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Putting new guidelines into practice is easier said than done

The new recommendations on cervical cytology are evidence-based and endorsed by our scholarly and professional societies. It’s difficult to disagree. Difficult, but not impossible.

December 2004 · Vol. 16, No. 12

The field is still evolving, and it is evolving so rapidly that I believe the changed recommendations may be premature. As our understanding of the high-risk types of human papillomavirus evolves, the time may soon come when exfoliative cytology as we know it may not be the screening method of choice. The introduction of liquid-based Pap smears and reflex high-risk HPV testing has caused tremendous change in how we collect and interpret smears.

But the task of putting new technologies into practice can be somewhat daunting.

Application of the new guidelines depends in part on an accurate sexual history, past and present. Even in this era of awareness and “safe sex,” we often cannot pinpoint at what age a patient became sexually active or whether her history includes multiple partners. Furthermore, use of Viagra among men, and the soon-to-be available testosterone patch for women mean we cannot assume that our graying population is sexually inactive, monogamous, or “safe.” To apply the guidelines consistently, we may need to adjust our own thinking and recognize today’s realities.

Patients need a clear message

But most important is the mixed message to patients. As Dr. Waxman acknowledges, patients have come to equate their annual visit with a Pap test—evidence of a successful public awareness effort since 1975, when an ACOG Technical Bulletin recommended the annual test. Every clinician would agree with Dr. Waxman that we must teach our patients that the value of the annual exam is not limited to cervical cytology screening.

But that is easier said than done. A massive campaign to raise awareness of the importance of annual exams is needed before we can expect patients to be comfortable with less frequent Pap testing.

As with most controversies, the answer probably lies somewhere in the middle.

Tell patients: Don’t stop annual exams

I use a hybrid approach. For a patient who has no history of cervical disease, I suggest that we forgo the Pap test for 1 year if she is older than 65 and sexually inactive, or, if she is younger than 65 and sexually active with a single partner.

However, I carefully point out to these patients that, although their risk is low, their annual visit is still important.