It was in 1928 that scientists first discovered pap smears — a procedure in which a doctor can scrape cells from a woman’s cervix, look at them under a microscope and identify cancer, or the start of cancer. By the 1940s, pap smears were administered widely through the United States and Western world.
Today, 50 million pap smears are done annually throughout the world, and deaths from cervical cancer in the Unites States are so low they don’t even reach the top 10 of cancer deaths. Cervical cancer has become the easiest gynecological cancer to prevent.
So it was a surprise to some that new guidelines were issued by the worldwide medical community in 2012 easing pap smear testing recommendations from annually to every three years.
While an annual gynecological visit is still highly recommended for women 21 and over, women now get a reprieve from the annual pap smear and only need one every three years, according to the experts. And, if the test is negative, the test can be pushed to an every-five-year schedule.
However, in keeping with studies strongly linking cervical cancer to HPV, or human papillomavirus, the new guidelines also call for women between the ages of 30 and 65 to be tested for HPV at the same time as the pap smear.
The new guidelines are the result of two years of study by researchers in the United States and Europe. They were issued jointly by the American Cancer Society, the American Clinical Pathology Association, the U.S. Preventive Services Task Force and other leading groups.
“Essentially we now know that all cases of cervical cancer are caused by the HPV virus,” said Dr. Daniel E. Bolet, medical director of the Jackson Medical Group and a gynecologist.
Bolet said his patients are surprised by the new guidelines, and some even insist on continuing their annual pap smear — which he tries to accommodate to ease their minds.
“We get a lot of patients who come in for their annual pap smear and that’s when we explain, you don’t need it,” he said. “But they still need a routine gynecological exam every year whether they get the pap smear or not. It’s a good opportunity to talk to the doctor about issues of childbirth, etc.”
Another change in the new guidelines is that is not considered necessary for women to get pap smears before the age of 21. Previously, women were urged to start visiting gynecologists and getting pap smears at the time they became sexually active.
However, it is estimated that only about 19 women under the age of 21 will develop cervical cancer in the United States, so it was felt the extraordinarily low number made the test unnecessary until 21.
Also, the test is recommended whether women are sexually active or not.
Pap smears only detect cervical cancer, not ovarian, uterine, vaginal or vulvar cancers.
If a woman’s pap smear and HPV test are both negative, she does not need to return for testing for five years. Testing is stopped altogether at the age of 65 if the women has had a history of clean pap smears. If she had a positive pap smear, she must be tested every five years for the next 20 years.
“This is based on statistical considerations, as well as a cost-benefit analysis,” explained Dr. Wilberto Nieves-Neira, interim division chief of gynecological oncology at University of Miami’s Sylvester Comprehensive Cancer Center. “Pap smears will not eradicate cervical cancer but we are seeing a 75 to 80 percent decrease in incidence and mortality rates comparing the 1940s to the 1990s.”
The new guidelines are based on research that shows the vast majority of cervical cancer is caused by the HPV virus. It is estimated that 80 percent of sexually active men and women carry the virus.
“HPV can turn into cervical cancer,” said Nieves-Neira. “Early detection is one of the most important ways we can fight it.”
In the United States, 12,000 women were diagnosed with cervical cancer in 2014, and 4,020 women died of the disease, representing just 1 percent of female cancer deaths. Florida, for some reason, has the third-highest number of cervical cancer cases in the country, with 960 cases diagnosed last year.
In developing countries, where pap smears and early detection are not common, it’s a different story. There, 490,000 new cases are diagnosed annually and 250,000 women die of the disease every year.
“It’s a major problem in third world countries,” noted Nieves-Neira.
In April, the U.S. Food and Drug Administration approved the first HPV test for cervical cancer screening to be used for women 25 and older. The test, called the cobas test, can provide information about the patient's risk for developing cervical cancer in the future.
The cobas test detects two types of HPV, called HPV 16 and HPV 18, which are considered high risk for cervical cancer development. If a woman tests positive for those two strains, a doctor will then perform a further test called a colposcopy, a device that illuminates and magnifies the cervix, “lighting up’’ questionable spots.
The new test “offers women and physicians a new option for cervical cancer screening,’’ said Alberto Gutierrez, director of the Office of In Vitro Diagnostics and Radiological Health at the FDA’s Center for Devices and Radiological Health, in a statement. The FDA approved the test following a study of 40,000 women 25 and older
Nieves-Neira said he can administer the cobas and colposcopy tests in his office.
Young women ages 9 to 26 are also being encouraged to get a relatively new vaccine called Gardisil that guards against four forms of cervical cancer. According to the drug manufacturer, the drug, which was approved by the FDA in 2006, prevents 75 percent of cervical cancer cases.
Bolet said most patients agree to the vaccine. “Very few and far between deny it.”
However, some questions have been raised about the safety of the vaccine and its side effects, particularly seizures.
As of March 2013, the Department of Health and Human Services paid 49 claims totaling $5.9 million for HPV vaccines as part of the government’s vaccine injury compensation program.
In Japan, the Ministry of Health ceased recommending the vaccine last year while adverse events are further investigated.