Guidelines for Pap Smear Screenings for Cervical Cancer

Additional Info

• Audio File:uab/ua181.mp3
• Doctors:Huh, Warner
• Featured Speaker:Warner Huh, MD
• CME Series:Clinical Skill
• Post Test URL:https://cmecourses.som.uab.edu/mod/quiz/view.php?id=4457
• Guest Bio:Warner Huh, MD is Professor and Director of the Division of Gynecologic Oncology, his areas of expertise include Gynecologic oncology, cancer vaccine, robotic surgery for gyn/onc, ovarian cancer, endometrial cancer.
  
  Learn more about Warner Huh, MD 
  
  Release Date: January 10, 2017
  Reissue Date: January 8, 2021
  Expiration Date: January 8, 2024
  
  Disclosure Information:
  
  Planners:
  Ronan O’Beirne, EdD, MBA
  Director, UAB Continuing Medical Education
  
  Katelyn Hiden
  Physician Marketing Manager, UAB Health System
  
  The planners have no commercial affiliations to disclose.
  
  Presenters:
  Warner K. Huh, MD
  Division Director and Professor, Division of Gynecologic Oncology
  
  Dr. Huh has the following financial relationships with commercial interests:
  
  Consulting Fee – DySIS Medical
  
  No other speakers, planners or content reviewers (Ronan O'Beirne, EdD and Katelyn Hiden) have any relevant financial relationships to disclose.
  
  There is no commercial support for this activity.
• Transcription:Melanie:  Welcome to the UAB Med Cast. I'm Melanie Cole, and I invite you to listen as we give an update on the latest guidelines for pap smear screenings for cervical cancer. Joining me is Dr. Warner Huh. He's the Chair of the Department of Obstetrics and Gynecology and a Gynecologic Oncologist at UAB Medicine. Dr. Huh, it's a pleasure to have you back with us again. You are a great guest, so let's get right into this. What are the current guidelines for pap smear and cervical cancer screening? What's different? Give us an update.
  
  Dr Warner Huh: Yeah, there's a lot to report on this topic. I think the last time we talked, the recommendation was that we screen women starting at 21 years of age and you can use a pap smear, which is, I think something that all women are familiar with and you can do that every three years, if the pap is normal.
  
  And then that starting at the age of 30, you can combine, what's known as an HPV test with a pap smear together. It's also known as co-testing. And if those test results are normal or are negative, then they can be screened every five years. And at that time that was a pretty marked change because we had greatly lengthened the interval of screening.
  
  What has changed since our last time you and I spoke, is that both the United States Preventive Services Task Force and the American Cancer Society have released new cervical cancer screening guidelines, that really, for the most part start really focusing on the value of what we call primary HPV screening.
  
  In other words, relying exclusively on just the HPV test and not a pap for screening. And some of your listeners may be wondering why. The reason is that we know that, HPV screening by itself is a much better test, for cervical cancer screening than the pap.
  
  And that, when you combine the two together, really the pap doesn't really add that much above and beyond the HPV test. And so what the United States Preventive Services Task Force, although they still, basically recommend co-testing, they do put an emphasis on consideration of things like primary HPV screening.
  
  But what's really very interesting is that the American Cancer Society earlier this year put out forth guidelines that basically look at another change, which is when to start screening. And so they actually now recommend initiation of screening at 25 years of age, not 21 years of age. And not so long ago, we had screened women at 18 years of age.
  
  And again, your listeners may be wondering why. And the reason for that is that we know that the rates of cancer in women between 21 and 25 is exceptionally small. And that you, if you start screening women that you - there's a real risk of things like overtreatment and exposing patients to procedures that they don't need.
  
  So that's the first major change, screening starting at 25 versus 21. And keep in mind that other countries like the United Kingdom, actually do this. So we're not the first to recommend this. The second one is that the American Cancer Society is very clear that they think that the future is, or the aspirational goal is basically primary HPV screening.
  
  And so they want, providers to use just the HPV test and not PAP as a screening modality. They do acknowledge that there are areas of this country that can't provide primary HPV screenings. So they do allow for co-testing. And so in the end, when you actually take these two guidelines into consideration, the biggest changes are, in summary one, is that we're pushing out screening to a later age. Some of that is a little bit controversial because some people still believe that we should be screening at 21, but two, is also the fact that we're very much pushing towards the ideal of using HPV testing alone as a screening test and pushing away from PAP. Because we have more and more women who are vaccinated against HPV and that number will only go up, the utility of the PAP is only going to go down. If you continue to PAP people, you're going to wind up missing disease. And that's why, switching over to an HPV test also becomes really important. So these are pretty marked changes. I think the one thing that we're all waiting on from in the women's health side is formal recommendation from the American College of Obstetricians and Gynecologists on where they stand on this issue.
  
