New cervical cancer screening guidelines ignore past progress

Doubtful person, hands on hips, choosing the way as multiple arrows on the road showing a mess of different directions. Choosing the correct pathway, difficult decision concept, confusion symbol.

Today more than ever, we need to commit to proven science. Building on what we know, and leveraging what works is by far our best course of action. During the current pandemic, the times we have faltered most have been the times we lost focus on what is scientifically proven to work.

I question why the American Cancer Society (ACS) would release new guidelines with the intent of removing Pap testing from cervical cancer screening. The ACS has described their approach, which recommends human papillomavirus (HPV) testing every five years from ages 25-65, as “less and more simplified.” In this case, less is indeed just less. As a pathologist with more than a decade of experience, I am concerned that these guidelines do not fit with real-world screening within the U.S. healthcare system.

A few things stand out to me as red flags concerning these new guidelines. First, major organizations like the American College of Obstetricians and Gynecologists (ACOG), the United States Preventive Services Task Force (USPSTF) and the Women’s Preventive Services Initiative (WPSI) continue to support the role of cytology in cervical cancer screening, and the American Society for Clinical Pathology (ASCP) spoke out to share several concerns about the new ACS guidelines.

Second, after using the Pap test to screen for cervical cancer for the past 50 years, cervical cancer has gone from the number one cause of cancer death in women to number 15, dropping 70%. Threatening to eliminate the Pap test now risks confusing patients and reversing the significant progress we have made in fighting this preventable disease, especially for Black and Hispanic women, who are at higher risk of cervical cancer, which the ACS recognizes.

And third, to exclude women under 25 from getting a simple test that has saved countless lives feels completely counterintuitive. That’s especially true at a time when there is absolutely not enough preventive care happening in the US, and the Pap test stands as one of the greatest successes in the history of preventive health. Why do young women in their early 20s not matter anymore?

This drastic change from the ACS comes at a time when recently published clinical evidence seems to point in the exact opposite direction of their new guidelines. Real-world clinical results show that using HPV testing on its own can miss twice as many cervical cancers as using co-testing. That statistic alone should be enough to make the ACS reconsider its new guidelines.

As a pathologist, I have seen HPV-negative cancers when reviewing cytology slides. Taking away the Pap test will only increase the chances that disease will be missed, and that women will be put at greater risk. Serious consideration must be given to the fact that the Pap test can also help detect infections and other asymptomatic cancers that may not be diagnosed otherwise.

Finally, as we’ve seen with Covid-19, not all data or models are created equal, and some even lead to poor predictions. The methods used to develop the data model that informed the new ACS guidelines have not been released for us to examine. And without truly understanding how the ACS came up with these drastically different recommendations, how can we evaluate the factors that led them to this decision?

I have seen the incredibly positive benefits that the Pap test alone and used in conjunction with the HPV test can have on protecting the lives of women. I need to have a much better understanding of why these changes are being made and why they are at odds with my experience in the lab. To make any changes, we must use models that incorporate real-world clinical experiences and integrate national data that closely represents our highly diverse population.

At this crucial time when we need to rely more than ever on proven science, it is unclear why ACS would potentially impact the lives of countless women with recommendations that contradict decades of real progress. I believe that we need to embrace the incredible successes we have achieved with the current standard of Pap testing for young women 21-29 years and co-testing with the Pap and HPV tests together for women 30-65 years to ensure that women continue to benefit from what science has proven and what healthcare providers and laboratory professionals trust most.

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