New guidelines for cervical cancer screening say women should delay their first Pap test until age 21, and be screened less often than recommended in the past.
The advice, from the American College of Obstetricians and Gynecologists, is meant to decrease unnecessary testing and potentially harmful treatment, particularly in teenagers and young women. The group's previous guidelines had recommended yearly testing for young women, starting within three years of their first sexual intercourse, but no later than age 21.
Arriving on the heels of hotly disputed guidelines calling for less use of mammography, the new recommendations might seem like part of a larger plan to slash cancer screening for women. But the timing was coincidental, said Dr. Cheryl B. Iglesia, the chairwoman of a panel in the obstetricians' group that developed the Pap smear guidelines. The group updates its advice regularly based on new medical information, and Dr. Iglesia said the latest recommendations had been in the works for several years, "long before the Obama health plan came into existence."
She called the timing crazy, uncanny and "an unfortunate perfect storm," adding, "There's no political agenda with regard to these recommendations."
Dr. Iglesia said the argument for changing Pap screening was more compelling than that for cutting back on mammography — which the obstetricians' group has staunchly opposed — because there is more potential for harm from the overuse of Pap tests. The reason is that young women are especially prone to develop abnormalities in the cervix that appear to be precancerous, but that will go away if left alone. But when Pap tests find the growths, doctors often remove them, with procedures that can injure the cervix and lead to problems later when a woman becomes pregnant, including premature birth and an increased risk of needing a Caesarean.
Still, the new recommendations for Pap tests are likely to feed a political debate in Washington over health care overhaul proposals. The mammogram advice led some Republicans to predict that such recommendations would lead to rationing.
Senator Tom Coburn, a Republican from Oklahoma who is also a physician, said in an interview that he would continue to offer Pap smears to sexually active young women. Democratic proposals to involve the government more deeply in the nation's health care system, he said, would lead the new mammography, Pap smear and other guidelines to be adopted without regard to patient differences, hurting many people.
"These are going to be set in stone," Mr. Coburn said.
Senator Arlen Specter, a Pennsylvania Democrat and longtime advocate for cancer screening, said in an interview: "And this Pap smear guideline is yet another cut back in screening? That is curious." Mr. Specter, who was treated for Hodgkin's lymphoma in 2005 and 2008, said Congress was committed to increasing cancer screenings, not limiting them.
Representative Rosa DeLauro, Democrat of Connecticut, said that the new guidelines would have no effect on federal policy and that "Republicans are using these new recommendations as a distraction."
"Making such arguments, especially at this critical point in the debate, merely clouds the very simple issue that our health reform bill would increase access to care for millions of women across the country," she said.
There are 11,270 new cases of cervical cancer and 4,070 deaths per year in the United States. One to 2 cases occur per 1,000,000 girls ages 15 to 19 — a low incidence that convinces many doctors that it is safe to wait until 21 to screen.
The doctors' group also felt it was safe to test women less often because cervical cancer grows slowly, so there is time to catch precancerous growths. Cervical cancer is caused by a sexually transmitted virus, human papillomavirus, or HPV, that is practically ubiquitous. Only some people who are exposed to it develop cancer; in most, the immune system fights off the virus. If cancer does develop, it can take 10 to 20 years after exposure to the virus.
The new guidelines say women 30 and older who have three consecutive Pap tests that were normal, and who have no history of seriously abnormal findings, can stretch the interval between screenings to three years.
In addition, women who have a total hysterectomy (which removes the uterus and cervix) for a noncancerous condition, and who had no severe abnormalities on previous Pap tests, can quit having the tests entirely.
The guidelines also say that women can stop having Pap tests between 65 and 70 if they have three or more negative tests in a row and no abnormal test results in the last 10 years.
The changes do not apply to women with certain health problems that could make them more prone to aggressive cervical cancer, including H.I.V. infection or having an organ transplant or other condition that would lead to a suppressed immune system.
It is by no means clear that doctors or patients will follow the new guidelines. Medical groups, including the American Cancer Society, have been suggesting for years that women with repeated normal Pap tests could begin to have the test less frequently, but many have gone on to have them year after year anyway.
Debbie Saslow, director of breast and gynecologic cancer for the American Cancer Society, said professional groups were particularly concerned because many teenagers and young women were being tested and then needlessly subjected to invasive procedures.
In addition, Dr. Saslow said, doctors in this country have been performing 15 million Pap tests a year to look for cervical cancer in women who have no cervix, because they have had hysterectomies.
Dr. Carol L. Brown, a gynecologic oncologist and surgeon at Memorial Sloan-Kettering Cancer Center, said the new guidelines should probably not be applied to all women, because there are some girls who begin having sex at 12 or 13 and may be prone to develop cervical cancer at an early age.
"I'm concerned that whenever you send a message out to the public to do less, the most vulnerable people at highest risk might take the message and not get screened at all," Dr. Brown said.
Dr. Kevin M. Holcomb, an associate professor of clinical obstetrics and gynecology at NewYork-Presbyterian/Weill Cornell hospital, said that when he heard the advice to delay Pap testing until 21, "My emotional response is 'Wow, that seems dangerous,' and yet I know the chances of an adolescent getting cervical cancer are really low."
As with the new mammogram recommendations, women may not readily give up a yearly cancer test.
"For people who've been having the testing regularly every year, it's a big emotional change to test less frequently and there's this fear of 'Oh my gosh, I might be missing something,' " said Ivy Guetta, 49, of Westport, Conn., who plans to continue with annual Pap tests. Ms. Guetta has three daughters, ages 17, 14 and 8, and at the moment, she would not encourage them to wait until they turn 21.
Jen Jemison, 24, a legal assistant from Babylon, N.Y., said she thought she began getting Pap smears when she was about 18, but said that if she had been aware that the procedure for treating precancerous lesions could lead to premature births, she would have waited until she turned 21.
On the other hand, Ms. Jemison said that now that she is over 21, "I would still go every year" for the Pap test.
"One of my cousins had cervical cancer, so that's in my head too," she said. "I'd rather get it checked out regularly than have to worry about that."
