For cervical cancer screening, any strategy is acceptable

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Primary care providers can confidently choose any of the three cervical cancer the screening strategies recommended by the American Cancer Society and the U.S. Preventive Services Working Group, experts said.


Dr. Rachel Brook

Cytology tests every 3 years, cytology /human papilloma virus Listed check-up every 5 years and primary HPV tests every 5 years are equally effective in reducing the risk of cervical cancer Rachel P. Brook, MD, from the University of California, Los Angeles Health Iris Cantor Women’s Health Center, during a presentation at the annual meeting of the American College of Physicians.

“The most important thing a primary care provider can do is examine with any test that is more accessible,” Brook said in an interview. He also noted that access to detection remains an urgent concern, especially among underrepresented groups and women in rural areas. Even when women can access the tests, follow-up after abnormal results may be inadequate, leading to an increased risk of cervical cancer mortality.

To address some of these shortcomings, Brook provided an overview of current guidelines and appropriate responses to abnormal test results.

First, during his presentation, he noted that the recommendations of the guidelines do not apply to patients with additional risk factors, including a compromised immune system, HIV infection, previous treatment of cervical cancer or a high-grade cancerous lesion, or in utero exposure to diethylstilbestrol.

“That’s very important,” Brook said during his presentation. “They should receive individualized care for their above-average risk of cervical cancer.”

Among women at medium risk, both the USPSTF Guideline 2018 and the ACS 2020 guideline it is recommended to avoid the detection of women under 21 years of age.

In a major change to the more recent ACS guideline, screening of women aged 21 to 24 is no longer recommended, in contrast to the USPSTF guideline, which still requires cytology every 3 years for this age group. This USPSTF recommendation extends to women ages 25 to 29, a group for whom ACS recommends primary HPV testing every 5 years, cytology / HPV cestation every 5 years, or cytology testing every 3 years . For both organizations, any of these three test methods are recommended for women ages 30 to 65, followed by test interruption after age 65, with appropriate prior examination.

“For all of these recommendations and guidelines, they are relevant to patients regardless of the status of the HPV vaccination,” Brook said. But he added that increased HPV vaccination rates could affect future detection patterns, as vaccinated patients are more likely to have false positive cytology results due to low-risk HPV strains. This trend may guide future recommendations toward primary HPV testing, Brook said.

Currently, for applicable age groups, the ACS guideline favors HPV testing alone over cytology alone or co-assessment, while the USPSTF guideline offers no preference between the three testing strategies.

Primary HPV vs. cytology testing

Brook said a single HPV-negative test provides more than 95% certainty that a patient will not develop cervical cancer or a cancer precursor in the next five years. A negative HPV test offers a reliability similar to approximately 3 negative cytology tests.

Switching to a five-year trial cycle can be disturbing for patients accustomed to obtaining a Test of Pap each year, but holding a conversation about the accuracy of the test can help calm patients’ concerns, he said.

Still, Brook emphasized that any of the three testing strategies is ultimately acceptable.

“The message we bring home is, really, that any of the recommended screening options will greatly reduce the risk of cervical cancer,” Brook said. “Then screen. And if there is confusion or concern with your patients about which [screening strategy to use], just help them decide on any of the three. But please screen. “

Self-assembly can improve screening in certain groups

To improve detection rates, especially for women with little access and those who are opposed to a speculum test, Brook highlighted self-buffered primary HPV tests, which will soon be available. Although no self-buffered HPV testing has yet been approved by the Food and Drug Administration, they offer a sensitivity rate of 76% for grade 2 cervical intraepithelial neoplasia and a rate of 85% for CIN3, compared to 91% for physician-collected samples.

Regardless of the exact HPV test, Brook advised proper reflex testing.

“We need to make sure that all primary HPV-positive screening tests for types other than HPV-16 or -18 will require additional reflex selection testing with cytology,” Brook said in an interview. “If not, if a woman has a positive primary HPV screening test and I can’t perform reflex cytology, I have to do an additional test and a speculum test to get cytology, which is an unnecessary burden for the patient, and also increases the tests “.



Dra. Kathy MacLaughlin

Kathy L. MacLaughlin, MD, associate professor of family medicine at the Mayo Clinic, Rochester, Minnesota, said this is a drawback of self-tamponade testing in an interview.

“If there is a positive HPV result [with a self-swabbing test], the patient must have a clinical appointment for Pap smear collection [if one of the ‘other’ 12 HPV types are identified], or be derived for colposcopy [if HPV types 16 or 18 are identified]“There have been plans to access these services,” MacLaughlin said.

By the way, women may face access barriers that need more self-buffered HPV testing, according to MacLaughlin.

“I think there is significant potential to improve screening rates among women who have not been tested and who are not tested and are the groups for whom this makes the most sense,” she said. “I don’t think anyone is suggesting that women who have the means and interest to schedule a face-to-face visit for the screening collected by the doctor move on to self-screening, but it’s a promising option. [once FDA approved] to reach out to other women and reduce disparities in screening rates. “

MacLaughlin suggested that self-exploration programs could work outside of normal work hours in a variety of settings, such as homes, community centers, and churches.

Until self-screening is an option, MacLaughlin agreed with Brook that any of the three testing strategies is appropriate for screening and recommended that primary care providers take advantage of the opportunities presented to them.

“Individual primary care providers can improve screening rates by offering to update cervical cancer screening at an appointment at the clinic, even if this was not the primary indication for the visit, especially for patients. women they had been waiting for a long time, ”MacLaughlin said. “If there is only time to adjust to the screening or the patient declines, order a return visit and have the patient stop at the appointment desk when he or she leaves.”

“I recognize that we are being asked to fit in more and less in less time, but I have found this to be effective when I have the ability to deliver it on the day of the clinic,” he added.

Brook and MacLaughlin did not report any conflicts of interest.

This article originally appeared on MDedge.com, which is part of the Medscape professional network.





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