriously,” Puleo said.
Because of the problem of non compliant patients, Puleo said his office will now require patients and their guardians to sign a sheet promising to return for their results and any follow-up appointments that are necessary, which is a practice he calls defensive medicine.
“We don’t want to have a problem down the road, so we’re trying to take care of it now,” he said.
Puleo said many “old-school” physicians overcompensate quickly when they get an abnormal pap result and do biopsies immediately, or more extensive surgeries, which is what the ACOG is trying to avoid with these new guidelines.
“The problem is the pendulum swings both ways,” Puleo said. “If the doctor doesn’t show concern about the patient’s results, the patient doesn’t take the steps to manage their condition and the problem may never be managed properly. We have to individualize these guidelines. The key word is screening - not management for everyone. These aren’t mandatory.”
Puleo said in young women, 21 and under, of those who receive an abnormal pap smear result, within one year 70 percent will have a normal pap again. But the problem is the 30 percent who won’t.
“The guideline system is not designed to circumvent common sense,” Puleo said. “We still want women to receive annual checkups and age-appropriate tests.”
The ACOG reported with these guidelines that the incidence of cervical cancer has decreased more than 50 percent in the past 30 years because of widespread screening with pap smears. In 1975 the rate was 14.8 per 100,000 women in the U.S and by 2006 it had been reduced to 6.5 per 100,000 women. Mortality from the disease has undergone a similar decrease.
The American Cancer Society estimates 11,270 new cases of cervical cancer in the U.S. in 2009, with 4,070 deaths from the disease. The estimates worldwide are much more dire with 240,000 deaths out of the 500,000 newly diagnosed cases.
The ACOG said in it’s report “despite the demonstrated success of cervical cancer screening, it is estimated that 50 percent of women in whom cervical cancer is diagnosed each year have never had a cervical cytology testing (pap smear). Another 10 percent had not been screened within five years before the diagnosis. Thus, one approach to reducing the incidence and mortality of cervical cancer would be to increase screening rates among women who currently are not screened or who are screened infrequently. Although rates of cervical cancer are on the decline in women born in the U.S., women who are immigrants to the U.S. from countries where pap smears are not the norm are at an especially high risk.”
The ACOG also said infection with the human papillomavirus (HPV), an easily sexually transmitted disease, is a necessary factor in the development of abnormal cells (which could develop in to cervical cancer) on the cervix, however most HPV infected women will not develop significant cervical abnormalities. Most women, especially younger women, have an effective immune system that clears the infection or reduces the viral load to undetectable levels in an average of eight to 24 months — another reason they’re recommending pap smears for women 21 and older.
For more information on the new guidelines, visit www.acog.org.
n Staff writer Eren Tataragasi can be reached at (910) 997-3111 ext. 19 or at etataragasi@yourdailyjournal.com.
Post a Comment
