Dr. Lockwood, Editor-in-Chief, is Dean of the Morsani College of Medicine and Senior Vice President of USF Health, University of South Florida, Tampa. He can be reached at DrLockwood@ubm.com.
In this interview, editor-in-chief Charles J. Lockwood reviews key changes in guidelines for preventive screening throughout a woman’s lifespan with experts in internal medicine and ob/gyn.
Pap smears and the annual exam
DR LOCKWOOD: It’s been a few years since I’ve seen routine annual exams when everyone received a Pap smear. What are the current guidelines for Pap smear screening and why the change?
EMILY HALY, MD: The US Preventive Services Task Force (USPSTF) did an analysis focusing on what frequency had the greatest value for screening. More screening doesn’t necessarily improve outcomes but does contribute to the higher cost of care.
CATHY LYNCH, MD: And as you know, more frequent screening of especially younger women increases risk of procedures like cone biopsies that could lead to subsequent complications in pregnancy. Younger women are much more likely to clear human papilloma virus (HPV) infection, so frequent screening can result in intervention when the body was already working on clearing the infection.
DR HALY: The current recommendations from the USPSTF and the American Society for Colposcopy and Cervical Pathology (ASCCP) are for cytology screening from ages 21 to 29 every 3 years. From 30 to 64 years, screening can be cytologic every 3 years or cytology with high-risk HPV (HRHPV) testing every 5 years (co-testing). In women who have had negative screening Pap smear, testing can be discontinued at age 65. HPV testing is not recommended for women under age 21.
DR LYNCH: Keep in mind that a woman under 21 may still need testing for sexually transmitted disease (STD) but that does not include a Pap smear. Women who have had a hysterectomy performed for indications other than severe cervical dysplasia or cervical cancer no longer need Pap smear screening. Although HPV testing is not indicated as a screen in the 21- to 29-year group, it can be performed as a reflex test for management of atypical squamous cells of undetermined significance (ASCUS).
DR LOCKWOOD: Are the recommendations any different for women who have received the Gardasil vaccine?
DR HALY: Women who have had the HPV vaccine still follow the same Pap smear screening guidelines. Of all the vaccines I recommend, I find this one to be unique in that it is the first vaccine that can actually prevent cancer. Although there have been three different HPV vaccines, with development of the 9-valent Gardasil 9, it has become the only HPV vaccine available today. With coverage against HPV types 16,18,31,33,45,52, and 58, Gardasil 9 provides prevention against cervical, vaginal, vulvar, anal, penile, and throat cancers. Because the vaccine also covers HPV types 6 and 11, it affords protection against the majority of HPV types associated with genital warts.
DR LYNCH: I recently had a mom ask me about the vaccine for her children that I had delivered. Her daughter is 14 and her son is 17. She said that she had been discussing the vaccine with them but they don’t like shots and they were not sexually active so she felt that they could delay getting the vaccine. I pointed out to her that since they didn’t like shots, it was to her daughter’s advantage to get the shot now when she would only need two shots versus waiting until 15 when she would then need three like her brother.
DR HALY: That’s a good point, between ages 9 and 14, only two shots are necessary to get immunity whereas for those ages 15 to 45, three shots are needed. The US Food and Drug Administration increased the age to 45 to help prevent HPV-associated diseases.1 The recommended time to administer Gardasil 9 to boys and girls is ages 9 to 14. That is because younger children respond with a higher immunologic response to the vaccine.
Testing for infectious diseases
DR LOCKWOOD: Have the guidelines changed for HIV testing?
DR HALY: The Centers for Disease Control and Prevention recommends testing all patients aged 13 to 64 for HIV. If prevalence of HIV is less than 0.1% then screening is not recommended. Patients can opt out of testing. In addition, you do not need their written consent to test for HIV. All pregnant women, patients initiating treatment for tuberculosis and those seeking treatment for STDs should be screened. 0HIV testing should be performed yearly on high-risk patients, including injection-drug users (IDU) and their sex partners, individuals who exchange sex for money or drugs, sex partners of HIV-infected individuals, and men who have sex with men (MSM) or heterosexuals who themselves or whose sex partners have had more than one sex partner since their most recent HIV test.2
DR LYNCH: In addition, STD testing should include yearly testing for chlamydia and gonorrhea in sexually active females under 25, and in those who are older if they have a new partner, multiple partners or a partner with a STD. Patients should be retested in 3 months after treatment for chlamydia or gonorrhea. Type-specific herpes simplex virus testing should be considered in patients who present for STD evaluation.
DR LOCKWOOD:Should I be testing for hepatitis C?
DR HALY: Hepatitis C testing should be done on women born between 1945 and 1965 and patients who are at high risk, including individuals born in regions of high endemicity (≥ 2% prevalence), IDU, MSM, individuals on immunosuppressive therapy, hemodialysis patients, and HIV-positive individuals.3
Screening for colorectal cancer
DR LOCKWOOD: I have heard that colonoscopy screening guidelines have changed. Is that true and if so, why?
