Are you using the best screening tools for malignancy? Here’s how ACOG recommends that you find 3 cancers

Cervical, colorectal, and breast cancer screenings are vital to a woman’s long-term health, but not all screening tools—or intervals—are equal

Senior Editor

When the American College of Obstetricians and Gynecologists (ACOG) updated its guidelines on cervical cancer screening last November—shortly after a brouhaha erupted over the US Preventive Services Task Force (USPSTF) recommendations on mammography—the specifics were almost lost in the furor.

The move by ACOG to push back the age for the first Pap test and relax cervical cancer screening intervals was widely misinterpreted as “rationing” health care, coming as it did on the heels of the USPSTF’s recommendation against screening mammography for women in their 40s. In many news cycles, the ACOG and USPSTF recommendations were conflated, treated as through they had been carefully coordinated.

ACOG and USPSTF recommendations
were not coordinated

In reality, the two sets of recommendations were completely unrelated, says Cheryl Iglesia, MD, chair of the ACOG Committee on Gynecologic Practice.

“It’s just a coincidence that cervical cancer screening guidelines were published the same week as the USPSTF breast cancer screening guidelines,” she says. “ACOG recommendations undergo regular review, and this revision had been in development.”

Dr. Iglesia is director of female pelvic medicine and reconstructive surgery at Washington Hospital Center and associate professor of ObGyn and urology at Georgetown University in Washington, DC. She also serves on the OBG Management Board of Editors.

So what, exactly, does ACOG have to say about cervical cancer screening? And while we’re on the subject of screening, what does the College recommend about two other pervasive malignancies—namely, breast and colorectal cancer?

In a recent sit-down with Dr. Iglesia, we asked these and other questions about cancer screening in ObGyn practice. Some of her answers may surprise you.

OBG Management: Let’s begin with cervical cancer screening. How did ACOG’s position change?

Dr. Iglesia: ACOG pushed back the age at which women should begin getting screened for cervical cancer—from 18 to 21 years. It also relaxed the screening interval for women in their 20s, from every year to every other year. In addition:

• women in their 30s and older who have had three normal Pap tests should switch to screening every 3 years, instead of every 2 to 3 years

• women 65 to 70 years old and older need not be tested if they have had three normal Pap tests

• women who have had a total hysterectomy with no history of high-grade cervical intraepithelial neoplasia (CIN) can discontinue screening

• women who have had a total hysterectomy but who have a history of high-grade CIN should continue to be screened as appropriate for their age group

• women 30 years and older may undergo cotesting (human papillomavirus [HPV] and Pap tests combined)

• women who test negative on both the HPV and Pap tests need not be rescreened for three years (TABLE).

OBG Management: Why was the age at which women undergo their first Pap test changed to 21 years?

Dr. Iglesia: Cervical cancer is extremely rare in women before the age of 21, and it takes years for HPV and dysplastic changes to develop into cervical cancer. Treatment of dysplasia in young women increases the risk of preterm labor and cannot be recommended without an offsetting benefit.

OBG Management: Do you think that extension of cervical cancer screening intervals could suggest to some women that screening isn’t that important?

Dr. Iglesia: I hope not! We could reduce the incidence of cervical cancer by 50% if women would just show up for their annual exam, because half of all cervical cancer cases occur in women who have not undergone Pap testing in years or who have never undergone a Pap test.

What ACOG recommends for detecting cervical, colorectal, and breast cancer in women at average risk of malignancy

Colonoscopy is the gold standard
for colorectal cancer screening

OBG Management: Let’s move on to colorectal cancer screening. What does ACOG recommend?

Dr. Iglesia: The College recommends that screening begin at age 50 for women who have an average risk of malignancy, and at age 45 for African Americans. Earlier screening is recommended in high-risk groups.

Colonoscopy is the preferred screening method, and should be performed every 10 years, but more frequent screening may be indicated in women who have an elevated risk of colorectal cancer.

Colonoscopy has many advantages, including the ability to remove polyps at the time they are detected. However, it is not available to all women, and some women will not agree to be screened by colonoscopy. In such cases, ACOG recommends one of the following options:

• annual fecal occult blood or fecal immunochemical testing.   This method requires that two or three samples of stool be collected by the patient at home and returned for analysis

• flexible sigmoidoscopy   every 5 years

• double-contrast barium enema   every 5 years

• computed-tomography colonography   every 5 years

• stool DNA testing.   The appropriate interval for this screening method has not been identified.

OBG Management: What about the collection of a single stool sample by digital rectal examination (DRE)? When is that appropriate?

Dr. Iglesia: It isn’t. There is a misperception among patients and some ObGyns that a single stool sample obtained by DRE is adequate for the detection of colorectal cancer. In fact, performing the single DRE sample may actually be detrimental to a woman’s health because she may believe she has been screened for colorectal cancer and forgo colonoscopy or the 2- to 3-day sample. The DRE test is extremely insensitive and may falsely reassure patients.

OBG Management: What is the biggest challenge facing ObGyns in regard to colorectal cancer screening?

Dr. Iglesia: Educating women about the need for it. Many women consider colon cancer to be a “man’s disease.”

ACOG stays the course on breast cancer screening …for now

OBG Management: What are ACOG’s current recommendations on screening mammography for women who have an average risk of breast cancer?

Dr. Iglesia: The College recommends:

• screening mammography every 1 to 2 years for women 40 to 49 years old

• screening mammography every year for women 50 and older

• clinical breast examination every year for women 19 and older

• breast self-examination.

These recommendations did not change in response to the USPSTF guidelines revision last November.

OBG Management: What about women who may have an elevated risk of breast cancer? How would you define that population, and what does ACOG recommend?

Dr. Iglesia: Any woman who has a history of breast cancer or a first-degree relative who has had breast cancer is considered at elevated risk. So are women who have multiple relatives who have had premenopausal breast cancer or ovarian cancer, as well as those who have a BRCA1 or BRCA2 mutation.

ACOG recommends that women who have an elevated risk of breast cancer discuss the possibility of earlier or more frequent screening with their physician.

OBG Management: The USPSTF guidelines on screening mammogram have captured a lot of media attention—but ACOG’s position on those guidelines, not so much. What is the College’s perspective on the USPSTF changes?

Dr. Iglesia: ACOG is evaluating the new recommendations and evidence. During this review period, the College continues to recommend the measures I listed.

OBG Management: The USPSTF recommended against breast self-examination for all ages. Do you think that was wise?

Dr. Iglesia: In its review of data, the USPSTF found that BSE did not reduce breast cancer mortality but did lead to additional imaging and biopsy. However, until ACOG finishes reviewing the data, it continues to recommend that patients be counseled to use BSE.

Is the annual exam a thing of the past?

OBG Management: Do you worry that women will interpret these new recommendations for longer screening intervals and a later age for the first Pap test and conclude that an annual check-up is no longer necessary?

Dr. Iglesia: There is more to an annual exam than a Pap test; age-adjusted risks need to be discussed, and routine health screening and symptom assessment continue to be important. An annual gynecologic exam includes inspection of the genitalia and assessment for uterine and adnexal pathology, as well as counseling about contraception, prevention of sexually transmitted infection, management of menopausal symptoms, and vaccination. Assessment of pelvic floor complaints and other routine primary health-care screenings are also important.

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