When to refer: PCP guide to Pap exams
Russell Dickey, MD, Ob/gyn, USMD
Serving the Dallas-Fort Worth metropolitan area with two hospitals and nearly 50 primary care and specialty clinics, the USMD Health System has a team of 250 patient-focused providers.
Our mission is to make the health system work better for everyone, inspiring people to live healthier lives. We seek to lead the transformation of quality and compassionate health care delivery.
Dr. Dickey has been in practice since 1990 and he currently serves as medical director for women’s health services and pediatrics at USMD Health System.
Women’s health screening, specifically the Papanicolaou (Pap) test is an essential piece of preventive health care. The Pap smear was developed in the 1940s by Dr. George Papanicolaou as a means to screen patients for precancerous and cancerous lesions of the cervix.
Widespread use of the Pap smear since the late 1960s resulted in a marked decrease in both the incidence and mortality of cervical cancer in developed countries. In the early 1900s, cervical cancer was the leading cause of cancer death for women in the U.S.
The most recent cancer statistics show that approximately 4,000 women die from cervical cancer annually in the U.S., making it number 15 on the list of cancer mortality for women in the U.S.
HPV and cervical cancer
The relationship between the human papillomavirus (HPV) and cervical cancer was discovered in the early 1980s and a DNA test for HPV was developed in 2006. It was determined that HPV-16 and HPV-18 accounted for 70% of all cervical cancers (HPV-16, 55%; HPV-18, 15%).
The causal relationship between HPV and cervical cancer is even stronger than cigarettes and lung cancer. The HPV vaccine, Gardisil, was introduced in 2006 and is recommended for all children over the age of 9. In 2014 an improved vaccine, Gardisil 9, was introduced.
This vaccine included protection against the HPV types responsible for 90% of cervical cancers and 90% of genital warts, as well as improved protection against HPV-related cancers of the vagina, vulva, penis, anus, rectum and oropharynx.
Pap exams and PCPs
As it is both preventive and exclusive to women, the test is done in both primary care and obstetrician/gynecologist (OB/GYN) offices.
Comfort with the provider, proximity of the office and affordability of the co-pay are reasons patients may choose to have their well woman check up with their primary care provider (PCP).
With increased time intervals for screening, it is imperative that the Pap specimen is adequate for testing. The plastic spatula and endocervical brush provide the best specimen for cervical cytology, according to the American Society for Cytopathology.
The "broom type" collection tool also provides an adequate specimen, but it must be rotated five times circumferentially around the cervix to collect the specimen, and adequate endocervical cells may not be collected in postmenopausal patients or in patients with cervical stenosis.
As specialists in preventative care, primary clinicians, with the screening and education they provide, are a critical part of cancer surveillance.
While no screening test or algorithm can prevent all cases of cervical cancer, appropriate screening using the current guidelines has the potential to prevent most cervical cancers and reduce what was formerly the #1 cancer killer of women to an extremely rare occurrence.
Two providers, one test
Two different caregivers both responsible for a critical screening can, however, lead to confusion. Guidelines for administering the test change frequently. Patients are not always sure when their last Pap test was, or what the results were.
For PCPs, it can be hard to know when it is appropriate to send a patient from primary care to an OB/GYN for specialty follow-up. Better safe than sorry is a well-meaning strategy in medicine, but it can lead to more tests, expense, discomfort and anxiety.
Being confident in understanding the current guidelines and having access to inter-disciplinary support is the answer to this conundrum.
In the interest of empowering PCPs to confidently and safely provide preventive care to women, below are algorithms from the American College of Obstetricians and Gynecologists detailing when to test patients, and, once the results are received, how to interpret whether the patient needs referral to and OB/GYN.
Screening guidelines have evolved over the years, from annual Pap smears in all reproductive age women to the current guidelines which were released in 2012.
- No cervical cancer screening for women under the age of 21
- For women age 21 to 30, pap tests every 3 years with no HPV contesting
- For women age 31 to 65, pap tests with HPV (high risk, oncogenic subtypes only) contesting every 5 years or Pap tests without co-testing every 3 years
- Women over the age of 65 can stop having pap test, provided that they have adequate negative prior screening tests and no history of CIN 2 or higher
Adequate negative prior screening results are defined as three consecutive negative cytology results or two consecutive negative HPV co-test results within the previous 10 years, with the most recent test being performed within the past five years.
Women with a history of CIN 2, CIN 3, or adenocarcinoma in situ should continue screening for a total of 20 years after the initial diagnosis and successful treatment.
- Women who have had a total hysterectomy, with complete removal of the cervix, and who have no history of CIN 2 or higher can discontinue cervical cancer screening.
Women who have undergone total hysterectomy and have a history of CIN 2 or higher, or cervical cancer, should continue screening for a period of 20 years after successful treatment of their CIN 2, 3, or cancer.
- Women who have undergone a supracervical hysterectomy should continue routine screening according to the 2012 guidelines.
Important exceptions/high risk groups:
- Immunocompromised women should have more frequent cervical cancer screening than the general population.
- HIV-infected women should initiate pap testing within one year of the onset of sexual activity or by age 21 at the latest. These patients should have Pap testing only every year until they have three consecutive negative tests. After three negative tests, the screening can continue every three years.
No HPV contesting is recommended under the age of 30. HIV-infected women over the age of 30 should have a Pap with HPV contesting, and if both are negative, they should continue Pap with HPV contesting every three years for the rest of their lives.
- Immunocompromised patients (such as those who have received solid organ transplants), should be screened the same as HIV-infected patients.
For all results of lesions graded low-grade squamous interepithelial lesion (LSIL) and higher, a referral to an OB/GYN is appropriate and preferred.
Collaboration between PCPs who are providing well-woman care with their colleagues in the women’s health and reproductive specialties should be encouraged. Screening tests like the Pap test are of great importance and guidelines for administration and result follow-up change often.
By working closely with one another, PCPs and specialists can be more confident in our recommendations, reduce duplication of care, and better care for patients.
This publication is informational and for educational purposes for practitioners only. The views and opinions expressed herein are those of the authors and do not necessarily represent the views of Optum Care. The views and opinions expressed may change without notice.