Recent changes in the recommended guidelines for mammograms and Pap smears have resulted in confusion and concern among women of all ages.

The US Preventive Services Task Force (USPSTF) announced changes in its recommendation for when to begin and how often to have a mammogram only days before the American College of Obstetrics and Gynecology (ACOG) announced revisions to its recommendations for when to begin and how often a woman should have a Pap smear. The first created controversy, overshadowing the second—so both beg a closer look.

The mammography guidelines
After reviewing the research evidence, the USPSTF revised mammography guidelines and now suggests that routine mammography screening for breast cancer be done only for women of ages 50 through 74. The experts reviewing the research data found as much benefit in mammography for women between the ages of 40 to 49 years as they did for women between 50 to 74 years; however for women 40 through 49 the risk for harmful mammography-related outcomes were greater than the benefit. “Harm” included an increase in false-positive results, “overdiagnosis,” possible unnecessary doctor visits, interventions and exposure to radiation. The reviewers did state that every-other-year mammography before age 50 should be made on an individual basis, taking into account a woman’s personal and family history plus her values that pertain to benefit versus harm of mammography.

ACOG, which published a revision to Pap test guidelines only days after the mammography guidelines were released by USPSTF, announced that it intends to continue to advise women in their 40s to have a mammogram every or every other year and move to annual mammogram when 50 or older while the organization looks more closely at the research data and the USPSTF analysis.

Chief Medical Officer of the American Cancer Society (ACS), Otis W. Brawley, M.D., stated that ACS will continue to recommend yearly screening via mammography and self-exam “for all women beginning at age 40” citing a somewhat different interpretation of the same research that USPSTF reviewed.

The controversy
Mammography had its critics long before the USPSTF released its revised guidelines. Mammography dates back to the early 1900s, but early image quality was poor. In the late 1960s Professor C.M. Gros discovered that forceful compression of the breast between two plates greatly improved image quality. However, unlike a Pap test that detects precancerous cells, by the time you feel a cancer in the breast or see it on a mammogram, it’s been there 8 to 10 years. Moreover, the success of mammography depends on the size and density of the breast, the quality of the x-ray machine, the skill of the person operating it, and the experience of the person interpreting the results.

The timing of the release of the revised guidelines added to the controversy given the ongoing debate over health care reform and concerns about rationing. This was exactly the concern of Carol Lee, MD, chair of the American College of Radiology (ACR) Breast Imaging Commission in her quote for an ACR press release. “These new recommendations seem to reflect a conscious decision to ration care,” she said. US Department of Health and Human Services (DHHS) Secretary Kathleen Sebelius seemed anxious to separate her department’s USPSTF research-based recommendations from the Obama administration and the healthcare reform debate, although Washington Post columnist Steven Perlstein was quick to chastise Secretary Sebelius for “cowardly disavowal,” avoidance and a missed opportunity to instruct the public.

Health writer Naomi Freundlich reminded women that unlike some of the most outspoken critics, the USPSTF recommendations were based on sound research evidence by study authors who “do not have conflicts of interest… are not connected to the government and did not have rationing of health care resources as their underlying mission.” And the recommendations made by the USPSTF supported similar findings noted earlier by others. Laura Esserman, MD, MBA, breast surgeon and director of the UCSF Carol Franc Buck Breast Care Center, came to similar conclusions as the USPSTF team in an October 2009 report for the Journal of the American Medical Association (JAMA). Plus, the new guidelines are similar to the interpretation of the research by the European community. In 2002 the International Agency for Research on Cancer (IARC) Working Group on the Evaluation of Cancer Preventive Strategies recommended every-two-year screening mammography be directed at women from 50 to 69 years, which is consistent with the Recommendation of the Council of the European Union of December 2, 2003 on Cancer Screening.

Pap test guidelines
Named for its inventor, Georgios Papanikalou, M.D., the Pap test has been in use for more than 50 years. It involves getting a sample of cells from the cervix during a pelvic exam. The cervical cells are sent to a lab where they are examined under a microscope for any abnormalities. Since the introduction of the Pap test, deaths due to cervical cancer have decreased by 65% because the test picks up on cervical cancers during the treatable, early stages of this usually slow-growing disease. Without Pap screening, cervical cancer is likely to have reached an invasive, advanced stage before symptoms are noticed.

The new Pap test guidelines, which have been in development since 2007, recommend young women wait until 21 years of age for an initial Pap test, and then be retested only once every two years rather than every year. Women age 30 and older can be rescreened every three years if they’ve had three negative Pap tests results in a row. Of course, women with certain risk factors should continue to be screened more often.

Despite the development of a vaccine against certain strains of the cervical cancer-causing human papilloma virus (HPV) and the fact this disease generally is a slow-growing cancer that is treatable in its early stages, it’s important that women not become complacent about cervical cancer screening. The HPV vaccine Gardasil® does not protect against all strains of HPV, so it will not prevent all cervical cancer. This disease remains one of the leading causes of death for women in underdeveloped countries, and in 2000 almost 20% of women in the USA had not had a Pap test within the last three years. Of those newly diagnosed with invasive cervical cancer, 60 to 80% had never had a Pap test or hadn’t had one in five or more years.

No debate over cervical cancer screening changes
Unlike the concern voiced about the changes in recommendations for mammograms, there has been universal support for the recommended changes regarding Pap smear screening. The updated Pap test guidelines will also save healthcare dollars but, if followed, should not compromise early detection of cervical cancer. And on a very positive note, the guidelines should help avoid unnecessary aggressive intervention, which has been associated with pregnancy complications and a greater risk of preterm birth. Considering the late preterm birth epidemic of the last decade or two, this could have a big impact.

What to do?
So what’s a woman to do? That’s a question each woman will have to answer for herself. Start by talking with your primary healthcare providers about the recommended changes and how they may affect you. Read the USPSTF breast cancer screening report in the November 17, 2009 issue of Annals of Internal Medicine and the cervical screening guidelines in the December 2009 issue of ACOG’s member journal, Obstetrics & Gynecology. Consider listening to a one-hour podcast interview with breast surgeon, Dr. Laura Esserman. Become familiar with other breast cancer screening tools–from the simple, and somewhat simplistic, 7-question online risk calculator to the blood test for breast cancer susceptibility genes BRCA1 and BRCA2 for women with certain family patterns of breast or ovarian cancer–and factors that decrease or increase a woman’s risk of developing female reproductive cancers. Also be aware that advances are being made in blood testing and ultrasound breast cancer screening tools that are more definitive and involve little or no risk.

No matter what health condition is discussed, it’s important to be aware of personal and family history and related health risks. Each knows her own body best and should listen when that body tries to signal that something is off. And be prepared to advocate on your own behalf to get needed care!