How to decrease your risk for cervical cancer

We do know, though, that persistence of high-risk HPV is worrisome.  And the older we are when we get it, or the longer we have it, the more at risk we become for cervical cancer.  

Will a Pap smear indicate if HPV is present? 
The Pap smear detects changes in the cervical cells that occur as a result of persistent viral infections. Liquid Pap smears, in which the cells are placed in a solution and filtered (so that they can be separated and stained) can also be used for “reflexive HPV testing.” This means that if mildly suspicious changes in the cells are noted, the leftover fluid is checked for HPV viruses.

If high-risk viruses are present, the doctor is notified and further testing with colposcopy (a special microscope that allows a physician to better view the cervix) and biopsy is indicated.  However, if more severe pre-cancerous changes are found in the Pap, it’s not necessary to do HPV testing since we assume that this will be positive. 

If all “bad” Pap smears are due to HPV infection, should women just get HPV testing and forego Pap smears?
There are indeed studies that show that testing for HPV is more sensitive than cervical cytology (the Pap smear) for the detection of pre-cancerous cells and cervical cancer. And when the HPV test is combined with a Pap smear it has what we call a negative predictive value of 99 percent to 100 percent. That means that the chance of missing a pre-cancer or cancer is approximately 1 in 1,000 (which is exceptional when we are talking about a screening test). But right now this is not generally considered the way we should screen younger woman (under 30) who are less likely (than those over 30) to be in stable, long-term relationships.  These women will have too many positive HPV results. However, if a woman over 30 in a stable relationship is negative for HPV and also has a normal Pap smear, and she is low risk (i.e. she and her partner are monogamous, she never had an abnormal pap, doesn’t smoke, doesn’t take steroids, and was not DES-exposed during her mother’s pregnancy), these two negative tests virtually assure her that nothing has been missed. She doesn’t need to repeat cervical cancer screening for three years.  

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If we know HPVs cause cervical cancer, will vaccines against HPV prevent it? 
Currently, vaccines against several of the most high-risk types of HPVs are being investigated.  Preliminary results show that they can prevent persistent viral infection and subsequent pre-cancerous changes. The hope is that, in the future, pediatricians and those caring for adolescents will be able to give a protective vaccine before any exposure to HPV (in other words, before this young population becomes sexually active) and thus virtually eliminate cervical cancer.  One of these vaccines may be submitted for FDA approval by the end of 2005. 

So what should women do to ensure that they get an A+ in their cervical-cancer screening? 
Here is the schedule that is currently recommended:

• Screenings for younger women: Start three years after the onset of intercourse and no later than age 21.
• Between 21 and 30: Repeat every year (conventional non-liquid Pap smear) or every one to two years (liquid-based Pap test)
• Over 30: Repeat liquid Pap every two years if “low risk” and have had three normal consecutive Pap smears. HPV screening should also be considered to establish that the result is conclusive. If this and Pap smear are negative, and “low risk” status continues, repeat in three years.
• After 70:  Stop Pap smears if had three normal Pap tests and no abnormal results in the last 10 years.
• After hysterectomy:  No need for Pap smear if hysterectomy was done for benign disease and the cervix was removed.

Dr. Reichman’s Bottom Line: Let’s remember that since Pap smears were introduced more than 50 years ago, cervical cancer mortality rates in the United States have decreased by 75 percent.  (In addition, half of the cervical cancers in the U.S. occur in women who have never been screened, and another 10 percent occur in women who have not been screened in the past 10 years.)  So let’s not discard a test that saves lives.  For those women who want further guarantees that they can safely wait between Pap smears, adding HPV testing is appropriate.  And perhaps in the future, HPV testing alone will become the standard method used to determine who should get a Pap smear and how often it should be performed. Better yet, future vaccines may free a new generation of women from cervical-cancer concerns. 

Dr. Judith Reichman, the “Today” show's medical contributor on women's health, has practiced obstetrics and gynecology for more than 20 years. You will find many answers to your questions in her latest book, "Slow Your Clock Down: The Complete Guide to a Healthy, Younger You," published by William Morrow, a division of HarperCollins. 

PLEASE NOTE: The information in this column should not be construed as providing specific medical advice, but rather to offer readers information to better understand their lives and health. It is not intended to provide an alternative to professional treatment or to replace the services of a physician.

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