Using Pap smears to detect abnormalities before they become serious is one of medicine's significant success stories. Thanks to regular screening programs, mortality rates from cervical cancer are down considerably, but "despite all the good technology, we're still seeing 10,000 cases of invasive cervical cancer per year," said Paul Callaway, M.D., clinical associate professor of family medicine at the University of Kansas School of Medicine, Wichita.
Although the American Cancer Society, American College of Obstetricians and Gynecologists, and U.S. Preventive Services Task Force have released new guidelines for screening, differing language, requirements and timelines in these guidelines can confuse family physicians and their female patients.
Callaway tried to alleviate some of this confusion Wednesday with his session, "Abnormal Pap Smears: Applying New Screening and Consensus Guidelines." According to Callaway, the new guidelines incorporate evidence-based research, as well as such new technology as liquid-based testing. "We now have some creditable experience" to base guidelines on, said Callaway.
He explained some of the differences between the new ACS, ACOG and USPSTF guidelines for screening. For example, although the guidelines all recommend screening for individuals at age 21 or three years after the onset of intercourse, they differ on the frequency of follow-up screening. The guidelines also differ on timing of Pap smears for women older than 30 and on the upper age limit for screening.
The guidelines offer different approaches, and FPs can choose to follow what works best for them and their patients, said Callaway. The key is that because the guidelines are evidence-based "(FPs) now know what is acceptable and approved," said Callaway. But he cautioned attendees to consider the patient when evaluating systems. It’s not just doing a simple Pap smear, he said. "The ramifications (of an abnormal Pap smear) can be overwhelming."
Callaway also detailed changes in the Bethesda system, including changes in terminology. "The concept behind the original Bethesda was to try to reduce confusion," said Callaway. The advent of more knowledge about the human papillomavirus, evidence-based research and new technology, such as liquid-based testing, prompted a revision of the system in 2001, he said.
Using patient examples to illustrate how new guidelines can be applied, Callaway drew attendees into a lively discussion about what to do in given situations. In particular, he focused on testing for HPV. As a result of Bethesda 2001 and new consensus guidelines from the American Medical Association, Callaway has changed his practice. He is now doing HPV testing, using liquid-based Pap smears, doing reflex HPV testing, evaluating for atypical glandular cells, assessing serial cytology versus colposcopy, and promoting conservative management of cervical intraepithelial neoplasia 1.
Callaway repeatedly urged attendees to remember that "the Pap is a screening test, not a diagnostic test, and it’s not 100 percent. If you have an abnormal screen, you need to go to a diagnostic test." He also urged attendees to be cautious in their approach to any abnormal results. "We don’t want our patients scared to death, so we have to walk them through the results," said Callaway.
