New Guidelines For Treating Women With Abnormal Pap Test Result< April 30, 2002 > New treatment guidelines promise to standardize care following an abnormal Pap test (also called Pap smear), and they could dramatically reduce the time a woman has to wait until she knows she is free of cervical cancer. The guidelines, sponsored by the American Society of Colposcopy and Cervical Pathology, brought together 29 national organizations and federal agencies and are published in an April issue of the Journal of the American Medical Association (JAMA). Each year, the hearts of some 3.5 million American women skip a beat when they find out their Pap test is abnormal. While only 0.1 to 0.2 percent will have invasive cervical cancer—with the overwhelming majority having no serious cervical disease—under the current guidelines it can often take weeks or even months for a woman to know for sure. That is because the current recommended follow-up is months of repeat Pap tests. "What we have tried to do is incorporate some of the new testing and treatment technologies with traditional care to come up with a standardized system that we hope will make it easier for women who receive an abnormal Pap smear result to get a faster diagnosis, and insure they are getting the correct and most up-to-date standard of care," says Dr. Thomas C. Wright Jr., associate professor of pathology at Columbia University College of Physicians and Surgeons and lead author of the new guidelines. Among the new suggestions includes following less serious Pap test abnormalities—test results known as ASC-US (atypical squamous cells of undetermined significance)—with liquid-based DNA testing for human papillomavirus (HPV), a sexually transmitted infection closely linked to cervical cancer. They also suggest the need for immediate use of biopsy following more serious Pap test abnormalities. For New York University professor Dr. Steven Goldstein, the standardized approach makes good sense. "I think that there are many physicians throughout the country who have been under-treating what is a potentially serious situation, and hopefully these guidelines will change that," says Goldstein, an obstetrician and gynecologist at New York University Medical Center. The only other option to repeated Pap tests is a colposcopy—an invasive examination of the cervix during which a biopsy of tissue samples is retrieved. Although the procedure yields immediate results, it can be uncomfortable as well as costly, and, as the new report points out, can raise false concerns as well as inviting over-diagnosis and over-treatment. While the report emphasizes that both of the current treatment recommendations do work, it also stresses the need for change. Wright says certain strains of HPV are thought to be the primary cause of cervical cancer. Because of that, the new guidelines suggest that following an ASC-US Pap test report with the new DNA test for this virus is a faster, easier, more efficient way to identify those women who have cervical cancer. "If a woman tests negative for HPV, chances are good she doesn't have cervical cancer," says Wright. If she tests positive, he says, further invasive treatment is justified. Additionally, because the laboratory can use the same fluid sample obtained for the Pap test to do the HPV test, Wright points out that a second physician visit would not be required, saving both time and money. The second guideline recommendation involves the treatment of a more seriously abnormal Pap test—a result known as LSIL (low-grade squamous intraepithelial lesion). Although the majority of these women either have no cervical lesions or a low-grade lesion that either regresses without treatment or is removed during biopsy with no further treatment needed, this is not always the case. Indeed, sometimes, says Wright, the panel noted a "small but real risk of delaying the identification of invasive cancers," as well as many women who eventually did need the colposcopy procedure to determine disease status. The new recommendation is that all LSIL reports should be immediately followed with colposcopy. The goal is not only to identify those with cervical cancer, but also to find and remove any precancerous lesions—something a colposcopy can easily accomplish. The third and final recommendation involves the most serious cervical abnormalities—Pap tests identified as HSIL (high-grade squamous intraepithelial lesion). Although representing just under 0.005 percent of all Pap tests, up to 75 percent of women with HSIL have precancerous cervical lesions, and up to 2 percent have invasive cervical cancer. The guidelines suggest a colposcopy, followed by rigorous assessment of the findings. When cancer or significant precancerous lesions are found, the guidelines suggest more extensive tissue removal and laboratory analysis. Each year, some 50 million women undergo Pap tests. Recently the National Cancer Institute revised the criteria by which cytologists (those reading Pap test results) categorize test results, as well as the terminology used in classifying Pap test reports. This, combined with a vast array of new knowledge about the causes of cervical cancer—including conclusive links to HPV—prompted the issuance of the new treatment guidelines. Always consult your physician for more information. Online Resources:(Our Organization is not responsible for the content of Internet sites.) American Society of Colposcopy and Cervical Pathology Journal of the American Medical Association (JAMA) |
For more information about Pap tests, cervical cancer, and/or HPV infections, please visit our Women's Health or Gynecological Health clinical content modules. What is a Pap test?A Pap test (also called Pap smear) is a way to examine cells collected from the cervix, or the "mouth" of the womb (located at the top of the vagina), for the presence of:
Why is a Pap test suggested to women?A Pap test, along with a pelvic examination, is an important part of a woman's routine health care because it may detect abnormalities that can lead to invasive cancer. Most invasive cancers of the cervix can be detected early if women have Pap tests and pelvic examinations regularly. As with many types of cancer, cancer of the cervix is more likely to be successfully treated if it is detected early. The Pap test is useful for detecting not only cancerous cells, but also other cervical and vaginal abnormalities including dysplasia (precancerous cells) and inflammation. Inflammation may be caused by:
Who should have Pap tests?According to the National Cancer Institute: Women who are or have been sexually active, or have reached age 18, should have Pap tests and physical (and pelvic) examinations regularly. Generally, there is no upper age at which Pap tests cease to be effective. Older women should continue to have regular physical examinations, including pelvic examinations and Pap tests. Women who have had a hysterectomy should consult their physicians about whether or not to continue having regular Pap tests. Thinprep - A Pap test alternativeA new way of testing cervical cells for abnormalities is gaining acceptance in the medical community. Though the cost of the procedure, call Thinprep, is double what a Pap test costs, studies show that Thinprep may require fewer repeat test and detects more early-stage lesions. Approved by the US Food and Drug Administration (FDA), Thinprep is a liquid-based procedure in which cells from the cervix are put into a vial of liquid instead of being "smeared" onto a slide. The liquid is then filtered and only the cervical cells are placed onto a slide for examination. Always consult your physician for more information. What is human papillomavirus (HPV)?Human papillomavirus (HPV) is a common sexually transmitted disease that can cause genital warts called condylomas. These condylomas can occur on the inside or outside areas of the genitals and may spread to the surrounding skin or to a sexual partner. Because HPV infection does not always cause warts, the infection may go undetected. Women with an HPV infection have an increased risk of developing cervical cancer. Regular Pap tests can detect HPV infection, as well as abnormal cervical cells. Although there is treatment for the condylomas (which sometimes go away on their own), the virus remains and warts can reappear. Smoking appears to increase problems related to HPV infection. Other types of HPV can also cause warts on other body parts such as the hands, called common warts, however, these do not generally cause health problems. Always consult your physician for more information. |