Updated Pap smear screening guidelines may delay diagnosis of cervical adenocarcinoma in situ

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1. Among patients with cervical adenocarcinoma in situ (AIS), >85% of women were diagnosed subsequent to an abnormal Pap test result.

2. Mean time from abnormal Pap test to AIS diagnosis was less than 3 years.

Revised Pap test screening guidelines, which recommend Pap smears every 3 years beginning at age 21, may result in delayed diagnosis of cervical adenocarcinoma in situ (AIS). In this study, the majority of Pap test abnormalities in women later diagnosed with AIS were squamous, not glandular, dysplasia. As such, most AIS cases were diagnosed by cervical biopsy or other procedure subsequent to an abnormal Pap result. Mean time from abnormal Pap test result to AIS diagnosis was 14 months in women age 30 and younger. Among women age 30 or less, those less than 21 (n=17) had an even higher incidence of pure squamous cytology (94.1%) and a mean time of 21 months between abnormal Pap and AIS diagnosis. With updated guidelines recommending no Pap tests for women under age 21 and Pap testing every 3 years for women ages 21-30, younger women may develop AIS between screenings.

Strengths of this study include a diverse study population. Limitations include those of a retrospective analysis and the lack of a comparison group to quantify what percentage of cases are missed. Ideally, this research question would be investigated in a randomized controlled trial where women are randomized by demographics to either current screening guidelines or previous screening guidelines to allow for direct comparison of morbidity, mortality and cost.

Click to read the study in Obstetrics & Gynecology

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1. Among patients with cervical adenocarcinoma in situ (AIS), >85% of women were diagnosed subsequent to an abnormal Pap test result.

2. Mean time from abnormal Pap test to AIS diagnosis was less than 3 years.

This [retrospective cohort] study included 242 women with an ICD-9 code diagnosis of cervical adenocarcinoma in situ (AIS) between 1998 and 2010 at Brigham and Women’s Hospital. Authors confirmed diagnosis with pathology reports and reviewed medical records for patient demographic information, clinical and treatment history.

In patients age 30 years and younger, (n=112), 85.7% had abnormal Pap smear results. In these women, 82.3% of abnormal results demonstrated pure squamous dysplasia. In patients older than 30 years (n=130), about 95% had abnormal Pap results, with 51.8% exhibiting squamous dysplasia. The mean time between abnormal Pap result and AIS diagnosis was 14 months in women 30 years and younger and 29 months in women older than 30 years. While the majority (73.7%) of AIS cases were diagnosed by cervical biopsy in patients older than 21 (n=225), patients under 21 (n=17) required additional procedures prior to diagnosis.

In sum: Revised Pap test screening guidelines, which recommend Pap smears every 3 years beginning at age 21, may result in delayed diagnosis of cervical adenocarcinoma in situ (AIS). In this study, the majority of Pap test abnormalities in women later diagnosed with AIS were squamous, not glandular, dysplasia. As such, most AIS cases were diagnosed by cervical biopsy or other procedure subsequent to an abnormal Pap result. Mean time from abnormal Pap test result to AIS diagnosis was 14 months in women age 30 and younger. Among women age 30 or less, those less than 21 (n=17) had an even higher incidence of pure squamous cytology (94.1%) and a mean time of 21 months between abnormal Pap and AIS diagnosis. With updated guidelines recommending no Pap tests for women under age 21 and Pap testing every 3 years for women ages 21-30, younger women may develop AIS between screenings.

Strengths of this study include a diverse study population. Limitations include those of a retrospective analysis and the lack of a comparison group to quantify what percentage of cases are missed. Ideally, this research question would be investigated in a randomized controlled trial where women are randomized by demographics to either current screening guidelines or previous screening guidelines to allow for direct comparison of morbidity, mortality and cost.

Click to read the study in Obstetrics & Gynecology

By Denise Pong and Leah Hawkins

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