Professional societies' disagreements regarding cancer screening have dominated the medical landscape of late. USPSTF says some women may appropriately defer breast cancer screening until age 50, while the American College of Radiography and American Cancer Society both recommend starting at age 40. USPSTF grades prostate cancer screening a "D" (not recommended) yet the American Urological Association advises shared decision making regarding the prostate specific antigen (PSA) test with all men aged 55-69 years. 21st century media-savvy patients are aware of these differences, and discussions about screening often occupy quite a bit of my time with patients these days.
How refreshing it is, then that the American College of Obstetrics and Gynecology (ACOG)'s new cervical cancer screening guidelines align well with the USPSTF's published last year. Last week's AFP summarized ACOG's stance nicely:
- No screening before age 21. EVER.
- Screen every 3 years between ages 21-29 only with cytology. (Because the rate of incidental HPV infection is so high in this age group, add HPV testing only when the pap test is abnormal.)
- Screen every 5 years between ages 30-65 with cytology and HPV. (Alternatively, screen every 3 years with just cytology.)
- No screening after age 65 unless 1 of the last 3 pap tests was abnormal or there is a history of high-grade dysplasia.
As Dr. Lin pointed out earlier this year, screening for cancer is not a zero risk proposition, and discussing cancer screening with patients is frequently more complex than a simple directive to "get a mammogram/PSA/etc." The AFP By Topic on Cancer includes several AFP articles from the last few years summarizing the evidence for multiple types of cancer screening if you'd like further reading.
Thankfully, the sensitivity and specificity of the pap test are both quite high, making the risks of a false positive or a false negative exponentially much lower than mammography or PSA. The jury may still be out on breast and prostate cancer screening (as for me, I follow the USPSTF's guidelines and discuss this openly with patients), but for cervical cancer screening, at least, we have consensus and clear recommendations as above.