In reply: Cervical cancer screening

In Reply: We thank Dr. Keller for his excellent comment. The rationale for discontinuing screening in a woman over 70 who has multiple sexual partners without a history of an abnormal Pap test is that she is at lower risk of new-onset cervical intraepithelial neoplasia (CIN) than a younger woman because of her decreased rate of metaplasia and less accessible transformation zone. In addition, postmenopausal mucosal atrophy may predispose to false-positive cytology. False-positive results are likely to be followed by additional invasive procedures, anxiety, and cost to the patient. However, she is still at risk for acquiring human papillomavirus (HPV) and CIN. Given that cervical cancer develops slowly and risk factors decrease with age, it is reasonable to stop screening at this point. Also, the recommendation of the 3-year screening interval in women over 30 with multiple sexual partners who had negative Pap and HPV tests is based on the fact that they can acquire HPV the day after screening and subsequently develop CIN, but we can detect HPV and CIN in the next round of screening (3 years later) and so will not miss the opportunity to treat cervical dysplasia.

However, practice guidelines are never meant to replace a physician’s sound clinical decision made on an individual basis.

In Reply: We thank Dr. Keller for his excellent comment. The rationale for discontinuing screening in a woman over 70 who has multiple sexual partners without a history of an abnormal Pap test is that she is at lower risk of new-onset cervical intraepithelial neoplasia (CIN) than a younger woman because of her decreased rate of metaplasia and less accessible transformation zone. In addition, postmenopausal mucosal atrophy may predispose to false-positive cytology. False-positive results are likely to be followed by additional invasive procedures, anxiety, and cost to the patient. However, she is still at risk for acquiring human papillomavirus (HPV) and CIN. Given that cervical cancer develops slowly and risk factors decrease with age, it is reasonable to stop screening at this point. Also, the recommendation of the 3-year screening interval in women over 30 with multiple sexual partners who had negative Pap and HPV tests is based on the fact that they can acquire HPV the day after screening and subsequently develop CIN, but we can detect HPV and CIN in the next round of screening (3 years later) and so will not miss the opportunity to treat cervical dysplasia.

However, practice guidelines are never meant to replace a physician’s sound clinical decision made on an individual basis.

In Reply: We thank Dr. Keller for his excellent comment. The rationale for discontinuing screening in a woman over 70 who has multiple sexual partners without a history of an abnormal Pap test is that she is at lower risk of new-onset cervical intraepithelial neoplasia (CIN) than a younger woman because of her decreased rate of metaplasia and less accessible transformation zone. In addition, postmenopausal mucosal atrophy may predispose to false-positive cytology. False-positive results are likely to be followed by additional invasive procedures, anxiety, and cost to the patient. However, she is still at risk for acquiring human papillomavirus (HPV) and CIN. Given that cervical cancer develops slowly and risk factors decrease with age, it is reasonable to stop screening at this point. Also, the recommendation of the 3-year screening interval in women over 30 with multiple sexual partners who had negative Pap and HPV tests is based on the fact that they can acquire HPV the day after screening and subsequently develop CIN, but we can detect HPV and CIN in the next round of screening (3 years later) and so will not miss the opportunity to treat cervical dysplasia.

However, practice guidelines are never meant to replace a physician’s sound clinical decision made on an individual basis.