Pap Smears

Recommendation

Don't perform Pap smears on women under the age of 21 or women who have had a hysterectomy for non-cancer disease.

• Most observed abnormalities in adolescents regress spontaneously, therefore screening Pap smears done in this age group can lead to unnecessary anxiety, additional testing, and cost.
• Pap smears are not helpful in women after hysterectomy (for non-cancer disease) and there is little evidence for improved outcomes.

_{Sources: US Preventive Services Task Force (USPSTF) (for hysterectomy), American College of Obstetrics and Gynecology (ACOG) (for age)}

In a 2012 report, the U.S. Preventive Services Task Force (USPSTF) reviewed research published since 2003 that evaluated liquid-based cytology and human papillomavirus (HPV) testing.⁽¹⁾ The USPSTF also commissioned researchers to develop a computer model to calculate the frequency of cervical cancer screening and the ages at which to begin and end this screening. The USPSTF issued the following recommendation statements ⁽¹⁾:

• The USPSTF recommends against screening for cervical cancer in women younger than age 21 years (D recommendation).
• Available studies show that precancer or cancer of the cervix is rare in women younger than age 20. Approximately 90 percent of HPV infections in girls and young women spontaneously clear within two years.
• The USPSTF recommends against screening for cervical cancer with HPV testing, alone or in combination with cytology, in women younger than age 30 years (D recommendation).
• The USPSTF recommends screening for cervical cancer in women age 21 to 65 years with cytology (Pap smear) every 3 years or, for women ages 30 to 65 years who want to lengthen the screening interval,  screening with a combination of cytology and HPV testing every 5 years (A recommendation).
• The USPSTF recommends against screening for cervical cancer in women older than age 65 years who have had adequate prior screening and are not otherwise at high risk for cervical cancer (D recommendation).

Harms of Treatment of Screening-Detected Disease

The excerpt below is from USPTF summary statement:
 
“Screening with cervical cytology or HPV testing can lead to physical and emotional harms. Abnormal test results can lead to more frequent testing and invasive diagnostic procedures, such as colposcopy and cervical biopsy. Evidence from randomized, controlled trials and observational studies indicates that harms from these diagnostic procedures include vaginal bleeding, pain, infection, and failure to diagnose (due to inadequate sampling). Abnormal screening test results are also associated with increased anxiety and distress.

The harms of treatment also could include risks from the treatment procedure (such as cold-knife conization and loop excision) which are associated with adverse pregnancy outcomes, such as preterm delivery, that can lead to low birth weight in infants and perinatal death. Evidence is convincing that many precancerous cervical lesions will regress and that other lesions are so slow-growing that they will not become clinically important over a woman's lifetime; identification and treatment of these lesions constitute overdiagnosis. It is difficult to estimate the precise magnitude of overdiagnosis associated with any screening or treatment strategy, but it is of concern because it confers no benefit and can lead to unnecessary surveillance, diagnostic tests, and treatments with the associated harms.”

References

1. Moyer VA, U.S. Preventive Services Task Force. Screening for cervical cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012;156:880-891. Accessed November 21, 2012.
   
2. ACOG Committee on Practice Bulletins--Gynecology. ACOG practice bulletin no. 109: cervical cytology screening. Obstet Gynecol. 2009;114:1409-1420.
3. Saslow D, Runowicz CD, Solomon D, et al. American Cancer Society guideline for the early
    detection of cervical neoplasia and cancer. CA Cancer J Clin. 2002;52:342-362.
4. Ho GY, Bierman R, Beardsley L, et al. Natural history of cervicovaginal papillomavirus infection in young women. N Engl J Med. 1998;338(7):423–428.
5. 2012 AAFP recommendations for preventive services guideline.