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Cervical cancer testing: Women can wait until 21

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Dr. Jennifer Ashton reports on new cancer screening guidelines affecting women that would recommend less frequent pap smears to detect cervical cancer.

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Dr. Anjali Martinez
Assistant Professor, Obstetrics and Gynecology, George Washington University Hospital
Friday, November 20, 2009; 1:00 PM

Dr. Anjali Martinez, assistant professor of Obstetrics and Gynecology at George Washington University Hospital, was online Friday, Nov. 20, at 1 p.m. ET to discuss today's news from the American College of Obstetrics and Gynecologists (ACOG), recommending that women can delay having their first Pap test for cervical cancer until they turn 21 and many can wait longer to go back for follow-up screenings.

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Los Angeles, Calif.: The new ACOG guidelines do not really address HPV testing. Should a women OVER the age of 30 get a HPV and Pap test done at the same time and if they BOTH come back negative, can she wait three (3) years til she comes back in for her next cervical cancer screen? AND if this is the right way to go, why was this not addressed in the ACOG guidelines??

Dr. Anjali Martinez: You are correct; if you are>30 with negative pap and a negative High Risk HPV test, you do not need another pap test for 3 years. I think it was not addressed because it is not a change (that was what was previously recommended).

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Washington, D.C.: Is it true that being tested for cervical cancer is really unnecessary (especially in your 20s) unless you have had multiple sex partners?

Dr. Anjali Martinez: No. Anyone who is sexually active is at risk for abnormal pap smears and cervical cancer. Multiple sex partners just increases your risk for both.

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Pittsburgh, Pa.: If a woman does not have HPV how often does she need Pap test? I'm 54, no irregular Paps in past, negative for HPV. Doc says only need Pap every 3 years. True?

Dr. Anjali Martinez: Yes, you are correct. With your history, Pap smears are recommended every three years AS LONG AS they continue to be normal.

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Northern Virginia: Hi Nancy. A few years ago, recommendations for vaccinations for cats changed because some vaccines (very rarely) lead to tumors at the injection site. My vet immediately changed her routine to reflect this and do fewer shots, for the better health of her animal patients. I am sure she suffered significant financial harm in doing so, since regular shots were a big source of income from pet owners.

I don't feel that the doctors for us humans are handling this quite as responsibly. I had no idea until today that any organization recommended Pap smears less frequently than on an annual basis -- apparently this was already true. In order to get my birth control pills, I must go in to my doctor once a year for an OB-GYN exam, and this has always been explained on the basis of the "required" annual Pap smear. Do you think doctors will change their demands on women patients so that we can follow the new guidelines and come in less often, or is the income stream from annual exams too important for their businesses? I'm upset, as you can tell, that my vet seems to be have been more responsible than my doctor -- at least from what I'm reading.

Dr. Anjali Martinez: Although many women do not require pap smears annually (some do based on their situation), routine annual exams ARE recommended for many other reasons even if the Pap smear part of it is omitted.

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Washington, D.C.: My wife is a cytotechnologist. Women occasionally get cancer after several negative Paps. This may indicate either that cancer sometimes develops very quickly, and/or that there are confusing cells that are very easy to overlook that can become cancer. Does this call for more frequent Paps, either because they are missed or because cancer can sometimes develop quickly? Is it also the case the young women who are very active with many partners starting at an early age can get cancer relatively young? Granted, I understand that HPV screening is not useful as a primary diagnostic tool in the young because many young people have it but overcome it.

Dr. Anjali Martinez: In otherwise healthy women, cervical cancer usually develops slowly. The new guidelines were made to maximize benefits and minimize harm of pap smear screening.