DR HALY: The American Cancer Society (ACS) has recently updated its colorectal cancer (CRC) screening guidelines to recommend screening average-risk patients for that disease at age 45. This recommendation changed based on an analysis (not a clinical trial) by ACS researchers showing that newer cases of colon cancers are occurring in younger patients.4
DR LYNCH: Other organizations are sticking with their 50-year-old threshold recommendation for average-risk patients. The most important thing is to get people screened. There are now different options, including colonoscopy every 10 years, computed tomographic colonography (CTC) every 5 years, sigmoidoscopy every 5 years, take-home high-sensitivity guaiac-based fecal occult blood testing yearly, take-home fecal immunochemical testing (FIT) yearly, and multitargeted stool-DNA testing every 3 years. If a non-colonoscopy test is positive, then a colonoscopy should be done.
DR LOCKWOOD: Have the guidelines changed for high-risk patients for CRC screening?
DR HALY: No. The guidelines still recommend screening at age 40 years or 10 years prior to age of diagnosis in a family member. Patients don’t want to have a colonoscopy because it is invasive and can be expensive, but it is the gold standard test. However, getting at least one of the tests that Dr. Lynch mentioned is better than none at all.
Breast cancer screening
DR LOCKWOOD: Can we talk about the different recommendations for breast cancer screening?
DR LYNCH: The controversy arises due to false-positive results at younger ages, which lead to unnecessary anxiety and further testing. Mammograms in younger women tend to be less accurate. Plus, there are no data to support that yearly screening in women less than 50 actually saves lives. All organizations recommend beginning screening in average-risk women no later than age 50 with the frequency varying from 1 to 2 years. If a patient has risk factors such as family history or genetic predisposition, then she should discuss screening with her physician.
New guidelines from the USPTF recommend mammography every 2 years for women over age 50. They do not recommend screening women aged 40 to 49, although 2 years ago, the American College of Physicians recommended optional mammograms for women aged 40 to 49. High-risk women (two first- or second-degree relatives who developed breast cancer before age 50 or three first- or second-degree relatives who developed breast cancer at any age or had a known gene mutation) should discuss with their physician the risks and benefits of routine screening. If a patient has a life expectancy of at least 10 years, then she should continue mammography every 2 years.
DR HALY: For high-risk women, the ACS recommends annual screening with mammography and magnetic resonance imaging (MRI) beginning at age 30. In July 2017, the American College of Obstetricians and Gynecologists revised their recommendations to emphasize patient and provider shared decision-making. The recommendations are that women at average risk of breast cancer should be offered screening mammography starting at age 40 and should begin screening mammography by no later than age 50. The decision about the age to begin mammography screening should be made through a shared decision-making process including discussion of the potential for false-positive testing requiring additional evaluation and the stress associated with such events. Screening should continue every 1 to 2 years with the interval determined by patient values and preferences. After age 75, the decision to continue screening should be based on the patient’s health status.
DR LOCKWOOD: What about 3D imaging, which is now covered by Medicare?
DR LYNCH: 3D imaging is also called tomosynthesis. That technology was created to overcome some of the drawbacks of standard mammography. From the patient’s perspective, she may notice that less tissue compression is required, however, the test takes longer, namely 7 seconds per exam as 11 images are obtained. They are then assembled into a 3D image by a computer. Because it takes a little longer to get the images, Aase et al recently published an interim analysis of their randomized controlled trial of digital breast tomosynthesis vs digital mammography and found that there was no difference in radiation dose between the two and no difference in the call-back rate for women with dense breasts (3.6% for both). In women with non-dense breast, however, the recall rate was decreased to 2.2% for digital breast tomosynthesis compared to 3.4% for digital mammography. (P = 0.04).5
DR HALY: MRI of the breast is the most sensitive test for breast cancer detection, however, the cost and time needed to perform it limits widespread use as a screening tool. There are current efforts, however, evaluating abbreviated dynamic contrast-enhanced (DCE) MRI protocols, so this will be something to keep an eye on for the future.6 Until then, MRI is limited to being performed for patients at high risk or women diagnosed with breast cancer to determine the extent of disease. There is no radiation exposure with MRI.
DR LOCKWOOD: Everyone is worried about cardiovascular disease (CVD). As physicians, we need to get a complete history from patients because women who have early-onset preeclampsia are at risk for CVD later in life.
