The American College of Obstetricians and Gynecologists announced Nov. 20 that it is now recommending delaying the start of cervical cancer screening until age 21 and then screening most patients every other year instead of annually.
In its revised guidelines, ACOG recommends cervical cancer screening every 2 years for women between ages 21 and 29 years. Women aged 30 or older who have had three consecutive normal results can be screened every 3 years if they have no history of cervical intraepithelial neoplasm (CIN) 2 or 3, HIV, immunocompromise, or in utero exposure to diethylstilbestrol. Both liquid-based and conventional methods of cervical cytology are acceptable.
Though there are no solid data, expert opinion suggests that these recommendations also would apply to women vaccinated against human papillomavirus.
The recommendations appear in ACOG Practice Bulletin number 109.
Previous guidelines issued separately in 2002-2003 by ACOG, the American Cancer Society, and the U.S. Preventive Services Task Force called for annual cervical cancer screening to start either at age 21 or within 3 years of the onset of sexual activity. Those guidelines also state that the interval of screening could be widened to every 2-3 years in those with three consecutive normal Pap test results.
“The change is subtle,” said Dr. Alan Waxman, who drafted the new guidelines for ACOG. The announcement is unlikely to cause the kind of controversy that arose starting on Nov. 16 over new USPSTF guidelines on breast cancer screening, according to Dr. Waxman, professor of ob.gyn., at the University of New Mexico, Albuquerque.
(The USPSTF now recommends against routine mammography screening in women aged 40-49 years. The previous recommendation in 2002 was for routine screening every 1-2 years in this age group. Additionally, in older women aged 50-74 years, the new recommendation downgrades the frequency of screening mammography from annual to biennial [Ann. Intern. Med. 2009;151:716-26]).
“We’re really pleased that ACOG came out with that recommendation,” said Dr. J. Thomas Cox, director of women’s health at the University of California, Santa Barbara, and immediate past president of the American Society for Colposcopy and Cervical Pathology.
Substantial data in recent years show no benefit to cervical cancer screening in adolescents but do show that interventions after abnormal Pap results significantly increase the risk of premature birth in later pregnancies, said Dr. Cox, who was not involved in the new ACOG Practice Bulletin. “I would really expect that the U.S. Preventive Services Task Force, which is getting ready to issue their recommendations on cervical cancer screening as well, would do the same,” he added.
But “I think ob.gyns. are going to [voice opposition]” about the cervical cancer screening changes, said Dr. Cox. Many ob.gyns. prefer annual cervical cancer screening because it brings women into the office for an exam at least once a year.
The new ACOG recommendations were foreshadowed by a June 2009 meeting of more than 20 medical organizations hosted by the ASCCP and the ACS at the U.S. National Cancer Institute in Bethesda, Maryland. The meeting’s role was to examine the risks of interventions in adolescent girls with abnormal Pap results, but “we switched gears, and there was consensus among almost everybody that screening should start at age 21,” said Debbie Saslow, Ph.D., director of breast and gynecologic cancer for the American Cancer Society, Atlanta.
“We think [the new ACOG guidelines] are great,” said Dr. Saslow. One in 1 million adolescents develop cervical cancer, and screening does nothing to decrease that risk, she noted.
In most older women, “we strongly support getting rid of the annual Pap,” she added. The ACS has started the process of revising its cervical cancer screening recommendations. The revision process typically takes 1-2 years.
Studies show no clinical or cost-effectiveness advantages of screening adolescents for cervical cancer. Additionally, the potential emotional harm to teen girls from abnormal Pap results and interventions was a factor in changing the guidelines, Dr. Waxman said.
Dr. Cox agreed. “All of us who take care of young adolescents have seen women who get abnormal Pap test results within months of starting intercourse, leading to biopsies and possibly interventions, and are really traumatized, then have sexual difficulties after,” he said.