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Massachusetts: I am a pediatric ED doc and, by nature of my patient population, tend to see high-risk behaviors in teens who do not have primary care physicians (and use the ED as their default PCP clinic). I worry that many of these teens (and young adults) may slip through the cracks if not tested before 21 years, when they are adults who may no longer be on a parent's insurance, working a job without insurance, or just young and healthy without a need of a regular check-up. Even I tended to lag on regular checkups during college, med school and residency, not following the advice I give to my patients. Do you think that these new recommendations will cause women to be tested even later that 21 years, regardless of risk?

Dr. Anjali Martinez: That is a valid concern. However, the new guidelines were made because of the concern that besides not being beneficial, the procedures that abnormal paps lead to in young women/teenagers may actually be harmful.

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Alexandria, Va.: I'm 30 years old, and in the past three years, have had two abnormal pap tests, and two cryrosurgeries to remove the abnormal cells. In each case, I had follow-up Paps every four months, then every six months for about 1.5 years before getting another abnormal test result. I haven't had an abnormal result for about a year now.

Given this, should I be worried about developing cervical cancer? Does one or two abnormal results indicate an elevated risk? I stay current with my Paps, but is there anything else I can do to manage this?

Dr. Anjali Martinez: The best thing for you to do is to continue getting your pap smears. At some point, if they all continue to be normal, the frequency at which you need pap smears will decrease.

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Washington, D.C.: Dear Dr. Martinez, As a cynical 36-year-old woman, I find the recent recommendations about Pap testing for women typical of the contradictory health-related information we receive every single day. I have endured scores of Pap tests over the years just to obtain my annual prescription of birth control pills. Now I hear that this testing was largely unwarranted and unnecessary. My question however, is, what is the implication of such findings for vaccines such as Gardasil against HPV-related cancers? Particularly in light of evidence that growths related to the HPV virus often recede on their own given time(90 percent within three years, according to one figure) was the push to vaccinate young women just more hype? I myself was skeptical of anyone being inoculated with a vaccine that was costly, only proven effective in limited cases and whose long-term effects were unknown. Do these findings justify my skepticism? What to believe?

Dr. Anjali Martinez: Although many women do not require pap smears every year, an annual exam is still recommended for many other reasons. In terms of your question regarding HPV, it does sometimes heal itself. However, the chance of it healing depends on many factors including age. HPV infections in young women/teenagers often resolve; this is a large part of the change to starting pap smears at age 21. However, as women age (20s, 30s, 40s etc), HPV is less likely to resolve on its own so they are at higher risk for cervical cancer, hence the need for pap smears. If a girl has the vaccine and as a result never gets the high risk types of HPV, she will have a significantly less risk of abnormal pap smears AND cervical cancer later in life.

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NYC: Two questions: Isn't a good idea for males to get vaccinated against HPV with Gardasil? What exactly is a pap smear?

Dr. Anjali Martinez: Theoretically it may be a good idea to vaccinate males, but to my knowledge it has only been approved for use in females. Careful testing is always required before a new use of a medication/vaccine can be recommended.

A pap smear is a sample of cells from the portion of the cervix where cervical cancer can develop. It is one of the few places in the human body where we can easily sample cells and find changes that may lead to cancer BEFORE cancer actually develops so that we can prevent cancer.

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Washington, D.C.: I've been getting a Pap every year because I need to have an annual exam in order to get my birth control prescription refilled. I had no idea the recommendation for someone with no negative pap history and no HPV was every three years. How can I go every three years and still get my birth control refilled?

Dr. Anjali Martinez: Although many women may not need a pap smear every year, annual exams are still recommended for many other reasons (even if the actual pap smear part is omitted). You will have to talk to your doctor about their prescribing guidelines, but I evaluate patients yearly to make sure they are healthy in other ways and to make sure that their medications (including birth control) are still appropriate. Sometimes other factors (such as your menstrual pattern, other medical problems, or blood pressure for example) may necessitate a change in what birth control is safe and effective for you.

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Fairfax, Va.: I'm somewhat suspicious that this news about cervical cancer screening and earlier this week about mammograms came out so close to each other. It's throwing everything out of whack, things that women have done for years. The Obama administration has backed off the mammogram news and seems to be disassociating itself from it. It was a private study but it sounded like it was under the auspices of the government.

