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New Guidelines for Managing Women with Abnormal
Each year 3.5 million women have some degree of abnormality on their
Pap smear the test most commonly used to screen for cervical cancer and
require additional attention. But until 2001 there were no national guidelines
on the best way for clinicians to treat these women.
The American Society of Colposcopy and Cervical Pathology brought together
experts in cervical cancer prevention to develop comprehensive specifications.
The guidelines they created could make things easier for women who have
inconclusive Pap smear results.
The most common abnormal Pap smear result, occurring in about 1 in 20
tests, is called atypical squamous cells of undetermined significance
(ASC-US). While most women with ASC-US do not have a significant cervical
lesion and only about 1 in 1,000 have cervical cancer, they are at considerable
risk for a high-grade cervical cancer precursor lesion and require some
form of follow-up.
The conference evaluated data supporting different approaches of ASC-US
management and found that three are safe and effective: repeating the
Pap test at least twice over an 8-12 month period, inspecting the cervix
with a colposcope and obtaining cervical biopsies, and testing for human
papillomavirus (HPV), a sexually transmitted disease that causes genital
warts and is linked to most cases of cervical cancer.
According to the Consensus Conference judgment, women with abnormal
Pap tests that are not ASC-US need to undergo a colposcopic examination
(inspection of the cervix using a microscopy) and cervical biopsies.
The guidelines also tout a relatively new technique, liquid-based cervical
cytology, in which cervical cells are collected in liquid instead of
smeared onto a slide, as in a Pap smear. The liquid-based screening makes
more cells available if additional HPV testing is needed, which means
women would only need to have one sample taken.
The complete set of guidelines can be found in the April 24, 2002, issue
of the Journal of the American Medical Association.
June 2002 Update
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A New Approach to Testing for Cervical Cancer
Most women know that regular Pap smears can almost eliminate the chances
of developing invasive cervical cancer. By examining the cervix for abnormal
(and potentially precancerous) cells, treatment can be started before
a real problem develops.
What many women may not know is that human papilloma viruses (HPVs) (which
cause genital warts) are responsible for the majority of cases of cervical
cancer. Two recent studies suggest that regular screening for HPV may
prove even more effective than the traditional Pap smear in preventing
The first study included 8,554 women who lived in the Gaunacaste Province
of Costa Rica, where there is a very high rate of cervical cancer. Researchers
found that HPV testing picked up 17% more high-grade cervical cell abormalities
The second study compared the Pap smear with testing vaginal samples
for HPV. 1,415 women in South Africa (who had not had any cervical cancer
screening) participated. The first HPV test was done by a doctor during
a routine physical exam. The HPV test was done on samples of vaginal
fluid the women collected themselves using a cotton swab. All the women
had Pap smears done as well. The HPV testing on samples taken by the
doctor detected far more cervical disease than the Pap smear (84% vs.
68%). The HPV testing done on the self-collected samples was not equivalent
to the HPV tests done on the physician-collected samples, but was just
as good as the Pap smear. And did not require a trip to the doctors
What are the important take-home messages from these studies? First,
each year in the United States there are an estimated 15,000 new cases
of cervical cancer. Each year, about 5,000 women will die needlessly
of the disease. Regular Pap smears are the most effective way to screen
for this disease. Second, although HPV is one of the most common sexually
transmitted infections, only a small number of women suffer complications,
including cervical disease. There are over 70 types of HPV, but only
13 are known to cause cervical cancer.
Still, screening techniques that include HPV testing may not only increase
the ability to detect abnormal cell changes early, but can also let a
woman know whether or not she carries one of the more dangerous viruses
(and therefore needs to be extra vigilant about screening). Finally,
self-collected samples for testing may take us a big step forward in
preventing this disease in places where women do not get regular visits
to the doctor.
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