Women Can Test Less Often for Cervical Cancer

For women aged 30 to 65, new national recommendations could mean end of Pap smear tests.

New recommendations for cervical cancer screening feature a significant change—giving women aged 30 to 65 the option to undergo one test every five years.

The recommendations from the U.S. Preventive Services Task Force give women in this age group three options for cervical cancer screening:

• Screening every three years with cytology alone. Cytology is also known as Pap smear testing.
   
• Screening every five years with testing for high-risk human papillomavirus (hrHPV) alone.
   
• So-called cotesting for cervical cancer with both cytology and hrHPV techniques every five years.

This is the first time women have been given the option to be screened with hrHPV testing alone. The recommendations, which were published this week in JAMA, replace guidance issued in 2012.

A JAMA article accompanying the new guidance says the option of hrHPV testing alone reflects a trend toward less frequent testing.  "These recommendations continue the trend of decreasing participant burden by lengthening screening intervals, making the 'annual Pap' a historical artifact," the article says.

The hrHPV test detects the DNA of human papillomavirus strains that have been linked with cervical cancer.

Weighing trade-offs
 

According to the new recommendations, cytology alone every three years or hrHPV testing alone every five years are the preferred cervical cancer screening methods for women aged 30 to 65 years.

Cotesting with cytology and hrHPV exams is considered an "alternative strategy" under the recommendations, but cotesting could result in more tests and procedures than either cytology or hrHPV testing alone.

Physicians and patients face sorting through trade-offs to determine the best screening strategy.

The recommendations estimate that hrHPV testing alone and cotesting would avoid about one additional cancer case per 1,000 women screened compared to cytology alone for a "very small" gain in life years. However, hrHPV testing and cotesting expose women to more tests and procedures than cytology alone.  

The JAMA accompanying article says there is a similar trade-off between cotesting and hrHPV testing.

"Cotesting is slightly better than primary hrHPV testing at detecting precancerous lesions but is associated with increased tests and diagnostic procedures that may not benefit the patient and that have real costs to the health system," the article says.

Cytology is the lowest cost option and could be the best fit for public health systems, according to the article.

"Public health systems in general will more explicitly face trade-offs between less expensive techniques (cytology every three years) involving more clinician visits and more expensive approaches with substantially fewer patient touch points," the article says.

With more screening options available, physicians and healthcare organizations need to increase educational efforts for patients.

"What is clear is that new strategies will be needed to assist healthcare consumers in making informed choices from a broader range of options. New risk communication tools and messaging strategies will be needed to promote adherence and to increase acceptance of the lengthened intervals," the article says.

Cost and value
 

While cytology is the lowest cost screening method, the new recommendations do not address the comparative cost or value of cytology, hrHPV testing, and cotesting.

However, a JAMA editorial accompanying the recommendations shows how healthcare organizations and researchers can assess the cost and value of the cervical cancer screening options.

One method to assess cost effectiveness and value is quality-adjusted life-years (QALY) analysis. The metric features both benefits and harms to estimate total costs per strategy and cost-effectiveness. Under QALY analysis, high-value screening strategies maximize benefits while minimizing harms and cost.

Physicians will have to help their patients assess value, the editorial says.

"If it is left to individuals to decide whether hrHPV testing or cotesting provides an appropriate balance of benefits and harms as compared with cytology, user-friendly educational tools will need to be developed to assure that women are making informed choices reflective of their preferences," the editorial says.