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Citing new evidence, the U.S. Preventive Services Task Force (USPSTF) in November recommended against routine mammography screening in women under 50. At the same time, the American Congress of Obstetricians and Gynecologists (ACOG) advised that women should delay their first Pap test until age 21 and be screened less often than in the past. Both sets of recommendations, reportedly in the works for several years, are intended to address the issue of unnecessary testing and possible harmful treatments.
“New mammography and Pap test recommendations have fueled controversy and confused women.”
“New mammography and Pap test recommendations have fueled controversy and confused women.”
However, they have fueled controversy among professional organizations and expert groups and confused many women. For years, women have been told they should have a mammogram every one or two years beginning at age 40. Similarly, annual Pap tests beginning within three years of sexual activity were considered the norm.
The Preventive Services Task Force, an independent body supported by the U.S. Agency for Healthcare Research and Quality, issued its last guidelines in 2002. According to their most recent (2009) guidelines:
The 2009 guidelines are based on new studies and analyses of old studies since 2002, fresh evidence about the harms of screening and a compilation of evidence weighing benefits against harms for stopping or starting screening. Working with the Oregon Health Sciences University Evidence Practice Center, the Preventive Services Task Force reviewed evidence regarding the question of starting age for mammograms, intervals for screening and when to end screening. The agency also looked at evidence gathered by the Cancer Intervention and Surveillance Modeling Network about benefits and harms from mammography screening.
“There is convincing evidence that screening with film mammography reduces breast cancer mortality, with a greater absolute reduction for women aged 50 to 74 than for women aged 40 to 49 years,” they wrote in a report published in the November 2009 Annals of Internal Medicine. “The strongest evidence for the greatest benefit is among women aged 60 to 69 years.”
The potential harms of screening that they cite include false positive test results, over-diagnosis and unnecessary treatment. False positive results were found to be more common among women age 40 to 49 and overdiagnosis was more common in the older age groups. False positives can lead to additional, unnecessary tests and invasive procedures such as biopsy. Over-diagnosis may result in needless early treatment in a slow-growing cancer that is unlikely to cause death.
ACOG, the American Cancer Society and the American College of Radiology are among several expert groups advising that earlier guidelines be followed. ACOG recommends mammography every one to two years from ages 40 to 49 and annually thereafter. The American Cancer Society calls for annual mammograms starting at age 40.
Opponents of the Preventive Services Task Force’s advisory cite studies showing that breast cancer mortality decreased by nearly 2 percent per year during the 1990s and for women younger than 50, the decline was more than 3 percent. Since 1989, the chances of dying from breast cancer have decreased by 29 percent. These declines have been attributed to mammography screening.
ACOG’s recommendations for Pap tests have been less controversial. The new guidelines advise women to begin the screening at 21 years of age, with biennial screenings thereafter. ACOG’s previous guidelines, published in 2006, called for yearly Pap tests, beginning within three years of starting sexual intercourse, but no later than age 21.
Their rationale for changing course is the mounting evidence that the vast majority of precancerous cervical lesions in adolescents and young women are likely to spontaneously resolve. Thus, screening this age group leads to “unnecessary and harmful evaluation and treatment in women at very low risk of cancer.”
Women 30 years and older who have had three consecutive normal Pap tests can now have tests at three-year intervals. And those in the 65-70 age group can stop having them altogether after three or more normal consecutive tests and no positive tests within the previous 10 years.
For more information, or to make an appointment with a UK HealthCare physician, please call UK Health Connection at 1-800-333-8874.
The new guidelines for breast and cervical cancer screenings are worrisome in their lack of attention to cancer risks in subgroups of the population. This oversight may put certain women at increased cancer risk.
“The highest rate of breast cancers is found in women who have not been screened.”
Mammography is designed to find breast cancers that are too small to be detected by other means. We know this test reduces mortality for breast cancer. The highest rate of breast cancers is found in women who have not been screened.
The recommendation to begin this mammography screening at age 50 makes sense for women who do not have risk factors that make them susceptible to breast cancer. But women need to know their own personal risk for breast cancer. For those with risk factors, screening may need to begin earlier. And some subgroups of the population, such as African-American women, seem to have increased risk of developing breast cancer before age 50. The new guidelines do not appear to take this into account.
Cervical cancer is a disease that can be prevented in nearly all cases. Pap tests can detect conditions that develop before cervical cancer and treating these conditions prevents the cancer. The keys to prevention are having a Pap test and, if an abnormality is found, getting the needed follow-up care.
“Cervical cancer can be treated successfully in just about every case when caught early enough.”
The new guidelines recommend that Pap tests begin at age 21, while in the past it was recommended that the timing of Pap tests be linked to the initiation of sexual activity. The reason for this linkage is that the risk of cervical cancer has been related to sexual activity.
More recently, certain types of human papilloma viruses (HPV) have been shown to be responsible for cervical cancer. These viruses are spread through sexual activity. The new guidelines have made the recommendations for Pap tests simpler; but like the new mammography guidelines, they do not focus attention on factors that increase cancer risk.
Cervical cancer is most often found in a woman who is past the age of child bearing. She may no longer get health care screenings and comes to the attention of doctors only after the disease develops and she is having symptoms. In younger women, cervical cancer can be very aggressive if not detected early. Both instances are unfortunate because cervical cancer can be treated successfully in just about every case when caught early enough.
Women need to learn about factors that may increase their vulnerability to breast or cervical cancer. For example, having a first-degree relative with breast or cervical cancer increases a woman’s chances of getting that cancer. So it is important for them to be sure their health care provider is aware of any family history of the disease. We know women are more likely to be screened if their physician recommends it. In fact many women, as well as men, don’t consider themselves to be at risk of diseases unless the doctor says they are.
Getting follow-up care after an abnormal Pap test is critical, but barriers such as a lack of transportation or child care keep some women from returning to the doctor. With this in mind, UK is working with rural public health departments in Kentucky to provide education, encouragement and support to women who have had abnormal Pap tests. The goal is to help them get the follow-up care that is recommended.
The Patient Navigation for Cervical Cancer Project employs local women who have been trained to help other women in many ways - arranging follow-up appointments, finding transportation and child care, understanding what their test results mean, and what the follow-up care will entail. We are hopeful this approach will be effective and will reduce the number of women with abnormal Pap tests who don’t get the care they need.
Dr. Dignan is director of the Prevention Research Center at the Markey Cancer Center and the principal investigator of several community based projects that focus on cervical cancer, colorectal cancer and rural Appalachian populations in Eastern Kentucky.
Each issue of Advances & Insights summarizes an important piece of medical news, accompanied by commentary from a UK expert.
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