Cervical Cancer Screening Guidelines – Role of HPV Testing

The American Cancer Society says women over 30 years old who have had three normal Pap smear test results in a row can get screened every 2-3 years rather than annually. They can be screened with a conventional Pap smear test or a liquid based Pap test or the HPV (Human Papilloma Virus) test.

A recent study at Kaiser Permanente Northern California from 2003 through 2005 suggested that HPV (Human Papilloma Virus) testing may be more accurate than Pap smears. Their analysis showed that:

>  For all women with a normal Pap smear test there were 7.5 cervical cancers detected per 100,000 woman/ years.

>  For all women who were HPV-negative the rate was 3.8 cervical cancers per woman/years.

>  For women who were both HPV-negative with normal Pap smears the rate was 3.2 cervical cancers per 100,000 woman /years.

Hormuzd Katki, PhD, of the National Cancer Institute in Bethesda, Maryland recognized the increased accuracy of HPV testing over Pap testing but encouraged co-testing.

“ Most women still undergo annual screening out of habit” according to Brent DuBeshter, M.D. of the University of Rochester Medical Center in Rochester NY. Even stranger is the case of women post hysterectomy with no cervix continuing to see their gynecologists on an annual basis for pap testing?

The recommendation for annual pap smears had been present for so many years that many doctors and patients aren’t “comfortable with the new guidelines that call for screening every three years in those at low risk for cervical cancer” according to DuBeshter.  “Many providers have a hard time changing habitual practice and adopting new evidence and practice guidelines,” says Ranit Mishori, M.D. of Georgetown University School of Medicine.

What is clear is that screening every three years in low risk patients works. What will need to be determined is the evidence based role of HPV testing in conjunction with, or as a replacement for, Pap smears.

Smoking Increases the Risk of Breast Cancer, Lung Cancer and Colon Cancer in Women

The Surgeon General of the United States issued another report on the dangers of smoking and its addictive potential last year.  At the time of release I was quite skeptical about the cost of the report and the need to remind Americans again that smoking is dangerous for you.  Then along comes a detailed review of the National Surgical Adjuvant Breast and Bowel Project. According to Stephanie Land, PhD, of the University of Pittsburgh, long-time smokers had a 59% increase in the risk of invasive breast cancer compared with nonsmokers.  The study looked at the links between four types of malignancy: breast, lung, colon, and endometrial cancer with smoking, alcohol use and leisure time activity.  The findings suggested that:

1.       Women who had smoked between 15 and 35 years had a 35% increase in the risk of breast cancer compared to non smokers. In that same group, if a woman smoked more than a pack a day she had a five – fold higher risk than non smokers.

2.       Women who had smoked 35 years or more had a 59% increase in the risk of breast cancer. These long-term smokers had a 30 times higher risk of lung cancer than non smokers.

3.       The risk of colon cancer among long–term smokers was five times higher than among non smokers.  A drink of alcohol a day reduced the risk of colon cancer by 65% compared to non drinkers.

4.       Inactive women had a 72% increased risk of uterine endometrial cancer compared to active participants in the study.

The study of almost 14,000 women highlighted the benefits of improving life style choices.  While researchers search for drugs and medication to prevent these life threatening illnesses, the study pointed out the benefits of altering the life style choices of women to prevent the development of cancer.

It is clear that smoking prevention and smoking cessation programs can do far more to prevent these cancers than pharmaceuticals. With cutbacks on funding for public health and the elimination of most health and hygiene classes in middle schools and high schools due to financial constraints, I wonder if we are being penny wise and pound foolish.

United States Preventive Task Force – Recommendations for Breast Cancer Screening Creates Confusion

Since I started practicing medicine in 1976 the American Cancer Society, The American College of Radiologists, and the American College of Obstetricians and Gynecologists have all been in agreement on the necessity for breast cancer screening in adult women.  Annual breast exams by a trained examiner were recommended beginning at age 19.  Breast self-exam was taught in most hygiene classes and by educators in physicians’ offices and was felt to be an inexpensive screening test.

It made great sense that early detection saved lives. It made greater sense that individual patients who educated themselves about the normal feeling of their breasts during different phases of the menstrual cycle were more likely to detect an early change and seek medical attention.

Mammograms were recommended for women on an annual or every other year basis beginning at age 40 and then annually from age 50 and above.  There were always individual variations for women who were at high risk or who had a family history of breast cancer at a young age but, for the most part, breast cancer screening suggestions were not controversial or forever changing.

In November 2009 the United States Preventive Task Force, the same group who questioned the efficacy of yearly physical exams and chest X rays annually on cigarette smokers, issued its revised guidelines. They cited the large number of biopsies done of women between forty and fifty for what turned out to be benign fibrocystic breast disease rather than cancer. The biopsies were often the result of an abnormal breast self exam finding a new lump, an abnormal professional exam and or a spot on a mammogram which was equivocal.

Citing the cost and anxiety involved in evaluating a breast abnormality and using research studies as evidence they suggested not teaching or using breast self exam. They additionally recommended changing the initial mammogram back to age 50 unless there was agreement between the patient and physician that their individual needs justified the test.   With women living longer and breast cancer occurring frequently in the elderly, they suggested no longer performing screening mammograms after age 75.

These recommendations have led to great controversy and confusion in the profession and general public. In a recent Harris Interactive Poll 45% of the women questioned felt the USPTF pushed back the recommended age to 50 to reduce health care costs and avoid administering tests. Eleven percent of those polled thought mammograms should begin at age 20 even for women with no risk factors, while 29 percent believe mammograms should start in their 30’s.

What is clear is that confusion reigns. Consultation with your doctor using your family history, personal history of age at the start of menses, pregnancy history, smoking history and medication history will all contribute to the decision when to start breast imaging screening and how often.

I still support breast self exam and an annual exam by a trained practitioner who examines the same patient annually. As physicians and educators, we need to do a far better job of educating ourselves and the public about the reasoning behind recommended changes to health screenings.