House call: Navigating changing cervical cancer protocol

It used to be that part of a woman’s annual physical exam included a Pap test to check for abnormal cells from the cervix, the lower part of the uterus. The purpose of looking for these abnormal cells is to prevent or detect cervical cancer. Over the years, we have learned that cervical cancer is typically a very slow growing cancer and that about 99 percent of cervical cancers are caused by the human papillomavirus (HPV).

This link, along with new tests that detect types of HPV that cause cervical cancer, have led to changes in the guidelines for screening. For women ages 21 through 29, a Pap test every three years is recommended. For women 30 years or older, a Pap test is recommended every five years, in conjunction with testing for HPV.

An HPV test can be done on the same sample that is collected for the Pap test, so there are not usually any additional steps involved in having both tests. Even if the Pap test detects mildly abnormal cells, we now know that we can continue routine screening schedules if there is no high-risk HPV present.

More frequent testing may be recommended for women with higher risk factors, such as a history of cervical cancer, HIV infection or immunosuppression. Talk to your health care provider about how often you should be having Pap and HPV tests.

Pap tests that are positive for abnormal cervical cells are reported within a range that describes the amount and type of cell changes. I tell my patients that there is a range that goes from normal to stages of what we call cervical intraepithelial neoplasia (CIN). Level 1 indicates minimal changes, while level 4 is approaching a true cancer.

When the level of abnormality is mild and the HPV test is positive we generally recommend a closer look with colposcopy. Colposcopy uses a lighted magnifying tool to look for worrisome areas of the cervix. If any are detected, small bits of tissue are removed to be examined by a pathologist. Areas of minimal change are watched with repeat testing every 6 to 12 months until they either go away or become abnormal enough to warrant removal. The whole idea of the Pap test is to find changes before they become cancer, and treat/cure them early. Pap results can also be negative for worrisome cells but still unclear. HPV test results are either positive or negative.

A positive HPV test is not cause for alarm. HPV infection is very common and usually goes away on its own without causing changes to the cells in the cervix, but HPV that does not go away for many years can eventually cause cellular changes that can turn into cervical cancer. If you are a smoker, quitting can improve your chances of clearing the HPV infection.

Whether your doctor recommends further testing, more frequent Pap and HPV tests, watchful waiting, or treatment will depend on the results of both of your tests.

The HPV vaccine is recommended for all girls and boys at age 11 or 12 (males also get HPV and HPV-related cancers), before the onset of sexual activity. It prevents infections with a number of the higher risk subtypes of HPV and the cancers that they cause. It is also likely to prevent many cancers of the head and neck. I highly recommend this vaccine for my patients.

You can get more information on Pap tests, HPV tests, cervical health and cervical cancer from the National Cervical Cancer Coalition (http://www.nccc-online.org, 800-685-5531).

Dr. Bob Riggs is a family medicine physician practicing at Group Health’s Riverfront Medical Center.