Annals of Internal Medicine
19 June 2012, Vol. 156. No. 12
http://www.annals.org/content/current

Editorials
Cervical Cancer Screening: Primum Non Nocere  [FREE]]
Nora Kizer, MD, MSCI; and Jeffrey F. Peipert, MD, PhD

Extract
The Hippocratic Oath cautions us to abstain from doing harm. We must remember this basic tenet of our profession as we address new evidence and guidelines for cervical cancer screening. The purpose of screening is to identify at-risk individuals and to enable early intervention to reduce mortality and suffering. As such, screening should fit the ideal of doing no harm, yet providing substantial benefit.

However, screening tests can unintentionally cause significant harm. False-positive test results can lead to overdiagnosis; misdiagnosis; and the potential for unnecessary diagnostic testing, procedures, and treatments and their inherent risks. For these reasons, screening tests, especially for a disease with a low incidence, must have high sensitivity in addition to acceptable specificity. Tradeoffs of increased sensitivity for decreased specificity can shift the balance of benefits and harms.

It is important to consider these issues as one reads the U.S. Preventive Services Task Force (USPSTF) most current recommendations for cervical cancer screening in this issue (1). The American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology (ACS/ASCCP/ASCP) have also published new joint cervical cancer prevention guidelines based on a broadly attended consensus conference (2). These 2 sets of recommendations are largely congruent and are important steps forward to maximally efficient and effective cervical cancer screening. Health care providers should welcome these new recommendations with enthusiasm and incorporate them into routine clinical practice…

…Unlike the USPSTF recommendations, the ACS/ASCCP/ASCP guidelines address women who have received the HPV vaccine, recommending that they continue routine screening. Although evidence shows the vaccine to be highly effective at preventing HPV 16/18–associated CIN3+ lesions in individuals not infected with HPV, 30% of cases of cervical cancer are attributable to other HPV strains. In addition, the vaccine’s true duration of coverage is unknown, which is of particular concern for women who received vaccination during early adolescence. Future evidence may show that less frequent screening is appropriate for vaccinated women, but given the limitations of current research and the low vaccination coverage among U.S. adolescents prior to first intercourse, the screening protocol should be the same for both vaccinated and unvaccinated women…

… Promotion of the HPV vaccine before first intercourse, when prophylactic vaccination is most beneficial, is another important prevention message. The United States lags far behind other health care systems, such as those in Australia and the United Kingdom, with only 32% of eligible women who have received the complete HPV 16/18 vaccine (4). Vaccinating young women before the onset of sexual activity should be encouraged (5)….

Clinical Guidelines

Screening for Cervical Cancer: U.S. Preventive Services Task Force Recommendation Statement [FREE]

Virginia A. Moyer, MD, MPH