For the December issue of OncoFacts, I will be updating you regarding 2 significant changes from organizations regarding routine screening recommendations for breast cancer and cervical cancer. However, prior to that, I would like to highlight a CDC collaborative report that focuses on prevention recommendations and usage for adults aged 50 to 64 in the United States.

CDC Collaborative Prevention Recommendations for Adults Aged 50 to 64

The Centers for Disease Control (CDC) website introduced their report with the following statement. “In 2008, CDC, AARP [the American Association of Retired Persons], and the American Medical Association initiated a collaborative project to develop a report highlighting data and opportunities to broaden the use of clinical preventive services among adults aged 50 to 64 years in the United States. This report delineates science-based strategies and highlights ‛calls to action’ that build on linkages between clinical and community efforts to facilitate the delivery of multiple preventive services.”

The report identifies a total of 14 recommended clinical preventive services for patients ages 50 to 64:

• Mammogram within the past 2 years
• Pap test within the past 3 years
• Colorectal cancer screening within the past 10 years
• Cholesterol screening within the past 5 years
• Flu shot within the last year
• Pneumococcal vaccine ever among patients at risk
• Increase physical activity
• Smoking cessation
• No binge drinking
• Decrease obesity
• Reduce blood pressure
• Monitor moderate depressive symptoms
• Make sure men and women, respectively, are up to date with services

The report cites the progress by state as to what percentage of its citizens are adherent to these recommendations.

Results:

• All 50 states met the target with regards to mammography with a target of >70%
• All 50 states met the target of >80% having had cholesterol screening within the past 5 years.
• Only 45 states met the target of <13.4% having binge drinking within the past 30 days.
• Only 33 states met the target of >50% regarding colorectal cancer screening.

The remaining 6 indicators have significant room for improvement:

• Pap test within the past 3 years: 5 states met the target of >90%
• No leisure time physical activity in the past month: 4 states met the target of <20%
• Smoking – current: 1 state met the target of <12%
• Influenza vaccination within past year: 0 states met the target of >60%
• Pneumococcal vaccination ever: 0 states met the target of >60%
• Obesity current: 0 states met the target of <15%

These baseline numbers will be important as benchmarks since there is attention in current legislation to expand preventive services as part of the efforts of health care reform. In addition, as uncertainty continues regarding screening recommendations for breast, cervical, and colorectal cancer, the percentage of the population who avail themselves of screening may well be reduced.

The full report can be found at the following website: http://www.cdc.gov/aging/pdf/promoting-preventive-services.pdf. Accessed December 20, 2009.

First Cervical Cancer Screening Delayed Until Age 21 Less Frequent Pap Tests Recommended

Women should have their first cervical cancer screening at age 21 and can be rescreened less frequently than previously recommended, according to newly revised evidence-based guidelines issued by the American College of Obstetricians and Gynecologists (ACOG) and published in the December issue of Obstetrics & Gynecology. Most women younger than 30 should undergo cervical screening once every 2 years instead of annually, and those age 30 and older can be rescreened once every 3 years.

Cervical cancer rates have fallen more than 50% in the past 30 years in the US due to the widespread use of the Pap test. The incidence of cervical cancer fell from 14.8 per 100,000 women in 1975 to 6.5 per 100,000 women in 2006. The American Cancer Society estimates that there will be 11,270 new cases of cervical cancer and 4,070 deaths from it in the US in 2009. The majority of deaths from cervical cancer in the US are among women who are screened infrequently or not at all. Cervical cancer is a slow growing cancer caused by certain strains of the human papillomavirus (HPV), an extremely common sexually transmitted disease among women and men. The human papillomavirus also causes genital and anal warts, as well as oral and anal cancer.

The American College of Obstetricians and Gynecologists now recommends that women from ages 21 to 30 be screened every 2 years, instead of annually, using either the standard Pap or liquid-based cytology. Women age 30 and older who have had 3 consecutive negative cervical cytology test results may be screened once every 3 years with either the Pap or liquid-based cytology. Women with certain risk factors may need more frequent screening, including those who have HIV, are immunosuppressed, were exposed to diethylstilbestrol (DES) in utero, have been treated for cervical intraepithelial neoplasia (CIN) 2, CIN 3, or cervical cancer.

Moving the baseline cervical screening to age 21 is a conservative approach to avoid unnecessary treatment of adolescents that can have economic, emotional, and future childbearing implications. The American College of Obstetricians and Gynecologists previously recommended that cervical screening begin 3 years after first sexual intercourse or by age 21, whichever occurred first. Although the rate of HPV infection is high among sexually active adolescents, invasive cervical cancer is very rare in women under age 21. The immune system clears the HPV infection within 1 to 2 years among most adolescent women. Because the adolescent cervix is immature, there is a higher incidence of HPV-related precancerous lesions (called dysplasia). However, the large majority of cervical dysplasias in adolescents resolve on their own without treatment.

Routine cervical cytology testing should be discontinued in women (regardless of age) who have had a total hysterectomy (removal of the cervix along with the uterus) for noncancerous reasons, as long as they have no history of high-grade CIN.

The American College of Obstetricians and Gynecologists’ recommendations on the upper age limit for discontinuing cervical screening remain the same. It is reasonable to stop cervical cancer screening at age 65 or 70 among women who have 3 or more negative cytology results in a row and no abnormal test results in the past 10 years. The American College of Obstetricians and Gynecologists also recommends that women who have been vaccinated against HPV should follow the same screening guidelines as unvaccinated women.

The American Cancer Society fully supports these recommendations, and they are currently evaluating their own cervical cancer screening guidelines that will be formally updated in 2010.

OncoFacts™ Editor:

Christy Russell, MD

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