DR HALY: Absolutely. We need to take a complete obstetrical history. Women with early-onset preeclampsia during pregnancy are at increased risk of developing CVD later in life. They have a more than 2-fold increased risk of dying from CVD later in life. Screening women with early-onset preeclampsia 9 to 16 years after index pregnancy found 42% of them could meet criteria for preventive measures, compared to 14.3% of healthy controls.7 Women who develop earlier onset preeclampsia (before 36 weeks’ gestation) or have multiple hypertensive pregnancies are at highest risk (RR, 3.4 to 8.12).8 These women did not have coronary artery disease (CAD) but did have risk factors that could lead to CAD/CVD. They may be at risk for hypertension, diabetes, CAD, and CVD, which can allow us to risk modify at an earlier age.
DR LOCKWOOD: Diabetes is prevalent in our society. Let’s talk about how we screen for it.
DR HALY: Starting at age 45, patients should be screened with a baseline fasting blood sugar and then have screening repeated thereafter at least every 3 years. Patients who are overweight or have risk factors for diabetes need to be screened every year.
DR LYNCH: Risk of diabetes within 5 to 10 years after a pregnancy is 3 to 7 times higher. It is important to screen for diabetes after pregnancy as well in patient who have hypertension, hyperlipidemia or obesity (aged 40-70). The best test is a fasting plasma glucose or non-fasting hemoglobin A1c. If fasting blood glucose is normal at < 100 mg/dL or A1c < 5.7%, retesting should be done at 3-year intervals. If the fasting blood glucose is 100 to 125 mg/dL or A1c is 5.7% to 6.4%, repeat testing should be done in 1- to 3- year intervals. Diagnosis of diabetes is confirmed if two consecutive A1c levels are ≥ 6.5%, two consecutive fasting plasma glucose levels are ≥ 126 mg/dL or fasting glucose and A1c are above the thresholds previously stated.
DR LOCKWOOD: Considering how important it is to treat CAD risk factors, are there any other changes in the guidelines?
DR HALY: The American Heart Association (AHA) changed the systolic blood pressure cut-off for diagnosis of hypertension from 140 mg Hg to 130 mmHg. That was changed based on a federally funded study called Sprint, which showed an adjusted risk ratio of 2%. The new guideline is 130/80 mgHg.9
DR LYNCH: In 2013, the A College of Cardiology and the AHA recommended using a risk -based approach to prescribing statins. Ob/gyns should use the risk calculator (cvriskcalculator.com) instead of low-density lipoprotein levels to determine whether use of statins is warranted. If a patient has a 10-year risk between 5% to 20%, then the Society for Cardiovascular Computed Tomography recommends coronary artery calcium scoring to determine need for statin therapy.10
Screening for osteoporosis
DR HALY: We all know how dangerous hip fractures can be as we age. Bone density testing should be performed in women over 65 and men over 70 with no risk factors. Follow-up testing should be done every 2 to 5 years depending on risk. Ob/gyns should use the FRAX (Fracture Risk Assessment Tool) guidelines to evaluate 10-year risk of fracture.
We hope the information discussed here will be of help to ob/gyns in their practices. This is, of course, not all-encompassing but it is a resource to help you with some of the new guidelines in caring for your patients.
The authors report no potential conflicts of interest with regard to this article.
1. U.S. Food & Drug Administration. FDA approves expanded use of Gardasil 9 to include individuals 27 through 45 years old. Available at https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm622715.htm Accessed December 7, 2018.
2. Branson BM, Handsfield HH, Lampe MA, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep. 2006 Sep 22;55(RR14);1-17..
3. Moyer VA; US Preventive Services Task Force. Screening for hepatitis C virus infection in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2013 Sep 3;159(5):349-357.
4. Wolf AMD, Fontham ETH, Church TR, et al. Colorectal cancer screening for average-risk adults: 2018 guideline update from the American Cancer Society. CA Cancer J Clin. 2018 Jul;68(4):250-281.
5. Aase HS, Holen AS, Pedersen K, et al. A randomized controlled trial of digital breast tomosynthesis versus digital mammography in population-based screening in Bergen: interim analysis of performance indicators from the To-Be trial. Eur Radiol. 2018 August 29.
6. Leithner D, Moy L, Morris EA, Marino MA, Helbich TH, Pinker K. Abbreviated MRI of the breast: Does it provide value? J Magn Reson Imaging. 2018 Sep 8.
7. Bokslag A, Teunissen PW, Franssen C, et al. Effect of early-onset preeclampsia on cardiovascular risk in the fifth decade of life. Am J Obstet Gynecol. 2017 May:216(5):523.e1-523.e7.
8. Harskamp RE, Zeeman GG. Preeclampsia: at risk for remote cardiovascular disease. Am J Med Sci. 2007 Oct;334(4):291-295.
9. Whelton PK, Carey RM, Aronow WS, et al. ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2018 Oct 23;138(17):e484-594.
10. Hecht H, Blaha MJ, Berman DS, et al. Clinical indications for coronary artery calcium scoring in asymptomatic patients: expert consensus statement from the Society of Cardiovascular Computed Tomography. J Cardiovasc Comput Tomogr. 2017:11(2):157-168.