Years of No Screening
Failure to be screened is a very significant clinical issue, according to Michelle Berlin, MD, professor and codirector of the Center for Women’s Health at Oregon Health & Science University in Portland, Oregon.
She said one major issue that needs to be considered in the context of these new study findings is that women commonly don’t report correctly whether they have had their cervix removed.
Second, she said that there are a significant number of women in the United States who stop getting Pap smears after they stop childbearing. Dr. Berlin said many women at age 65 are getting a Pap smear for the first time in many years.
“Women may not get their Paps for a long time. So, they may have cervical cancer for a long time, but they don’t have it diagnosed until they get on Medicare at age 65. If a woman is uninsured, she may not have had a Pap smear in a long time. There may be a 20-year period where they don’t get it, but once they are enrolled in Medicare they get a head-to-toe screening check,” Dr. Berlin said in an interview with Cancer Therapy Advisor.
Dr. Berlin believes this Medicare factor may be playing a significant role in why this new study found such high incidence rates in women aged 65 to 69 years. Dr. Berlin said greater efforts are needed to make sure women receive adequate screening throughout each decade of their lives.
She noted that many women don’t get care or it is deferred care. Gynecologic oncologist L. Stewart Massad, MD, of the Siteman Cancer Center at Washington University School of Medicine in St. Louis, Missouri, agreed with Dr. Berlin. He said spotty screening is a significant problem.
“This is an important new study that helps us understand the importance of age. It seems clear from other studies that women with prior negative screening are at very low risk for cervical cancer and should stop at age 65,” Dr. Massad told Cancer Therapy Advisor.
“However, women who have had spotty or no prior screening should continue screening. Adequate screening is three negative paps or two negative human papillomavirus (HPV)/Pap test combinations in the 10 years prior to stopping, including negative tests within 5 years. Clinicians should pay close attention to the screening histories of women as they age and make sure that they continue screening until adequate negative test results are in.”
Dr. Massad said, in his opinion, there is a problem with both under-testing and over-testing. He said that more studies are warranted that examine the current screening guidelines and how they are being implemented by clinicians.
“In my opinion, based on data from the United States Centers for Disease Control and Prevention, clinicians in the United States continue to screen women too frequently. Many continue with annual Pap testing or even annual co-testing, which increases risk of false-positive results compared to recommended 3-year Pap and 5-year co-testing intervals. A high rate of false-positive results puts women at risk for harms of screening with minimal benefit,” said Dr. Massad.
“Harms include stigmatization from identification of HPV destined to resolve without treatment, since HPV is a sexually transmitted disease and the costs of and injury from treatments for lesions destined not to progress to cancer.”
HPV infections are linked to cervical cancer and, in recent years, there has been a strong push for HPV vaccination. There are more than 109 types of HPV and several are considered high risk for causing cervical cancer (especially types 16 and 18).
In what is believed to be the largest and most detailed genetic analysis of its kind, researchers at New York University Langone Medical Center have found that 69% of healthy American adults are infected with one or more strains of HPV.2 Only 4 of the 103 men and women whose tissue DNA was publicly available through a government database had either of the two HPV types known to cause most cases of cervical cancer.
Researchers said that, while most of the viral strains so far appear to be harmless and can remain dormant for years, their overwhelming presence suggests a delicate balancing act for HPV infection in the body, in which many viral strains keep each other in check. This may help prevent other strains from spreading out of control.
- Rositch AF, Nowak RG, Gravitt PE. Increased age and race-specific incidence of cervical cancer after correction for hysterectomy prevalence in the United States from 2000 to 2009. Cancer. 2014;120(13):2032-2038.
- Ma Y, Madupu R, Karaoz U, et al. Human papillomavirus community in healthy persons, defined by metagenomics analysis of human microbiome project shotgun sequencing data sets. Poster presented at: The American Society for Microbiology Meeting; May 20, 2014. Poster 2357.