JANUARY IS CERVICAL HEALTH AWARENESS MONTH!

(Share the American College of Obstetricians and Gynecologists patient FAQs)

In this blog I’ll be addressing cervical cancer incidence and mortality, risk factors, the role that the Human Papilloma Virus (HPV) plays in the development of cervical cancer, as well as screening recommendations. 

Incidence and Mortality:

It is estimated that in the U.S., in 2021, there were 14,480 new cervical cancer diagnoses, and 4,290 cervical cancer deaths (American Cancer Society, 2021). 

Approximately 1,250,000 women are diagnosed with precancers annually by cytology using the Papanicolaou (Pap) smear. Lesions can regress, persist, or progress to malignancy (American Cancer Society, 2021).  

Who’s At Risk / The Role of HPV:

Carcinogenic types of HPV are the primary agents that cause virtually all cases of cervical cancer (U.S. Department of Health and Human Services).  Once HPV infection occurs, additional risk factors are associated with a higher risk of the development of cervical cancer.  For example: high parity (5 or more pregnancies with gestational ages greater than or equal to 20 weeks), long-term use of oral contraceptives, as well as active and passive cigarette smoking. Diethylstilbestrol (DES) exposure in utero is also associated with an increased risk of developing cervical dysplasia.

HPV vaccination:

• Based on reliable evidence, vaccination against HPV types 16 and 18 is effective in preventing HPV infection in HPV negative individuals and is associated with a reduced incidence of cervical intraepithelial neoplasia 2 and 3. By extrapolation, these vaccines should also be associated with a reduced incidence of cervical cancer.
• Magnitude of Effect: Vaccination against HPV types 16 and 18 reduces incident and persistent infections with efficacy of 91.6% (95% confidence interval [CI], 64.5%–98.0%) and 100% (95% CI, 45%–100%), respectively (U.S. Department of Health and Human Services).
• All forms of the HPV vaccine are currently recommended by the Centers for Disease Control and Prevention (CDC) in the United States as a two-dose schedule at least 6 months apart for adolescents younger than 15 years. The current CDC recommendation for older individuals is to receive the original three-dose series.

Cervical Cancer Screening:

Screening With the Papanicolaou (Pap) Test:

• Based on reliable evidence, regular screening with the Pap test in an appropriate population of women reduces mortality from cervical cancer. The benefits of screening women younger than 21 years are small because of the low prevalence of lesions that will progress to invasive cancer. Screening is not beneficial in women older than 65 years if they have had a recent history of negative test results.
• Magnitude of Effect: Regular Pap screening decreases cervix cancer incidence and mortality by at least 80%.

Screening With the Human Papillomavirus (HPV) DNA Test:

• Based on reliable evidence, screening with an HPV DNA or HPV RNA test detects high-grade cervical dysplasia, a precursor lesion for cervical cancer. Additional studies show that HPV DNA testing is superior to other cervical cancer screening strategies.
• Magnitude of Effect: In one prospective, clustered, randomized trial, HPV DNA testing was superior to other strategies for preventing cervical cancer mortality

Screening With the Pap Test and the HPV DNA Test (Co-testing):

• Based on reliable evidence, screening every 5 years with the Pap test and the HPV DNA test (co-testing) in women aged 30 years and older is more sensitive in detecting cervical abnormalities, compared with the Pap test alone. Screening with the Pap test and HPV DNA test reduces the incidence of cervical cancer.
• Magnitude of Effect: HPV based co-testing provides 60% to 70% greater protection against invasive cervical carcinoma, compared with cytology (pap smear) alone

Screening Women Without a Cervix

• Based on reliable evidence, screening is not helpful in women who do not have a cervix as a result of a hysterectomy for a benign condition.
• Magnitude of Effect: Among women without cervices, fewer than 1 per 1,000 had abnormal Pap test results.

 

U.S. Preventive Services Task Force (USPSTF) cervical cancer screening recommendations adopted by the American College of Obstetricians and Gynecologists (ACOG):

Barriers: In 2020, the American Cancer Society (ACS) updated its cervical cancer screening guidelines to recommend primary hrHPV testing (High Risk HPV DNA testing) as the preferred screening method for average-risk women aged 25–65 years.  Despite the efficacy and efficiency of primary hrHPV testing, adoption of this screening method has been slow secondary to the limited availability of FDA-approved tests and the laboratory infrastructure changes required to switch to this screening platform (The American College of Obstetricians and Gynecologists, 2021).

Future Implications:

• The ACS strongly advocates phasing out cytology-based screening options (pap smears) in the near future
• Although HPV self-sampling has the potential to improve access to cervical cancer screening, and has been identified as effective, it is still investigational in the United States
• The Journal of the American Medical Association (JAMA) published a study demonstrating that self-collected menstrual blood capture and testing for hrHPV is a
  feasible and accurate approach for cervical cancer screening. This study found that this
  method is associated with superior performance in identification of HPV genotypes and true-negative events compared with cervical HPV testing (Zhang, 2021).

Risk Mitigation:

As a means to reduce the risk of delayed or missed cervical cancer diagnosis, and to ensure cervical cancer treatment is rendered in accordance to current standards of care, it is essential to be aware of cervical cancer signs and symptoms, risk factors, screening guidelines, as well as treatment recommendations.

P.S. Comment and share if you have learned of other alternatives to self-collected hrHPV DNA testing options that are currently being studied.

References:

American Cancer Society: Cancer Facts and Figures 2021. American Cancer Society, 2021. Available onlineExit Disclaimer. Last accessed October 8, 2021.

Moyer VA; U.S. Preventive Services Task Force: Screening for cervical cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 156 (12): 880-91, W312, 2012. [PUBMED Abstract]

The American College of Obstetricians and Gynecologists. (2021). Practice advisory, Updated cervical cancer screening guidelines.

U.S. Department of Health and Human Services, National Cancer Institute https://www.cancer.gov/search/results?swKeyword=cervical

Zhang J, Tian X, Chen Y, et al. (2021). Feasibility and accuracy of menstrual blood testing for high-risk human papillomavirus detection with capture sequencing. JAMA. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2787432?resultClick=3