Cervical cancer screening tests-Pap smears and HPV tests-are frequently overused among commercially insured women with average risk of developing cancer, a new study from researchers at Columbia University's Vagelos College of Physicians and Surgeons and Herbert Irving Comprehensive Cancer Center finds.
The study, involving nearly 2 million women who were screened for cervical cancer between 2013 and 2014, found that nearly two-thirds received unnecessary tests in the next three years, before their next recommended screening.
"If there was no potential for harm from screening, it would not be unreasonable to do more frequent testing," says Jason D. Wright, MD, the Sol Goldman Associate Professor of Gynecologic Oncology at Columbia University Vagelos College of Physicians and Surgeons and senior author of the study. "The issue is there are real downsides to over-screening."
The CUIMC Newsroom spoke with Wright about what women and their providers need to know about cervical cancer screening. Below are excerpts from our conversation:
Women with average risk for cervical cancer don't need annual screening tests.
The way we screen for cervical cancer has changed a lot over the last 10 to 15 years. Initially, cervical cancer screening only involved an annual Pap smear, which looks for abnormal cells from the cervix. Widespread use of the test-which increased beginning in the 1950's-has been credited with slashing cervical cancer death rates dramatically.
With the introduction 20 years ago of HPV (human papillomavirus) testing, which is much more sensitive than Pap tests, we realized that women didn't need to be screened as frequently. In 2012, new guidelines recommended screening with a combination of the Pap smear and an HPV test and spacing out interval between screenings to every three years. And in 2020, guidelines relaxed even further: if you have a negative HPV test or a negative Pap smear in combination with an HPV test, you only need to be screened again in five years.
I think that both patients and providers are hesitant to give up more frequent screening, because they worry it could increase the risk of cancer. But the guidelines are backed by science: there are very good studies that show that screening every three to five years is enough to detect cancer among women with average risk.
Over-screening for cervical cancer can be harmful.
With more screening there is a much higher risk of detecting mild abnormalities that are not clinically significant and would likely resolve on their own. HPV is extremely common, and a positive HPV test doesn't necessarily indicate a worrisome abnormality. The problem is that detection of HPV and mild abnormalities often lead to more invasive procedures, like colposcopy and cervical conization, that have their own risks. It also leads to unnecessary anxiety among women who are scared that an abnormal test result means they have cervical cancer.
Another issue with over-screening is cost. Women need to take time off from work to have more tests and procedures. And there's an economic consequence to the health care system by performing tests that are of minimal benefit to patients.
Women still need annual gynecological exams.
A potential unwanted consequence of decreased screening is that women may be less likely to undergo routine gynecologic examinations. In our study, we found that 74% of women who did not have extra cervical cancer screenings also did not have a gynecologic examination. I think in women's minds, annual gynecological exams and cervical cancer screening tests are indelibly linked. But that doesn't necessarily need to be the case.
Just because you're not scheduled for an HPV or Pap test doesn't mean you don't need an annual gynecologic exam, which includes a pelvic exam, often a breast exam, and discussions about immunizations and other health concerns related to a patient's stage of life.
There is debate as to whether average-risk women need an annual pelvic exam, which is performed to look for infections, pelvic inflammatory disease, and early signs of cancer. But physicians can also use an annual gynecological exam as an opportunity to counsel patients about a variety of health concerns, from reproductive health to mental health. In addition, it's possible that some women will be less likely to show up for repeat screenings at the appropriate time if they don't have an annual gynecological exam.
Guidelines are only meant to be guidelines.
Our study focused on average risk women who are aged 30 to 65. Some women have higher risk-including women who are immunosuppressed, have had a transplant, or had an abnormal test in the past. For these women, more frequent screening is often indicated.
There are also some women who are genuinely anxious about not having yearly screening for cervical cancer. If that's the case, I think talking about the risks and benefits with their provider, and coming to an individual plan or strategy for screening is certainly something that's reasonable.
References
More information
The article, titled "Overuse of Cervical Cancer Screening Tests Among Women with Average Risk in the United States from 2013 to 2014," was published in JAMA Network Open on April 29, 2021.
Authors (all from Columbia) are Jason Wright, Ling Chen, Ana Tergas, Alexander Melamed, Caryn St. Clair, June Hou, Fady Khoury-Collado, Allison Gockley, Melissa Accordino, and Dawn Hershman.
Dr. Wright receives grants from Merck and personal fees from Clovis Oncology and UpToDate. Dr. Tergas receives personal fees from Auro Vaccines.
Support for the study was provided by the Herbert Irving Comprehensive Cancer Center (P30CA013696).