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11月20日，美国妇产科医师学会(ACOG)宣布：现建议将宫颈癌的初始筛查时间推迟至21岁，之后大部分患者可每隔1年筛查1次，无需每年筛查。
ACOG在修订后的指南中建议，对于年龄在21~29岁的女性，可每2年进行1次宫颈癌筛查。对于年龄在30岁或30岁以上且连续3次筛查结果正常的女性，如果没有2级或3级宫颈上皮内瘤变(CIN)、HIV、免疫功能低下或己烯雌酚宫内暴露史，则可每3年筛查1次。液基或传统的细胞学检查方法均可接受。
虽然没有确切的数据，但专家观点认为上述推荐意见也同样适用于接种过人乳头状瘤病毒疫苗的女性。
ACOG第109号实践公报中公布了上述推荐意见。
先前的指南分别由ACOG、美国癌症协会(ACS)和美国预防服务工作组(USPSTF)于2002~2003年发布。这些指南均建议从21岁或初次性生活后3年内开始宫颈癌筛查，每年筛查1次。这些指南还声称，对于连续3次巴氏涂片检查结果正常的女性，可将筛查的间隔时间延长至每2~3年筛查1次。
作为这份ACOG新指南的起草者，阿尔伯克基市新墨西哥大学的妇产科学教授Alan Waxman博士指出，“这次改动并不大。”新指南不太可能像11月16日USPSTF发布的乳腺癌筛查新指南那样引发争议。
[USPSTF目前反对对年龄介于40~49岁的女性常规开展乳房X线筛查。先前的2002年版推荐意见建议对该年龄组的女性每1~2年常规筛查1次。此外，对于年龄在50~74岁的女性，新的推荐意见建议将乳房X线筛查的频率从每年1次减少到每2年1次(Ann. Intern. Med. 2009;151:716-26)]。
加州大学圣巴巴拉分校女性健康中心负责人兼美国阴道镜与宫颈病理学协会(ASCCP)前任会长J. Thomas Cox博士称，“我们很赞同ACOG发布的这份新指南。”
Cox博士指出，近年来，大量数据表明，对青少年进行宫颈癌筛查并没有意义。数据还显示，发现巴氏涂片结果异常后所采取的干预措施显著增加了妊娠后期出现早产的风险。“我由衷希望USPSTF也采取相同的行动，其目前正准备发布乳腺癌筛查指南。”Cox博士并没有参与制定这份新的ACOG实践公报。
但Cox博士也表示，“我认为部分妇产科医生可能会反对更改宫颈癌筛查方案。”许多妇产科医生更赞同每年进行1次宫颈癌筛查，因为这样会使女性们至少每年去诊所检查1次。
2009年6月，ASCCP和ACS在位于美国马里兰州贝塞斯达的国家癌症研究所召开了一次会议，共有20多个医学组织参会。会上预告了ACOG即将发布新的推荐意见。亚特兰大美国癌症协会乳腺及妇科癌症组主任Debbie Saslow博士称，这次会议原本是为了评价对巴氏涂片结果异常的青少年女性所采取的干预措施存在的风险。但“我们改变了初衷，最终几乎所有人都一致认同筛查应从21岁开始。”
Saslow博士表示，“我们认为新的ACOG指南非常好。”100万名青少年中仅1名可能出现宫颈癌，筛查对降低这一风险毫无帮助。
Saslow博士补充道，对于年龄稍大的女性，“我们强烈建议取消每年1次的巴氏涂片检查。”ACS也已经开始修订其宫颈癌筛查指南。整个修订过程一般会需要1~2年。
Waxman博士称，研究表明，对青少年进行宫颈癌筛查没有临床意义，在成本效益方面也没有优势。此外，巴氏涂片结果异常以及所采取的相应干预措施对少女的潜在情感伤害也是ACOG更改筛查指南的原因之一。
Cox博士对此表示赞同。“所有接诊过青少年的妇产科医生都会发现，如果女性在开始性交后数月内出现了巴氏涂片检查结果异常，并因此接受了活检甚至干预措施，那么很可能会给她们带来精神上的创伤，从而引起性交困难。”
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