Cervical cancer screening with a pap smear has been an essential part of a woman's routine health care for many years. However, the guidelines are changing and the test we've relied on for so many years may now be an adjunct to the HPV test. My guest today is Dr Ann ricks she is an obstetrician and gynecologist at Summit Medical Group.
Listen in as Ann M. Ricks, MD obstetrician and gynecologist at Summit Medical Group, discusses the new guidelines for cervical cancer screening.
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Cervical Cancer Screening: HPV or Pap Smear?
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Learn more about Ann M. Ricks, MD
Ann M. Ricks, MD
Ann M. Ricks, MD, specializes in obstetrics and gynecology. Prior to joining Summit Medical Group, she practiced in Hackettstown, NJ. Dr. Ricks is a fellow of the American College of Obstetricians and Gynecologists and a member of the American Society for Colposcopy and Cervical Pathology and the Phi Beta Kappa Honor Society.Learn more about Ann M. Ricks, MD
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Cervical Cancer Screening: HPV or Pap Smear?
Melanie Cole (Host): Cervical cancer screening with a Pap smear has been an essential part of a woman's routine health care for many years. However, the guidelines seem to be changing a bit in the test we've relied on for so many years now, may be an adjunct to the HPV test. My guest today is Dr. Ann Ricks. She's an obstetrician and gynecologist at Summit Medical Group. Welcome to the show, Dr. Ricks. What is the current guideline for screening a woman, as of now, for cervical cancer?
Dr. Ann Ricks (Guest): Hello, Melanie. Thanks for having me on your show. I appreciate it. The most recent guideline for cervical cancer screening that have been put out by the American College of Obstetricians and Gynecologists and the American Society for Clinical Pathologists and Colposcopy, they divided the recommendations into age groups. I will say this is for most healthy women. There are some different guidelines if a woman has HIV, if she's been exposed to diethylstilbestrol (DES) in utero, then those are completely different scenarios. This is just for run into mill, healthy women. They recommend starting Pap smears at age 21. So, before age 21, no woman should be having a pap smear except for some exceptions. Between 21-24, I recommend just a Pap smear screening. There's no reason to do HPV testing in between age 21-24 because, honestly, eighty percent of people who have ever been sexually active get HPV and that tends to be a lot of young women. So, we get a lot of positive HPV tests. For that reason, and because it's so ubiquitous, and most women will clear it, we don't recommend testing for HPV between 21-24. Between 25-30, Pap smear and HPV test if there's an indeterminate result. Then, after 30, we are recommending a Pap smear and an HPV test together because HPV is less common after age thirty. If you have HPV after thirty, then it's more likely to hang around and cause problems. The recommend age is 30-65, a Pap smear and HPV test together. After age 65, unless you've had a high grade Pap smear or cervical lesion in the past or cervical cancer, I don't recommend continuing Pap Smears after 65, and if you've had adequate screening up to that point, it doesn't need to be continued. You're more likely to get false positives and have to follow up on results, you'll know that this is just a false positive but you still have to follow up on it and do some extra testing. As far as the frequency of the Pap smears, which I think that's the part where it gets a little controversial, I guess, because for so many years it's been drilled into our heads that you need to get your Pap smear every year because Pap smears have really decreased the rate of death from cervical cancer dramatically. One of the leading killers of women in the world, and still is in some parts of the world, but in the United States it’s almost 10,000 from cervical cancer a year. So, it's very uncommon now because of the screening that we're doing. But now, with the HPV test, as we understand more about the natural history of HPV leading into cervical cancer, we really don't need to be doing Pap smears every year. The guidelines say it can be for the women who are age 21-29, every three years if the results are normal. Then, after age thirty, if you're doing an HPV test along with the Pap smear, it can be up to five years. Although I will say, personally, in my practice, I still stick with that three year interval, I don't go to the five years. I like to do three years because the studies that were done compared annual Pap smears to three years, and then they compared three years to five years, and they say it's all the same, but for me doing a Pap smear every year is the gold standard that we compare to, and so doing it every three years so you know that those are equivalent. So, I in my practice do every three years but the guidelines say that you can wait five years for women over 30 with a normal Pap smear and a negative HPV test.
