JOGNN

EDITORIAL

Whats a Woman to do About the New Breast and Cervical Cancer Screening Recommendations?

Nancy K. Lowe Editor

n one short week in November 2009, recommendations for breast and cervical cancer screening changed in the United States. On November 17, the US Preventive Services Task Force (USPSTF) released its newest recommendation statement on Screening for Breast Cancer in the Annals of Internal Medicine. In this document, the USPSTF made a substantial departure from its previous recommendations. Specically, the new screening recommendations are for screening mammography every 1 to 2 years beginning at age 50; an individualized decision for biennial screening between 40 and 49 years; and no regular screening recommendation for women 75 years and older. In addition, the USPSTF recommended that self-breast exam (SBE) not be taught to women because the evidence indicates this self-screening is ineective in reducing breast cancer mortality. These recommendations do not apply to women with a known genetic mutation for breast cancer or with a history of chest radiation. In other words, the new screening recommendations apply to women age 40 and older whose risk for breast cancer is the same as the general population of similarly aged women. Taking opposing views to the USPSTF recommendations are the American Cancer Society (ACS) and the American College of Obstetricians and Gynecologists (ACOG). Both organizations swiftly rearmed their positions that women aged 40 and older should continue to receive annual or biennial mammography. However, the American College of Preventive Medicine supports the USPSTF recommendations and noted that they were promulgated by a process considered to be the gold standard for evidence-based analysis of and guidelines on the use of clinical preventive services (American College of Preventive Medicine, 2009). In this issues Current resources for evidencebased practice article, R. Rima Jolivet, CNM, MSN, MPH, provides a tutorial on the epidemiologic methods used to develop general population^

based screening recommendations. It is a complex task based on a review of the evidence to weigh the benets and harms of various screening algorithms for people in dierent age groups. The USPSTF concluded that age 50 is where the benets of mammography screening outweigh the harms, such as follow-up care for false-positive screening results, unnecessary treatment, and radiation exposure. According to the Centers for Disease Control and Prevention, breast cancer is the 7th leading cause of death and the leading cause of cancer death for US women. In the October 21, 2009 issue of the JAMA, Esserman and colleagues asserted that the past two decades of mammography screening has increased the diagnosis and incidence of breast cancer, increased the relative proportion of breast cancers that are early stage, and has not substantially decreased the incidence of regional (aggressive or later stage) breast cancers. Currently, a womans lifetime risk of a breast cancer diagnosis is 1 in 8 compared to 1 in 12 in 1980. These authors concluded that 20 years of mammography screening has increased the burden of low-risk cancers through overdiagnosis, overtreatment, and complications of treatment, although its contribution to the observed decreased mortality from breast cancer is questionable. The improvement in breast cancer mortality can be most clearly linked to improved treatment for breast cancer rather than a benet of increased screening and diagnosis of early-stage disease. Esserman and colleagues further proposed four future strategies to signicantly decrease morbidity and mortality from breast cancer including:  Development and validation of biomarkers to dierentiate signicant- and minimal-risk cancers;  Reduction of the treatment burden for minimalrisk disease by using current and emerging methods to dierentiate low- and high-risk disease, adjust terminology for minimal risk lesions, and adjust therapy accordingly;

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& 2010 AWHONN, the Association of Womens Health, Obstetric and Neonatal Nurses

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Editorial

 Development of tools to support informed decisions including information about risks of screening and biopsy prior to screening, and a  Focus on prevention for the highest-risk women. On November 20, 2009, a revised ACOG Practice Bulletin was published in Obstetrics & Gynecology that recommended that women should have their rst cervical cancer screening at age 21 and be rescreened every 2 years until age 30, and every 3 years thereafter with either conventional or liquid-based cytology. In an ACOG press release, Alan G. Waxman, MD, who chaired the development of the Practice Bulletin, stated A review of the evidence to date shows that screening at less frequent intervals prevents cervical cancer just as well, has decreased costs, and avoids unnecessary interventions that could be harmful. Unlike the USPSTF breast cancer screening recommendations, ACOGs new cervical cancer screening guidelines are supported by the ACS. Cervical cancer was previously the leading cause of cancer death for women in the United States. The past 40 years of Pap smear screening has produced a signicant decline in the incidence of cervical cancer and mortality from the disease. Of more than 11,000 annual new cases of cervical cancer in the United States, 50% occur in women who have never had a Pap smear and another 10% in women who have not been screened in the preceding 5 years (ACOG, 2009a). Pap smear screening is successful because cervical cancer is a slow-growing disease, and premalignant lesions can be detected via screening and eliminated through cervical intraepithelial neoplasia (CIN) ablation by colposcopy. One reason behind ACOGs new recommendation to begin Pap smear screening at age 21 is that human papillomavirus infections are usually acquired by young women shortly after their heterosexual debut, but these infections are cleared by the immune system in 1 to 2 years without causing neoplastic cervical changes in most women. Hence, invasive cervical cancer is extremely rare in women before

age 21, whereas dysplasia is common. The overtreatment of cervical dysplasia with excisional procedures has been linked to a signicant increase in preterm birth (Kyrgiou et al., 2006). Many women and health care providers may be confused and concerned about these new guidelines, particularly those who have faithfully complied with the former screening recommendations for breast and cervical cancer. A realistic concern is if and how soon private and public health care insurers will change their coverage standards for these services. Because the new cervical cancer recommendations have been publically received with minimal controversy, most informed clinicians and consumers likely will adopt these new standards. The debate over standards for breast cancer screening via mammography is, however, likely to continue. In the meantime, clinicians must acknowledge the confusion of the public due to opposing advice from medical experts and continue to educate themselves about the issues, the uncertain science of screening recommendations, and the benets and harms of various screening decisions.

REFERENCES
American College of Obstetricians and Gynecologists. (2009a). Cervical cytology screening. ACOG Practice Bulletin No. 109. Obstetrics and Gynecology, 114, 1409-1420. American College of Obstetricians and Gynecologists. (2009b). First cervical cancer screening delayed until age 21, less frequent pap tests recommended. Retrieved from http://www.acog.org/from_ home/publications/press_releases/nr11-20-09.cfm American College of Preventive Medicine. (2009). ACPM response to mammography recommendations. Retrieved from http://www. acpm.org/Response-MammographyRecs.htm Esserman, L., Shieh, Y., & Thompson, I. (2009). Rethinking screening for breast cancer and prostate cancer. Journal of American Medical Association, 302(15), 1685-1692. Kyrgiou, M., Koliopoulos, G., Martin-Hirsch, P., Arbyn, M., Prendiville, W., & Paraskevaidis, E. (2006). Obstetric outcomes after conservative treatment for intraepithelial or early invasive cervical lesions: Systematic review and meta-analysis. Lancet, 367, 489-498. US Preventive Services Task Force. (2009). Screening for breast cancer: US preventive services task force recommendation statement. Annals of Internal Medicine, 151, 716-726.

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JOGNN, 39, 133-134; 2010. DOI: 10.1111/j.1552-6909.2010.01099.x

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