Q+A: Should cervical cancer tests start later?

by Sunanda Creagh
Women in Australia are encouraged to have pap smears from the age of 18, while in the UK the age has been raised to 25. Credit: AAP

UK health authorities have recommended women start having pap smears later in life, suggesting women wait until they are at least 25 before having their first cervical cancer screening.

The aim is to reduce the number of women having unnecessary tests and treatments, given that in women below the age of 25 is rare.

Women in Australia are advised to start having pap smears at age 18 or two years after they first have sex, whichever occurs later, but the suggested age is under review by the National Health and Medical Research Council. The results of the review are due in 2014.

Here is a Q+A on the topic with Professor Michael Permezel, President of the The Royal Australian and New Zealand College of Obstetricians and Gynaecologists and a lecturer in obstetrics at the University of Melbourne.

What do you think of the change in the UK?

I think it's something that I would be cautious about in the Australian situation.

It really is a risk-benefit decision, there are obviously positives of screening early as we have all seen very sad, rare cases of cervical cases under 25.

But on the other hand as Dr Falconer points out, we certainly don't want women under 25 having unnecessary treatment.

So before making a similar decision for the Australian population, we really need to look at factors such as the incidence of abnormal pap smears and particularly of abnormal pap smears going on to develop cancer in that under 25 age group.

That could well differ from country to country and from risk group to – because clearly within the population not everybody has the same risk.

In Australia the age is 18 or 2 years after the first sexual intercourse. Is that considered low, worldwide?

In the article, it points out it varies from country to country but 18 is probably at the young end and 25 at the high end of the spectrum recommended.

Clearly the number of cases between those two years is going to be small and it's an issue whether or not that small number of cases that would be prevented is cost effective.

And then there is the anxiety created and other issues, it's not just the cost.

Abnormal generate some anxiety and some women will have treatment that turns out to be unnecessary as Dr Falconer says when the condition would have resolved spontaneously.

Nevertheless a very small number of cancers might be prevented – so it really is a risk benefit decision based on the incidence in the population in question. It's all changing, so you can look at the data in the past but as the vaccine becomes more and more prevalent then the incidence in the population is going to get less.

It seems that there is a debate not just in cervical cancer but in prostate and breast cancer about whether or not we are screening unnecessarily, what the benefits are of all the testing we're doing?

That's absolutely right, but every test should be questioned and it's good that people are questioning whether we are doing these tests too often or not enough.

Are we starting too early or are we starting too late? These are all very good questions to be asking and we should be continually interrogating our current practice to decide whether or not it is the best thing to be doing. Especially in an area that's changing, so with the enormous changes in the pattern of cervical cancer with the vaccine and with the HPV testing and so forth, something that was completely appropriate 10 or 15 years ago may well be inappropriate next year or the year after.

Prostate cancer, again the development of the PSA test and other interventions for prostate cancer mean that it's a changing field and recommendations made five or 10 years ago might not necessarily be right in five or 10 years from now.

So I think they are exciting areas. One mistake people make is it's not necessarily always going to be better to test more often and start earlier, because in almost every situation there'll be consequences of the testing, not just anxiety, but sometimes, the treatment of something that turns out not to be cancer, could have its own adverse consequences. You wouldn't want overdiagnosis leading to overtreatment in a population where the cancer is extremely rare. So there is a balance between not overtesting – and not undertesting either.

You don't want to be in a situation where people think it's not worth getting the test?

Equally, you don't want to be in a situation where somebody with a one-in-a-million chance is rushing around having tests and being caused a whole lot of anxiety and maybe even having treatment that is completely unjustified.

And these tests are all good – nobody's doubting prostate, breast or cervical cancer screening – it's just a matter of some fine-tuning to make sure it's being done in the right population at the right time.

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