Melanie Cole: Dr. Ricks, women--are worried well who say, “Three years seems even too long. I know that there are these other tests but I'm still nervous?”
Dr. Ricks: Absolutely. I do offer it to my patients because health insurance companies do pay for a Pap smear every year still. I will offer the option. I will explain what the guidelines are, and say that we see the same rates of cervical cancer prevention by doing Pap smears every three years, with fewer false positive results, fewer unnecessary interventions, but if you feel more comfortable, we will do it. Most women are happy to have the choice, and not feel forced to forego the screening test that they've been told for so many years that it needs to be done every year. I think it's important but it is important to understand too that with screening tests, there are risks to doing the screening tests more often. The more often you do it, you may get false positives that require interventions, and sometimes that can lead to a lot of procedures. It's not necessarily a benign thing to do more screening than is necessary but I think it should be up to the woman if the insurance covers it, or if she's willing to pay out of pocket for it.
Melanie Cole: Are we seeing the change to this HPV test as the vaccine, which can only be given really up to 26 years old becomes more prevalent?
Dr. Ricks: The HPV vaccines. Well, the first on, Quadrivalent protects against two high risk strains of HPV, which those are the ones that can eventually lead to cervical cancer and to low risk drains, which are associated with genital warts, which are unpleasant but not really part of this discussion. There's a more recent one; it’s new. I think it's a benign valent vaccine to protect against more of the high risk strains of the HPV. But, there are dozens of high risk HPV strains out there. They're less common, but we don't have a vaccine to protect against all of them. So, right now we are not recommending any change in screening recommendations to women who have been vaccinated against HPV versus women who have not been vaccinated because there's still a lot of those other strains out there, and we also don't know-- once we start vaccinating against some high risk strains it could be some other high risk strains may become more prevalent once the vaccine is more widespread and there's less prevalence to the strains that are protected against.
Melanie Cole: What do you want women to know about HPV testing and how often that will happen as compared now to the Pap smear? What should they be worried or looking for?
Dr. Ricks: I want to say first that even if we don't do a Pap smear every year, it is still essential that women go to their gynecologist every year for an annual well woman exam. The well woman exam isn't just the Pap smear, it's getting a chance to speak with the doctor, addressing concerns. It's important to have a breast exam every year and also to have a pelvic exam even if we don't do the Pap smears, still looking inside the vagina, looking at the cervix. Sometimes we are able to pick up on some things. You know, you can't see inside yourself. Sometimes we can see things the woman may not have been aware of that we catch in an annual exam that otherwise if it would have gone longer it could cause problems later. That's the first thing I wanted to say. It's very important. A Pap smear every three years does not mean that you go to the doctor every three years. We still want to see you every year. I think as far as HPV testing primarily, I think most physicians, at least ones that I've spoken to, are still doing the Pap smear and HPV testing for women over 30 every three years, or every three to five years if it's normal. There is an algorithm for primary HPV screening. I don't really know too many physicians that are using that, but it is that you do the HPV test and then you could do a Pap Smear after that if that's normal. It's a newer recommendation and it's not one that I know a lot of people follow. So, I can't actually speak too much to it, but that is another option.
Melanie Cole: Wrap it up for women, and you've given us such great information because it can be a little confusing for women about these guidelines and cervical cancer Pap smear, HPV. So, give us a good wrap up as an obstetrician/ gynecologist, what you really want women to know?
Dr. Ricks: Almost all cases of cervical cancer are due to the human papilloma virus. As I said, the human papillomavirus is actually transmitted but eighty percent of people who've ever been sexually active get it at one time or another. Men don't even get tested or screened for it because it doesn't cause them the problems that it causes women. I think there's a lot of anxiety about having a positive Pap smear, having a positive HPV test, which I really want to put for women who do get positive results that it is extremely common to get this and most of the time, with the positive HPV test, women cleared in two to three years. Even a low grade abnormality on a Pap smear, most of the time the body clears out on its own and we don't need to intervene. It's only when HPV virus hangs around for a long does it lead to cervical cancer, and we're talking from getting HPV to when you get cervical cancer, on the order to fifteen to twenty years. So, it's important to get done but even if you get an abnormal result, it's not the end of the world. It doesn't mean you have cancer, we just know that we now need to screen this woman a little bit more closely. It still is important to get it done within those three to five years and it's so important to see your doctor every year to discuss other health issues.