  And I think they will, I can't guarantee this, but likely think that they will wind up making similar recommendations. But I think it's important for the listeners to recognize that cervical cancer screening is rapidly changing. I think it's changing for the better. And there are multiple variables to take into consideration, including rates of HPV vaccination. Again, the messaging is that we're going to be relying more on HPV testing as the foundation for screening.
  
  Melanie: Wow. That's so interesting, Dr. Huh. I was going to get to ACOG. That was my next question is where do they stand on this? And so now tell us about women for other providers that are answering these questions, for gynecologists that are answering these questions for their patients; what do you want them to be able to say as far as if the woman is too old, I'm 56, for example, so I didn't get the Gardasil vaccine. So what about the older generation who are more at risk for cervical cancer, just based on their age, is HPV still going to be something that is just looked at? What's changed for the older population?
  
  Dr Warner Huh: I think the last time we spoke, HPV vaccination now is approved up to 45 years of age, both in men and women. So that's a pretty marked difference because previously it was 26 years of age. And, and so HPV is unfortunately not something that goes away with age. And matter of fact, I would argue that, yeah, that we see about maybe a 20 to 25% of the cervical cancer cases that we see in our practice, and this is a true probably nationally occur in women after 65 years of age. So cervical cancer in women is a lifelong problem. To your question, again, is there any value to HPV vaccination in older women?
  
  I mean, I think perhaps there is, it's definitely going to be a lot less than someone who's 10 or 11 or 12 years of age. But the one thing I will note is that the vaccine is extraordinarily safe. I mean millions and millions of doses have been given. And I would argue that this vaccine has been heavily scrutinized and it's a safe vaccine.
  
  The problem is coverage and its off label and unfortunately patients will have to pay for it, but I think the greater issues that women need to continue screening. And the one message I'll leave with listeners is that, if we screen the entire United States, the way that we're supposed to, regularly and reliably and accurately, the issue of HPV vaccination, as it relates to cervical cancer would be somewhat irrelevant.
  
  Cervical cancer would be truly a non-existent or rare disease. But, we don't live in that world and we still have breakthrough cases of cervical cancer because women are not getting screened in the United States. But what I want to stress is that really is that screening is still the cornerstone for cervical cancer prevention and that we're learning a lot more about HPV vaccination, but it is now officially approved up to 45 years of age.
  
  Melanie: Thank you so much, Dr. Huh. As we wrap up, and I hope you'll come back on and update us as ACOG comes out with their statements and thing changes. What's new and exciting in the field of gynecologic oncology? Any game-changers in cancer treatment that you'd like other providers to know, things that you're doing at UAB that are really exciting?
  
  Dr Warner Huh: I mean there's the lots of incredible stuff on, not the least of which is that a class of drugs called PARP inhibitors, which are oral pills, revolutionized the treatment landscape of patients with ovarian cancer, particularly women would that have BRCA mutations. There's been a lot of research done in the last, many years and multiple drug approvals, but, we know that this medication, particularly in BRCA mutated women with ovarian cancer has really revolutionized their outcomes.
  
  That's the first thing. I think the second thing that we've seen as with other solid tumors is the role of immunotherapy and what we call checkpoint inhibition. In certain subsets of women that have, certain molecular alterations, again, some of these therapies are lifesaving. I think the bottom line is that we've had more drugs approved in the gynecologic oncology space in the last four to five years than we have in the probably the last 20 years combined.
  
  And, much of it is basically geared towards a very personalized medicine. And so going forward, we look at each patient differently in terms of what their molecular alterations are, as it relates to their cancer. And those molecular alterations then define what kind of treatment they receive. So I suspect in the next couple years, again, our treatment paradigms are going to look completely different, but for the better. I really am highly optimistic that the outcomes for our patients going forward are going to be so much better than they have been in the last 10 years.
  
  Melanie: Well I'm sure with docs like you on the case, you're just an excellent guest, Dr. Huh. Thank you so much for coming on and updating us this morning. A community physician can refer a patient to UAB Medicine by calling the MIST line at one 800-UAB-MIST. And that wraps up this episode of UAB Med Cast. For more information on resources available at UAB medicine, please visit our website at UABmedicine.org/physician. Please also remember to subscribe, rate and review this podcast and all the other UAB Medicine podcasts. I'm Melanie Cole.
  
  
• Hosts:Melanie Cole, MS