Letter to ACOG - Save the Pap!
Letter to ACOG - Save the Pap!
Dear ACOG Representative:
We are writing regarding the new ACS guidelines that were published recently, suggesting that we move toward HPV testing alone and away from cervical cytology. We, as America’s frontline women’s health physicians, would like to express our concerns about this change and ask that ACOG affirm and uphold its current guidelines, rather than moving toward HPV-based screening.
Our primary concerns with the new ACS guidelines include:
1) No longer recommending the Pap test in women under 30 and Pap + HPV co-testing for women over 30 in favor of HPV testing alone
2) Changing the age to start screening for cervical cancer from 21 years to 25 years
Risks of HPV Testing Alone
The ACS guidelines devalue the Pap test in favor of HPV testing alone, ignoring the role of Pap testing in reducing the burden of disease from cervical cancer, as well as its overwhelming acceptance with women and providers. The rate of cervical cancer, which was once a leading cause of death among women, has fallen by more than 70 percent since the Pap test was introduced over 50 years ago.1 Previously, cervical cancer was the leading cause of cancer death in women, but now it is the fifteenth most frequent. Additionally, women and the healthcare providers who treat them do not agree with these recommendations. New data from National Association of Nurse Practitioners in Women’s Health and HealthyWomen show that providers view the Pap test (95%) and Pap + HPV testing (89%) as essential to managing cervical cancer risk and women agree, with 90% saying the Pap test is important to overall health and well-being.2
The ACS’ rationale for moving toward HPV testing alone is based largely on a proprietary model, the details of which have not been fully released to the scientific community for analysis, and conclusions based on this model are inherently contradictory. Specifically, the model predicts the identification of more treatable pre-cancer (CIN2 and CIN3) using the current standard of care over the newly recommended approach, yet counter-intuitively it also predicts increased rates of cancer incidence and death using the current standard of care.
Although some countries in Europe have moved towards HPV testing alone, those countries benefit from HPV vaccination and healthcare that is more universal. Access to care in the United States is often fragmented and limited, and we have to account the fact that we also have higher-risk groups, such as Black and Hispanic populations, who are disproportionately impacted by cervical dysplasia and cancer, as well as disproportionately less likely to have access to the healthcare system. Along with these healthcare system risks, recent data show that HPV testing alone would miss twice as much cervical cancer as co-testing.1 For these reasons, we support continuation of co-testing. It is important that when we see women, sometimes for the first and only time, we gather as much information as possible to try to risk-stratify their cervical surveillance.
Risks of Raising the Screening Age
We also have concerns about increasing the screening age to 25 years. Although the rate of cervical cancer is low in patients younger than 25 years, it is not nonexistent. The ACS guidelines document that 120 young women would develop cervical cancer if screening is delayed until age 25, which represents approximately 1% of cervical cancers in the United States. The ACS points out concerns for overtreatment leading to future increased risk of preterm birth in this age group, which is a valid concern. However, the ASCCP allows for observation of CIN 1 and 2, which mitigates the concern for overtreatment in this age group. Therefore, we feel that the balance of benefits lies in screening these women.
We also note that in the new ACS guidelines, there is reference to the decision analysis looking at current screening practice versus moving to HPV-based screening at 25. When we compare these options, we actually see an increased number of colposcopies in the HPV-based group. HPV infection is very common in younger women, and most of these infections are naturally cleared through the patients’ immune response. HPV testing alone in this population could lead to a very high rate of false positives, resulting in young women — who may never actually develop cervical cancer — undergoing expensive and painful invasive procedures unnecessarily. We as practicing OB/GYNs believe that the patient experience is not negatively impacted by having cytology performed, because for HPV-based testing, women are already undergoing a pelvic exam and sample collection. On the other hand, we do feel that increasing the number of colposcopies needed for patients is a move in the wrong direction. Colposcopy is a procedure that is unpleasant and anxiety-provoking for patients, and we feel that it is in the best interest of women to continue co-testing rather than increasing the number of colposcopies needed at a population level.
Delaying screening in younger women would also introduce secondary negative effects on their overall well-being. When the initiation of cervical cancer screening was raised to the age of 21 years old several years ago, it resulted in a significant decrease in chlamydia screening for young women 15 to 21 years old without a decrease in office visits. Raising the age to 25 years threatens to accelerate this decline even further.
We ask that ACOG consider the factors above, as well as the important relationship between women, especially young women, and their providers and not adopt these recommended changes. Re-evaluation and simplification of screening guidelines should not come at the expensive of young women’s lives. Given the dramatic changes that the ACS advises, we also believe that a statement from ACOG affirming and upholding its current recommendations would provide helpful clarity and guidance to clinicians in practice. We appreciate your time and dedication to the improvement of women’s health in the United States.
Alison D. Cowan MD, MS, FACOG
Rebecca F. Dunsmoor-Su, MD, MSCE, FACOG
1. Kaufman H., et al. Contributions of Liquid-Based (Papanicolaou) Cytology and Human Papillomavirus Testing in Cotesting for Detection of Cervical Cancer and Precancer in the United States. Am J Clin Pathol. July 8, 2020.
2. Albright DM, Rawlins S, Wu JS. Cervical cancer today: survey of screening behaviors and attitudes. Women's Healthcare. 2020;8(3):41-46.