Cervical Cancer and CVD Screening Guidelines: Important Points to Consider
A number of new guidelines and statements affecting women’s health were issued within the past year. Among them were the 2018 US Preventive Services Task Force (USPSTF) cervical cancer screening recommendation statement and the 2018 American College of Cardiology (ACC) and American Heart Association (AHA) cholesterol management guidelines.
However, certain parts of the guidelines may require clarification, says Melissa McNeil, MD, MPH, chief of the Section of Women’s Health in the Division of General Internal Medicine at the University of Pittsburgh.
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Dr McNeil discussed the guidelines further in an update on women’s health at the 2019 American College of Physicians Internal Medicine Meeting in Philadelphia, Pennsylvania.1 Consultant360 spoke with Dr McNeil about interpreting the new guidelines and how they may impact screening for these conditions.
Cervical Cancer Screening
In August 2018, the USPSTF issued a recommendation statement for cervical cancer screening.2 In its statement, the USPSTF recommended screening every 3 years with cervical cytology alone, every 5 years with high-risk HPV (hrHPV) testing alone, or every 5 years via co-testing (hrHPV testing in combination with cytology) in women aged 30 to 65 years.2
However, despite this recommendation, it remains unclear that the option of hrHPV testing alone is superior to co-testing with hrHPV and cervical cytology, Dr McNeil told Consultant360.
HrHPV screening alone will likely detect the same number of cervical cancers compared with co-testing, but likely at the cost of more “false-positive” test results, leading to more callback tests, Dr McNeil explained. Typically, this is where co-testing with cytology can help determine next steps in terms of testing.
“Some hrHPV resolves on its own and does not require treatment, and typically cytology can help clarify whether further testing is needed. However, with the new guidelines that recommend hrHPV testing alone as a screening option, it is a bit unclear what the follow-up algorithm should be when abnormal cervical specimens are detected,” she said.
Dr McNeil noted that in the future, performing cytology alone in HPV-positive individuals may serve as a reasonable alternative, but when to implement hrHPV testing alone and the follow-up procedures for this screening strategy will likely need clarification in future guidelines.
Cardiovascular Disease Screening
The ACC and AHA, along with 10 other organizations, released new clinical practice guidelines for cholesterol management in November 2018.3 One of the guideline’s 10 recommendations is for clinicians to initiate statin therapy in adults aged 40 to 75 years without diabetes mellitus, with an intermediate 10-year atherosclerotic cardiovascular disease (ASCVD) risk, and with additional risk-enhancing factors.3
Notably, the intermediate 10-year ASCVD risk category was expanded. Now, it is defined as 7.5% to 19.9% risk in the new guidelines.3
“The intermediate 10-year ASCVD risk category in the new guidelines is a very large interval,” Dr McNeil told Consultant360. “The million-dollar question is, who in that group would benefit from early initiation of statin therapy?”
One factor that can aid in triaging who should and should not receive statin therapy after calculating ASCVD risk score is reproductive history, said Dr McNeil. Conditions unique to women including eclampsia, preeclampsia, and gestational hypertension are all markers of early CVD.
Women without diabetes who have an intermediate risk profile and one additional CVD risk factor, as determined by taking reproductive history, would likely benefit from statin therapy, Dr McNeil said. However, she noted, this patient population may still benefit from additional testing prior to initiating a statin to ensure its necessity.
“Further risk assessment with a low-radiation coronary artery calcium (CAC) scan can help prevent overtreatment in this patient population. In my own practice, I have patients with an intermediate risk profile and one additional risk factor – such as preeclampsia – undergo CAC screening. If a patient’s CAC score is above 0, I will usually start a statin,” said Dr McNeil.
—Christina Vogt
References:
1. McNeil M, DiNardo D. Update in women’s health. ACP Internal Medicine Meeting 2019; April 11, 2019; Philadelphia, PA.
2. US Preventive Services Task Force. Screening for cervical cancer: US Preventive Services Task Force recommendation statement. JAMA. 2018;320(7):674-686. doi:10.1001/jama.2018.10897.
3. Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol: executive summary. J Am Coll Cardiol. 2018. doi:10.1016/j.jacc.2018.11.002.