Doctors should stop ordering yearly Pap tests for most women, and routine screening for cervical cancer in younger women should be abandoned altogether, a federal task force is recommending.
For the first time in nearly 20 years, the Canadian Task Force on Preventive Health Care has released an updated guideline for cervical cancer screening that recommends starting screening when women are older, and screening them less often in order to avoid the risks of over-testing.
Published Monday in the Canadian Medical Association Journal, the new guideline recommends that women aged 25 to 69 without symptoms of cervical cancer who are, or who have ever been, sexually active, be screened once every three years with a Pap test, which detects abnormal cells in the cervix.
The 1994 guideline recommended screening every three years, but only after two consecutive normal Pap tests.
The old guideline also recommended Pap smears for women once they turn 18 or become sexually active.
But the task force says that, in women under 25, the risks of screening outweigh any possible benefits.
Nearly half — 42%— of women aged 18 to 19 have reported being screened at least once within the previous three years, the authors write in the Canadian Medical Association Journal. But the incidence of cervical cancer in women under 20 is low (0.2 cases per 100,000), and no deaths from cervical cancer were reported among Canadian women under 20 between 2002 and 2006.
Neither could the task force find any data to support the argument that screening younger women helps prevent deaths from cervical cancer when they're older. The risk of cervical cancer increases after age 25, and peaks in a woman's 50s.
Younger women are more likely to have abnormal Pap results. A substantial proportion will have "false positive" results, leading to unnecessary and invasive treatments for abnormalities that would never progress to cancer — procedures that can cause pain, bleeding and scarring to the cervix that can jeopardize a woman's chances of carrying a future pregnancy.
Over the past 50 years, deaths due to cervical cancer have fallen dramatically, the panel writes. Today, a woman's risk of dying from the disease is 0.2 per cent.
"Cervical cancer was, and still is a horrible disease," said task force member Dr. James Dickinson, chair of the guideline work group. "It spreads right through the whole of a woman's pelvis and causes horrible problems with bowel and bladder. It can be a truly horrible disease," said Dickinson, a professor of family medicine and community health sciences at the University of Calgary.
Without Pap testing, the disease would affect 1.5% of women. "This is probably the most successful screening test that we have available," Dickinson said.
Expert advisory bodies have for several years been recommending doctors do away with annual Pap testing and instead screen every three years. "It's just that (doctors) and women have got into this habit of annual Pap smears, and we'd like to get them out of that habit," he said. "The evidence says that three years is enough to get the benefits."
Some women do need more frequent screening, including those who have HIV or are immune suppressed.
The Canadian Cancer Society currently recommends women have regular Pap tests starting by age 21 if they're sexually active.
The organization says it will consult with cervical cancer screening experts across the country to determine "whether this is something we should consider changing," said Gillian Bromfield, director of cancer control policy. She said most provincial and territorial cancer agencies recommend screening starting at age 21.
Bromfield said women should continue to be screened even if they're no longer sexually active. Women who have been vaccinated with the HPV (human papillomavirus) vaccine also need to be screened because the shots do not protect against all forms of the virus.
In 2012, an estimated 1,350 new cases of cervical cancer were diagnosed in Canada, with about 400 deaths.
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Tuesday, January 8, 2013
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