Cervical Cancer Screening - A Success Story. Hate Pap Smears? Read This!

Of all cancer screenings, cervical cancer screening is arguably the greatest success story. Screening for cervical cancer has been largely responsible for decreasing deaths from cervical cancer in American women by more than 80% between 1930 and 2012.¹ Not only that, the number of new cases of cervical cancer have been almost cut in half since 1975.²

Cervical cancer is caused by the human papilloma virus, or HPV, in over 99% of cases.³ There are many strains of HPV, some of which are dangerous and can cause cervical cancer, while some are not very dangerous and only cause warts. These lower-risk strains are more of a nuisance than a major public health risk. Of the high-risk strains of HPV, types 16 and 18 are responsible for 70% of all cervical cancers.⁴ The human papilloma virus is a sexually-transmitted disease, so unsurprisingly, the risk factors for contracting this virus are early onset of sexual activity and having multiple sexual partners. Other risk factors include low socioeconomic status, micronutrient deficiencies, long-term use of oral contraceptive pills, tobacco use, and immunosuppression.²

Cervical cancer screening is accomplished by performing a minor office procedure called a Pap smear. This is a pelvic examination, and a vaginal speculum is used so that the cervix can be seen. The cervix is the “tip” of the uterus, and is small and shaped somewhat like a donut. Once the cervix is visualized, the specialized skin cells on the surface of the cervix are sampled with a small brush. After the cells are collected, the sample is sent to a lab for analysis. 

The Pap smear can be done either by itself, or in combination with testing for the presence of high-risk HPV strains. When you undergo a Pap smear and HPV testing together, this is called “co-testing”. 

Here are the current recommendations for cervical cancer screening:⁵

• Age 21 through age 29: Pap smear (without co-testing) every three years. 
• Age 30 through 65: Either co-testing every five years, or a regular Pap smear every 3 years. 
• Pap smears are not recommended for women under the age of 21, or over the age of 65 with adequate normal cytology history. 
• Screening is also not recommended as part of a routine “annual exam“ and this has not been a recommendation for quite some time. Some doctors still practice this, but it’s not recommended. 
• Also, if a patient has had a hysterectomy (surgical removal of the uterus and cervix), as long as the hysterectomy wasn’t for cervical cancer, further screening is not recommended.*

                                                               ^{* If a woman has a history of CIN2 or worse, screening may still be necessary.}

These recommendations are from the United States Preventive Services Task Force (USPSTF), and fortunately there is very little disagreement about screening recommendations for cervical cancer among the other various societies. 

Once cells sampled by Pap smear are analyzed, here is a list of potential results: 

• Normal cytology (“cytology” = cells)
• ASCUS, which means “atypical squamous cells of undetermined significance”.
• LGSIL, which means “low-grade squamous intraepithelial lesion”.
• HGSIL, which means “high-grade squamous intraepithelial lesion”.

If a screening test comes back abnormal, follow the recommendations of your health care professional. It’s never fun to receive news of an abnormal screening, but catching abnormalities early is the whole reason to be screened in the first place. Depending on the results of the screening, you may need to follow-up with another Pap smear sooner than would normally be recommended, or possibly undergo a colposcopy. A colposcopy is a more involved and lengthy pelvic exam that uses cell staining and magnification to help identify worrisome patterns. Sometimes during a colposcopy, biopsies (small tissue samples) need to be taken to provide your doctor more information. 

Depending on the degree of dysplasia, individuals may need to undergo treatment to prevent these abnormal cells from turning into cervical cancer. Some procedures can include cryotherapy, LEEP, or conization.⁶ 

Your health care provider will be following the guidelines set by the ASCCP, a society dedicated to the treatment of disease caused by HPV. The process of surveillance is algorithmic, and very involved. If you have undergone a Pap smear and received an abnormal result, click here to view the algorithms and better understand your surveillance plan.

Risks of screening for cervical cancer include some minor discomfort such as cramping and bleeding during and after the test. Sometimes these symptoms can be concerning to women, but they are usually not serious. Also, receiving news of abnormal results can certainly lead to anxiety. And as always, there’s a risk of false positives which would lead to the potential for unnecessary testing such as colposcopy and biopsies.² 

As far as other prevention methods, there is the HPV vaccine. This is the only vaccine currently available that actually prevents cancer! The HPV vaccine targets the strains of the virus that cause cervical cancer most frequently, and is highly effective (close to 100%) at preventing transmission of the HPV strains that it targets. Alternatively, using condoms and other barrier methods are only about 70% effective at preventing HPV transmission.⁷

So, to review the key points:

1. Screening for cervical cancer is one of the most effective cancer screening methods available. 
2. Women should start being screened for cervical cancer at the age of 21, with Pap smears every three years until they turn 30.
3. Between ages of 30 and 65 women should either continue Pap smears every three years, or undergo co-testing with Pap smear and HPV testing in 5-year intervals. 
4. If the Pap smear comes back abnormal, it's necessary to follow the advice for further evaluation and surveillance from a healthcare professional, which will be guided by ASCCP algorithms. 
5. Vaccination for HPV can prevent transmission, and the risk of resultant abnormalities and cervical cancer. 

Please, pass/forward this information on to someone you love, so they can know the recommendations for screening. You never know when you may save a life!

References:

1. Siegel RL, Miller KD, Jemal A. Cancer statistics, 2017. CA Cancer J Clin. 2017.

2. Caitlyn M. Rerucha, MD, Rebecca J. Caro, DO, Vernon L. Wheeler, MD. Cervical Cancer Screening. American Family Physician. April 1, 2018.

3. Walboomers JM, Jacobs MV, Manos MM, et al. Human papillomavirus is a necessary cause of invasive cervical cancer worldwide. J Pathol. 1999.

4. National Cancer Institute. HPV and cancer. https://www.cancer.gov/about-cancer/causes-prevention/risk/infectious-agents/hpv-fact-sheet#q1. Accessed April 25, 2018.

5. Final Recommendation Statement: Cervical Cancer Screening. U.S. Preventive Services Task Force. March 2012. www.uspreventiveservicestaskforce.org

6. Updated Consensus Guidelines on the Management of Women with Abnormal Cervical Cancer Screening Tests and Cancer Precursors. American Society for Colposcopy and Cervical Pathology (ASCCP). 2013.

7. Juckett G, Hartman-Adams H. Human papillomavirus: clinical manifestations and prevention. American Family Physician. November 15, 2010.