Which screening prevents uterine cervix cancer? Go with the co-test

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With regard to cervical cancer screening, American women can choose the Pap test or the human papillomavirus (HPV). The Pap test has been the mainstay of the screenings since Georgios Papanicolaou developed it in the late 1920s – the most successful cancer screening program in history. The HPV test looks for the most at risk strains of the virus responsible for almost all cervical cancers.

The debate over the most effective and reliable way of detecting and preventing cervical cancer has led to frequent and often confusing changes in the cervical cancer screening guidelines of several medical organizations in the United States. during the last decade. Force a few weeks ago.

While the USPSTF's recommendations for women aged 21 to 29 have remained the same as before (a smear every 3 years), the USPSTF gives women aged 30 to 65 a choice: a smear every 3 years, a test every 5 years.

So, what's a woman to do?

Choose both.

At least, that's what almost every other competent medical organization is recommending and what the published evidence seems to be supporting at the moment. In fact, the day before the USPSTF published its recommendations, a study in the American Journal of Clinical Pathology found that Pap tests detected more cancers than HPV testing in more than 300,000 screenings between 2003 and 2009.

"The co-test is the safest way for patients to detect cervical cancer," said lead author of the study, R. Marshall Austin, MD, Professor of Pathology and Director of Cytopathology at the Magee-Womens Medical Center of the University of Pittsburgh. in Pennsylvania.

Austin said many women do not realize that it is still possible to contract cancer even with regular screenings. No screening test is perfect there will always be missed cases (false negatives) and false alarms (false positives).

But the co-test offers the best of both worlds. The development of HPV in cancer can take decades. Identifying current infections with a high-risk HPV strain gives physicians the opportunity to set up follow-up surveillance for women before cancer has a chance to develop.

And Pap tests have come a long way since the "Pap test" used from the 1930s to the end of the 20th.^e century. Today's liquid-based cytology – an examination of cervical cells under the microscope – is even more accurate in revealing abnormal cell patterns than the smear on a blade so long used.

"We have done badly to educate people that even the best screening is not going to result in any cancer," said Austin. "But if you want as close as possible to no cancer, there is no doubt about it – the data all indicate that there is a co-test."

By preferentially suggesting to women a Pap test or an HPV test, the USPSTF recommendations differ from those of 23 other organizations that developed consensual guidelines in 2012 and recommend co-testing (Pap test and HPV every 5 years) .

Some two dozen organizations that continue to recommend co-testing include the American Academy of Obstetricians and Gynecologists, the American Cancer Society, the American Colposcopy and Cervical Pathology Society, and the American Society of Clinical Pathology.

Yet, the co-tests were not even featured in the USPSTF's original draft recommendations when they published the draft for public comment in September 2017. This is only the case. After researchers and patient advocates strongly supported the inclusion of color co-tests, the USPSTF went back and added the co-test as one of the recommended options .

Professional disagreements about different screening methods can become intense. When Austin submitted his study for review, one of his reviewers was Mark Schiffman, MD, MPH, a senior investigator at the National Cancer Institute who has long championed the value of HPV testing for screening. Schiffman wrote at length about the results of a study he conducted that contradicted what Austin had found, suggesting that Pap tests were not as effective as the HPV test.

But Austin said it depends on the quality of the Pap and his analysis – and what you are willing to learn.

"We are trying to learn examples where the system fails," Austin said. "For over 20 years, I've been studying cases of women being screened and still having cervical cancer."

His institution uses computer-aided imaging to interpret pathology findings from Pap tests.

"I realized early on that there are certain types of cellular patterns that you see on these Pap tests that are very significant but that may not be recognized, and that's how I form our cytologists and pathologists, "Austin said. "Because of that, I am quite convinced that our lab is catching things that are commonly missed."

In facilities or clinics that are not as conscientious or conscientious with Pap tests as the Austin lab, the benefits of the co-test may not be so obvious. In his study, 13% of cervical cancer cases developed after a negative HPV test, but a positive Pap test result. But even if other institutions only took half, it would mean that one in 15 women with cervical cancer would be identified from the beginning instead of being forgotten as cancer continues to develop. develop.

The co-test also helps doctors plan more accurate follow-up when the results of the two tests are contradictory, which could allow women to avoid extra travel or more invasive procedures such as biopsies (depending on the results of the tests). tests).

In any case, the recommendations of the USPSTF certainly do not end the debate on the best cervical cancer screening regiment.

"The USPSTF has not changed the ACOG guidelines or the ASCCP or ASCP guidelines," Austin said. "They're going to be revisited, and this will be another debate that will continue, but currently these guidelines are that the co-test is the preferred method."

