New Guidelines for Women With Abnormal Pap Smears

Oct. 11, 2007 – Clinicians should be wary of over-treating women who present with abnormal Pap smears in combination with cervical cancer precursors, according to new cancer guidelines co-authored by a physician from the Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine.

The American Society of Colposcopy and Cervical Pathology (ASCCP) Consensus Guidelines, issued Oct. 1 in co-sponsorship with 29 medical organizations, were written for the approximately 3.5 million women annually who are told they have some degree of abnormality on their pap test and require additional evaluation or follow-up.

“Women need to know that their clinician has read these guidelines and isn’t working on outdated information,” says Siteman gynecologic oncologist L. Stewart Massad, MD, professor of obstetrics and gynecology at Washington University School of Medicine and head of the committee for high-grade changes with the ASCCP.

“While it’s important for women with high-grade cancer precursors to get treated, treatment poses risks for people with borderline changes that often go away on their own,” Massad says.

The new guidelines are a revision of information first put together by the ASCCP in 2001. They were updated after some physicians found flaws in that original version.

“We had new information that women who had treatment for cervical precancers might be at higher risk for preterm delivery if they got pregnant in the future, suggesting we should be less aggressive in treating people with precursors,” Massad says.

Worldwide, cervical cancer is the second-leading cause of cancer-related death in women. Approximately 50 to 60 million women in the United States are screened for cervical cancer each year with the Pap test, which has gone a long way toward reducing cervical cancer among American women.

Of those Pap tests, about 3.5 million of these are classified annually as abnormal and require some form of medical follow-up. Determining which women with abnormal Pap tests are at risk for significant cervical disease and treating them presents a major public health challenge and a multibillion-dollar cost to our health care system. The goal of the ASCCP Consensus Guidelines has been to identify women at high risk efficiently using the best current science while minimizing cost and anxiety for women at low risk.

“My take on the guidelines is that more people are at risk for overtreatment,” Massad says. “They have borderline changes on the cervix that usually go away – most of them related to human papillomavirus (HPV) infections. They don’t require treatment, but many clinicians still worry about those changes and treat them. That’s put many women at risk for problems.”

Those problems in the short term are the risk of complications, such as injury to the bladder or rectum, infection or bleeding.

“The longer term risk of treatment is that removing part of the cervix to treat the precancerous change can make it harder to carry a pregnancy to term in the future,” Massad says. “So women who’ve been treated have a higher risk of preterm delivery and low birth weight than women who haven’t been treated.”

The guidelines are posted on the ASCCP website, www.asccp.org/consensus/media.shtml.

The 2006 Consensus Guidelines for cytology and histology were published in the American Journal of Obstetrics & Gynecology 2007;197(4):2007; 346-55 and 2007;197(4):340-345, respectively.