Thursday, October 20, 2011

New Cervical Screening Guidelines Introduced

It has been five years since the last series of guidelines regarding cervical screening were introduced. This was the culmination of newly acquired information from 2000 (the time of the previous guidelines) to 2005. Given that significant and substantial information has been gained in these past five years, release of these recommendations was certainly anticipated.

The means by which they have been released especially with regard to public comment is certainly unacceptable. Having been released two days ago, comments are only being accepted through November 15, 2011 at which time comments will be reviewed and final recommendations issued. The ACS will review all information and make its recommendations some time in 2012.

The individuals most affected by this virus (HPV) should certainly have the ablitity to comment of screening procedures and other relevant issues yet nothing has been promoted via any media outlets informing women of the opportunity to have their voices heard, nor has there been a more patient-friendly version of these recommendations provided that would clearly summarize the changes for the lay person.

One thing which strikes me is the fact that they admit they have no information available to determine how to incorporate known risk factors into these guidelines! One must ask, with all the research being conducted - why not?

As a registered nurse, a patient's risk factors for any disease were always considered with respect to that patient's follow-up and treatment, yet this isn't the case here. I disagree with the exclusion of testing of all women under 21 years of age. This blatantly disregards two of the known risk factors which can effect persistent disease; early sexual onset and multiple partners. Yet in the 2006 guidelines, this same organization stated: "Indirect evidence suggests most of the benefit can be obtained by beginning screening within 3 years of onset of sexual activity or age 21 (whichever comes first).." and "The USPSTF concludes that the benefits of screening substantially outweigh potential harms."

If this were a static situation and people never changed relationships perhaps these proposals would be more plausible but this simply isn't the case. By way of example, if a woman changed relationships a month after receiving her pap, she may then be dealing with a high risk strain of HPV for three years before being tested again. I have spoken to too many women, even those in monogomous relationships, whose HPV has advanced at a far faster pace than this.

They point to "notable limitations in the current evidence" as it relates to harms of HPV testing. Also mentioned is the need for more research to incorporate individual risk factors thereby preventing overdiagnosis and overutilization of resources. Are these the same risk factors which they have totally ignored in making their current recommendations. Even without specific and direct evidence, it is only common sense that a woman's risk factors play an obvious part in her treatment. How will the two risk factors of early sexual onset and multiple partners be accurately assessed if an entire cohort of women (those under 21) are being excluded from testing?

What these organizations also fail to take into consideration is that guidelines or not, many of the unnecessary treatments and procedures are made because of the total lack of knowledge and education with regard to HPV. Doctors recommending LEEP or other such procedures for CIN1 lesions which is clearly contradicted in the current guidelines since 90% of these regress within 24 months; total hysterectomies for CIN3, also contraindicated by current guideilnes but being done by physicians none-the-less. Where does the acknowledgement of a need for better training of these physicians come in?

A very interesting point is the total reversal of the recommendations made in the 2006 guidelines regarding HIV-infected women which, according to those guidelines, should be no different than the screening for non-infected women. This made no sense to me from the onset since HIV is know to reduce the body's immune system and leave the individual compromised regarding other infections including HPV.

The point here is not HIV but how organizations so convinced that they know what is right have now in essence acknowledged that they've had it wrong for the past five years. The new proposal states the following: "In contrast, women who are HIV positive are at such increased risk that the U.S. Public Health Service has issued separate screening guidelines suggesting that they be screened twice within the first year after initial HIV diagnosis and annually thereafter." This is quite a turn around from the recommendations which have been followed for the last five years. Can we afford to be waiting five years for these organizations to recognize the error of their ways with these newly proposed guidelines?

It was the initiation of pap screening (obviously in conjunction with the frequency of which it was performed) which has reduced the cervical cancer rate over the past fifty years in the area of 70%. It appears that women are in for a rude awakening if these guidelines are implemented by ACOG and ACS. It is truly unfortunate for those women whose precancerous and cancerous lesions would have otherwise been discovered will now have to joint the ranks of "survivors" if they make it that far. Why should we have to be waiting five years for a spike in cervical cancer as a result of these changes and the admitted lack of information being incorporated in them? No woman, or her surviving family should have to learn five years down the road that yet another mistake was made as it has in the case of women with HIV.

You can read the draft recommendations at the following link:

Please provide your comments before November 15th at the following link:

I will participating in the cervical cancer screening briefing by the US Preventative Services Task Force tomorrow afternoon and will provide any additional information after that time.