Melanie Cole: Thank you so much for being with us today and clearing that up Dr., Ricks. You're listening to SMG Radio, and for more information you can go to www.summitmedicalgroup.com. That's www.summitmedicalgroup.com. This is Melanie Cole. Thanks so much for listening.
Cervical Cancer Screening: HPV or Pap Smear?
Melanie Cole (Host): Cervical cancer screening with a Pap smear has been an essential part of a woman's routine health care for many years. However, the guidelines seem to be changing a bit in the test we've relied on for so many years now, may be an adjunct to the HPV test. My guest today is Dr. Ann Ricks. She's an obstetrician and gynecologist at Summit Medical Group. Welcome to the show, Dr. Ricks. What is the current guideline for screening a woman, as of now, for cervical cancer?
Dr. Ann Ricks (Guest): Hello, Melanie. Thanks for having me on your show. I appreciate it. The most recent guideline for cervical cancer screening that have been put out by the American College of Obstetricians and Gynecologists and the American Society for Clinical Pathologists and Colposcopy, they divided the recommendations into age groups. I will say this is for most healthy women. There are some different guidelines if a woman has HIV, if she's been exposed to diethylstilbestrol (DES) in utero, then those are completely different scenarios. This is just for run into mill, healthy women. They recommend starting Pap smears at age 21. So, before age 21, no woman should be having a pap smear except for some exceptions. Between 21-24, I recommend just a Pap smear screening. There's no reason to do HPV testing in between age 21-24 because, honestly, eighty percent of people who have ever been sexually active get HPV and that tends to be a lot of young women. So, we get a lot of positive HPV tests. For that reason, and because it's so ubiquitous, and most women will clear it, we don't recommend testing for HPV between 21-24. Between 25-30, Pap smear and HPV test if there's an indeterminate result. Then, after 30, we are recommending a Pap smear and an HPV test together because HPV is less common after age thirty. If you have HPV after thirty, then it's more likely to hang around and cause problems. The recommend age is 30-65, a Pap smear and HPV test together. After age 65, unless you've had a high grade Pap smear or cervical lesion in the past or cervical cancer, I don't recommend continuing Pap Smears after 65, and if you've had adequate screening up to that point, it doesn't need to be continued. You're more likely to get false positives and have to follow up on results, you'll know that this is just a false positive but you still have to follow up on it and do some extra testing. As far as the frequency of the Pap smears, which I think that's the part where it gets a little controversial, I guess, because for so many years it's been drilled into our heads that you need to get your Pap smear every year because Pap smears have really decreased the rate of death from cervical cancer dramatically. One of the leading killers of women in the world, and still is in some parts of the world, but in the United States it’s almost 10,000 from cervical cancer a year. So, it's very uncommon now because of the screening that we're doing. But now, with the HPV test, as we understand more about the natural history of HPV leading into cervical cancer, we really don't need to be doing Pap smears every year. The guidelines say it can be for the women who are age 21-29, every three years if the results are normal. Then, after age thirty, if you're doing an HPV test along with the Pap smear, it can be up to five years. Although I will say, personally, in my practice, I still stick with that three year interval, I don't go to the five years. I like to do three years because the studies that were done compared annual Pap smears to three years, and then they compared three years to five years, and they say it's all the same, but for me doing a Pap smear every year is the gold standard that we compare to, and so doing it every three years so you know that those are equivalent. So, I in my practice do every three years but the guidelines say that you can wait five years for women over 30 with a normal Pap smear and a negative HPV test.
Melanie Cole: Dr. Ricks, women--are worried well who say, “Three years seems even too long. I know that there are these other tests but I'm still nervous?”
