By Stacey Butterfield
It's understandable to be confused about cervical cancer screening recommendations, Pelin Batur, MD, MSCP, FACP, reassured attendees in a Friday morning session on Pap testing.
Dr. Batur, an internal medicine physician and a professor of OB-GYN and reproductive biology at Cleveland Clinic Lerner College of Medicine of Case Western Reserve University in Ohio, showed a chart with all the recommendations for different age groups and from different societies and panels combined.
"This took me a hot minute to make, because it does get confusing," she said. "And that's what internists pride themselves on—we follow guidelines. When they're confusing, it's really frustrating."
In broad strokes, testing for human papillomavirus (HPV) is only recommended for patients 25 years and older, and whether to do so is flexible in those ages 25 to 29 years. For older patients, expert societies differ more significantly on the frequency of testing and how to combine HPV and Pap tests, noted Dr. Batur, who encouraged attendees to just choose one group's protocol to follow.
"Pick whatever you want, and then stick to it," she said.
But don't forget the cases where the guidelines don't apply. "These are the situations where people do fall through the cracks," said Dr. Batur. Patients need more frequent screening if they have HIV, were exposed to diethylstilbestrol (DES) in utero, or were previously treated for cervical interepithelial neoplasia (CIN) 2 or 3 or cervical cancer, among other factors.
Anyone who is immunosuppressed is also at higher risk and should be screened more often, so remember to check what medications a patient is taking. "This is one of those questions that we would all get right on a board exam, but when we're busy in clinic and we're 40 minutes behind, we forget to ask," said Dr. Batur.
Another thing not to speed through is the patient's Pap test history in the electronic medical record. Don't assume you'll be alerted if the previous screen was inadequate or positive. "Just trusting the EMR [is the] biggest mistake that I see," Dr. Batur said. "It's just one click to make sure it was an adequate specimen and that it was normal."
Her copresenter Sharon A. Sutherland, MD, MPH, highlighted additional concerns about the state of screening. Cervical cancer screening rates in the U.S. went down in recent years, she reported, citing a study that found 86% of women were up to date in 2005 compared to 77% in 2019.
Coverage and access are barriers, but so is confusion. "Half of women not getting screened said that they didn't know what they needed or when they needed it, and sometimes they were with a provider in that window and it wasn't offered," said Dr. Sutherland, an OB-GYN and clinical assistant professor at Cleveland Clinic Lerner College of Medicine of Case Western Reserve University in Ohio.
Certain groups are particularly likely to be underscreened, including patients who are LGBTQ, Asian, or rural, she reported. There are also concerning statistics with regard to race. "Black and Hispanic women in particular are showing an increased incidence of cervical cancer with each passing decade" of patient age, she said.
The trend starts toward the end of the reproductive years and likely relates to lack of health care coverage. "We know that after childbirth, some women will be phased out of government insurance and will not opt back in until they hit 65," said Dr. Sutherland.
Lack of regular screening can also be tied to the dire cervical cancer outcomes currently seen in the U.S. "In general, cervical cancer diagnosis now has a 33% mortality rate within five years, the reason being many of them are presenting in later stages," said Dr. Sutherland.
If a patient hasn't been screened for a while and comes in after becoming Medicare-eligible, you should screen them for a decade prior to stopping, she advised. In general, the rule for low-risk women is to stop screening after age 65 years if three consecutive Paps or two consecutive Pap/HPV tests have been negative within the previous 10 years.
That rule doesn't apply to higher-risk patients, including those with immunosuppression or previous CIN 2 or higher results, the speakers noted. They should continue with screening.
If that sounds like a lot to remember, both speakers recommended an app from the American Society for Colposcopy and Cervical Pathology to guide your screening and referral pathways through the maze of guidelines.
"I do over 500 colposcopies a year, I use this app every single day," said Dr. Sutherland. Remember, of course, that an app does not replace clinical judgment, she added. "Above all, follow your gut." ■