Update on Cervical Cancer Screening

Hospital Physician May 2007 15 I n 1941, George Papanicolaou revolutionized the detection and management of cervical cancer with the introduction of cytology-based screening.1 Although it took 20 years to be fully incorporated into accepted medical protocols, the Papanicolaou or “Pap smear” test has dramatically reduced the incidence of cervical cancer in developed countries. Between 1950 and 1970, the mortality rate as well as the incidence of invasive cervical cancer decreased more than 70% in the United States.2 Since then, the rates have continued to fall, with a 3.8% annual decrease in cervical cancer mortality in all US women between 1996 and 2003.3 Developing countries, where routine Pap testing has not been incorporated, have not experienced such dramatic decreases. Of the approximately 273,505 deaths caused by cervical cancer worldwide each year, between 80% and 85% occur in developing countries.4,5 In 2006, there were an estimated 9700 new cases of cervical cancer and 3700 deaths due to cervical cancer in the United States.6 Once the most common cancerrelated cause of mortality in women, cervical cancer currently ranks 12th in cancer-related deaths in women.7 The life-time risk of being diagnosed with cervical cancer is 0.74%.7 While some guidelines suggest that cervical cancer screening can be discontinued in the 7th decade, in a study of women who developed cervical cancer, the median age at diagnosis was 65 years.8 Cervical cancer screening is efficient and effective. The vast majority of new cervical cancer cases in the United States are in women who have never undergone screening or who have had suboptimal screening (Figure 1).7 It is of great importance that primary care and women’s health physicians understand the significance of, and maintain the accepted standard of care for, cervical cancer screening and management. This article reviews current guideline recommendations on cervical cancer screening and highlights acceptable screening practices; however, more detailed discussions of the guidelines are available.9–15 In addition, the 2006 National Institutes of Health consensus guidelines, which are expected to be published later this year, emphasize more conservative evaluation and management for adolescent women (aged ≤ 20 yr) and for women with low-grade squamous intraepithelial lesions (LSIL). These principles have been incorporated in this article. C l i n i c a l R e v i e w A r t i c l e