Dr. Ricks: Absolutely. I do offer it to my patients because health insurance companies do pay for a Pap smear every year still. I will offer the option. I will explain what the guidelines are, and say that we see the same rates of cervical cancer prevention by doing Pap smears every three years, with fewer false positive results, fewer unnecessary interventions, but if you feel more comfortable, we will do it. Most women are happy to have the choice, and not feel forced to forego the screening test that they've been told for so many years that it needs to be done every year. I think it's important but it is important to understand too that with screening tests, there are risks to doing the screening tests more often. The more often you do it, you may get false positives that require interventions, and sometimes that can lead to a lot of procedures. It's not necessarily a benign thing to do more screening than is necessary but I think it should be up to the woman if the insurance covers it, or if she's willing to pay out of pocket for it.
Melanie Cole: Are we seeing the change to this HPV test as the vaccine, which can only be given really up to 26 years old becomes more prevalent?
Dr. Ricks: The HPV vaccines. Well, the first on, Quadrivalent protects against two high risk strains of HPV, which those are the ones that can eventually lead to cervical cancer and to low risk drains, which are associated with genital warts, which are unpleasant but not really part of this discussion. There's a more recent one; it’s new. I think it's a benign valent vaccine to protect against more of the high risk strains of the HPV. But, there are dozens of high risk HPV strains out there. They're less common, but we don't have a vaccine to protect against all of them. So, right now we are not recommending any change in screening recommendations to women who have been vaccinated against HPV versus women who have not been vaccinated because there's still a lot of those other strains out there, and we also don't know-- once we start vaccinating against some high risk strains it could be some other high risk strains may become more prevalent once the vaccine is more widespread and there's less prevalence to the strains that are protected against.
Melanie Cole: What do you want women to know about HPV testing and how often that will happen as compared now to the Pap smear? What should they be worried or looking for?
Dr. Ricks: I want to say first that even if we don't do a Pap smear every year, it is still essential that women go to their gynecologist every year for an annual well woman exam. The well woman exam isn't just the Pap smear, it's getting a chance to speak with the doctor, addressing concerns. It's important to have a breast exam every year and also to have a pelvic exam even if we don't do the Pap smears, still looking inside the vagina, looking at the cervix. Sometimes we are able to pick up on some things. You know, you can't see inside yourself. Sometimes we can see things the woman may not have been aware of that we catch in an annual exam that otherwise if it would have gone longer it could cause problems later. That's the first thing I wanted to say. It's very important. A Pap smear every three years does not mean that you go to the doctor every three years. We still want to see you every year. I think as far as HPV testing primarily, I think most physicians, at least ones that I've spoken to, are still doing the Pap smear and HPV testing for women over 30 every three years, or every three to five years if it's normal. There is an algorithm for primary HPV screening. I don't really know too many physicians that are using that, but it is that you do the HPV test and then you could do a Pap Smear after that if that's normal. It's a newer recommendation and it's not one that I know a lot of people follow. So, I can't actually speak too much to it, but that is another option.
Melanie Cole: Wrap it up for women, and you've given us such great information because it can be a little confusing for women about these guidelines and cervical cancer Pap smear, HPV. So, give us a good wrap up as an obstetrician/ gynecologist, what you really want women to know?
Dr. Ricks: Almost all cases of cervical cancer are due to the human papilloma virus. As I said, the human papillomavirus is actually transmitted but eighty percent of people who've ever been sexually active get it at one time or another. Men don't even get tested or screened for it because it doesn't cause them the problems that it causes women. I think there's a lot of anxiety about having a positive Pap smear, having a positive HPV test, which I really want to put for women who do get positive results that it is extremely common to get this and most of the time, with the positive HPV test, women cleared in two to three years. Even a low grade abnormality on a Pap smear, most of the time the body clears out on its own and we don't need to intervene. It's only when HPV virus hangs around for a long does it lead to cervical cancer, and we're talking from getting HPV to when you get cervical cancer, on the order to fifteen to twenty years. So, it's important to get done but even if you get an abnormal result, it's not the end of the world. It doesn't mean you have cancer, we just know that we now need to screen this woman a little bit more closely. It still is important to get it done within those three to five years and it's so important to see your doctor every year to discuss other health issues.
Melanie Cole: Thank you so much for being with us today and clearing that up Dr., Ricks. You're listening to SMG Radio, and for more information you can go to www.summitmedicalgroup.com. That's www.summitmedicalgroup.com. This is Melanie Cole. Thanks so much for listening.