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With regard to cervical cancer screening, American women can choose the Pap test or the human papillomavirus (HPV). The Pap test has been the mainstay of the screenings since Georgios Papanicolaou developed it in the late 1920s – the most successful cancer screening program in history. The HPV test looks for the most at risk strains of the virus responsible for almost all cervical cancers.

The debate over the most effective and reliable way of detecting and preventing cervical cancer has led to frequent and often confusing changes in the cervical cancer screening guidelines of several medical organizations in the United States. during the last decade. Force a few weeks ago.

While the USPSTF's recommendations for women aged 21 to 29 have remained the same as before (a smear every 3 years), the USPSTF gives women aged 30 to 65 a choice: a smear every 3 years, a test every 5 years.

So, what's a woman to do?

Choose both.

At least, that's what almost every other competent medical organization is recommending and what the published evidence seems to be supporting at the moment. In fact, the day before the USPSTF published its recommendations, a study in the American Journal of Clinical Pathology found that Pap tests detected more cancers than HPV testing in more than 300,000 screenings between 2003 and 2009.

"The co-test is the safest way for patients to detect cervical cancer," said lead author of the study, R. Marshall Austin, MD, Professor of Pathology and Director of Cytopathology at the Magee-Womens Medical Center of the University of Pittsburgh. in Pennsylvania.

Austin said many women do not realize that it is still possible to contract cancer even with regular screenings. No screening test is perfect there will always be missed cases (false negatives) and false alarms (false positives).

But the co-test offers the best of both worlds. The development of HPV in cancer can take decades. Identifying current infections with a high-risk HPV strain gives physicians the opportunity to set up follow-up surveillance for women before cancer has a chance to develop.

And Pap tests have come a long way since the "Pap test" used from the 1930s to the end of the 20th.^e century. Today's liquid-based cytology – an examination of cervical cells under the microscope – is even more accurate in revealing abnormal cell patterns than the smear on a blade so long used.

"We have done badly to educate people that even the best screening is not going to result in any cancer," said Austin. "But if you want as close as possible to no cancer, there is no doubt about it – the data all indicate that there is a co-test."

By preferentially suggesting to women a Pap test or an HPV test, the USPSTF recommendations differ from those of 23 other organizations that developed consensual guidelines in 2012 and recommend co-testing (Pap test and HPV every 5 years) .

Some two dozen organizations that continue to recommend co-testing include the American Academy of Obstetricians and Gynecologists, the American Cancer Society, the American Colposcopy and Cervical Pathology Society, and the American Society of Clinical Pathology.

Yet, the co-tests were not even featured in the USPSTF's original draft recommendations when they published the draft for public comment in September 2017. This is only the case. After researchers and patient advocates strongly supported the inclusion of color co-tests, the USPSTF went back and added the co-test as one of the recommended options .

Professional disagreements about different screening methods can become intense. When Austin submitted his study for review, one of his reviewers was Mark Schiffman, MD, MPH, a senior investigator at the National Cancer Institute who has long championed the value of HPV testing for screening. Schiffman wrote at length about the results of a study he conducted that contradicted what Austin had found, suggesting that Pap tests were not as effective as the HPV test.

But Austin said it depends on the quality of the Pap and his analysis – and what you are willing to learn.

"We are trying to learn examples where the system fails," Austin said. "For over 20 years, I've been studying cases of women being screened and still having cervical cancer."

His institution uses computer-aided imaging to interpret pathology findings from Pap tests.

"I realized early on that there are certain types of cellular patterns that you see on these Pap tests that are very significant but that may not be recognized, and that's how I form our cytologists and pathologists, "Austin said. "Because of that, I am quite convinced that our lab is catching things that are commonly missed."

In facilities or clinics that are not as conscientious or conscientious with Pap tests as the Austin lab, the benefits of the co-test may not be so obvious. In his study, 13% of cervical cancer cases developed after a negative HPV test, but a positive Pap test result. But even if other institutions only took half, it would mean that one in 15 women with cervical cancer would be identified from the beginning instead of being forgotten as cancer continues to develop. develop.

The co-test also helps doctors plan more accurate follow-up when the results of the two tests are contradictory, which could allow women to avoid extra travel or more invasive procedures such as biopsies (depending on the results of the tests). tests).

In any case, the recommendations of the USPSTF certainly do not end the debate on the best cervical cancer screening regiment.

"The USPSTF has not changed the ACOG guidelines or the ASCCP or ASCP guidelines," Austin said. "They're going to be revisited, and this will be another debate that will continue, but currently these guidelines are that the co-test is the preferred method."