This causes mass confusion and that's what the women are going through now. How can everyone get on the same page about it?

Dr. Anjali Martinez: It takes time for everyone to be on the same page. For example, the American College of Obstetricians and Gynecologists acknowledge the new mammogram guidelines by the U.S. Preventive Services Task Force, however; they have not changed their own guidelines yet because they have not yet reviewed the scientific studies behind the change. In this age of internet technology, patients and doctors learn about a change at the same time and it can be overwhelming to all of us to sort out all the information when new guidelines come out.

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Toronto, Canada: As a retired teacher, one of the things that concerns me about these new recommendations is that young women -- high school age -- now won't get to an OB/GYN and therefore won't have an opportunity to ask about STDs, birth control, the HPV shot and what have you. I think the "required" pap smear was a way for them to get in the door, and worry that there will be unfortunate, unintended consequences of this recommendation on Paps. What do you think?

Dr. Anjali Martinez: A valid concern. See my answer to "Massachusetts"; the new guidelines are to minimize harm to teenagers. But I feel that teenagers SHOULD see a gynecologist (or a family practitioner, pediatrician, etc) and talk about all the things you mentioned. These issues can be covered in routine annual exams. It is unfortunate that some people will miss annual exams just because they don't need a pap (which is just one aspect of a multipurpose annual exam).

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Washington, D.C.: Sorry, I'm a male and I have (probably) a dumb question. It seems that the reason for the Pap test is that females get something from males that is due to sexual contact. Is that right? If girls don't have intimate contact with males does that mean they don't need to be tested? Does a man transmit something to the female which puts her at risk? I don't understand.

Dr. Anjali Martinez: Not a dumb question, but this is a very simplified answer. Abnormal cervical cells (detected by a Pap smear) can lead to cervical cancer. The most likely cause of abnormal cervical cells is an infection by a virus called HPV, which is sexually transmitted.

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Richmond, Va.: Currently, Gardasil is recommended for those 26 and under. Do you know if they have plans to increase the age range so insurance companies will cover the vaccine for older patients?

Dr. Anjali Martinez: Good question. Before any vaccine is used/recommended, it has to be carefully tested to prove its safety and efficacy. Since the HPV vaccine was only tested in females aged 9-26, it is only approved and recommended in this specific population. I don't know if they have plans to test an expanded population (different ages or males).

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Washington, D.C.: You say if a woman is over 30 and has normal Pap results, she can wait 3 years between Paps. My question is what exactly is an abnormal Pap result? That might seem obvious, but it's not always so clear cut. In my 20s, I frequently got results that indicated "cellular changes," but no sign of cancerous or pre-cancerous cells. Since the introduction of the "thin prep" Pap, I've not had anything but normal results, going back multiple years now.

Given that history, in your estimation, would I fall into the "every 3 year" category?

Thanks.

Dr. Anjali Martinez: I'd have to see your exact results over the years to make a conclusion. You should discuss this with your doctor.

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Partners and cervical cancer: I'm confused by all of this coverage -- some places seem to basically say that cervical cancer is always caused by an STD? If so, why would someone have an abnormal Pap if they are not and have never been sexually active? And why do the guidelines require Paps after 21 for those that aren't sexually active?

Thank you

Dr. Anjali Martinez: The majority of cervical cancers are thought to be due to HPV, a sexually transmitted virus. As a result, women who have never been sexually active are at low risk for cervical cancer but the risk is not zero. Currently, the guidelines seem to recommend Paps starting at age 21 regardless of onset of sexual activity.

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Dr. Anjali Martinez: Thanks to everyone for their excellent questions regarding the new Pap smear guidelines. Although the recommended frequency of getting pap smears depends on your particular situation, please remember that getting pap smears remains the best way to prevent cervical cancer.

Goodbye!

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