Although at least some epidemiologic data support Pap testing as frequently as every two to three

years, annual testing appears to be of limited additional benefit in lowering mortality. It has been
estimated that screening women aged 20 to 64 every thee yeers reduces the cumulative incidence of
invasive cervical cacer by 91 percent, requires about 15 test per woman, and yields 96 caes of
cervical cancer for every 100,000 Pap smears. Annual screening reduces incidence by 93 percent
but requires 45 tests per woman and yields only 33 cases of cervical cancer for every 100,000 tests
Annual testing, however, is common. A survey of recetly trained gynecologists found tha 97
percent recommend that women have Pap tests at least once a year. The preference of many
clinicans for annual Pap smears is based on concerns that less frequent testing may result in more
harm than goog, but reliable scientific data to support these concerns are lacking. Specifically,
advocates of annual testing have expressed concerns that data demonstrating litle added value in
annual tests are based on retrospective studies and mathematical models that are subject to biases
and invalid assumptions; that an interval longer than one year may permit aggressive, rapidly
growing cancers to escape early detection; that women may obtain Pap smears at an even lower
frequency than that publicized in recommendations; that a longer interval might affect compliance
among high-risk women, a group with poor coverage ever with an annual testing policy; that
repeated test ing may offset the false-negative rate of the Pap smear; that the test is inexpensive and
safe, and that a lange proportion of women believe it is important to have an annual Pap test and,
while visiting the clinician, may receive other preventive interventions. Definitve evidence to
support these concerns is lacking.
Women who do not engage in sexual intercounrse are not at risk for cervical cancer and therefore
do not require screening. In addition, screning of women who have only recently become sexually
active (e.g.,adolescents) is likely to have low yield. The incidence of invasive cancer in women
under age 25 is only about one to thee per 100,000, a rate much lower than that for olden age
groups. One study found that most women with cervical intraepithelial neoplasia who had become
sexually active at age 18 were not diagnosed as having severe dysplasia or carcinoma in situ until
age 30.
Although invasive cervical cancer is uncommon at young ages, a numer of authorities advocate
initiating screening with the onset of sexual activity. This policy is based in part on the concern that
a proporton f youg women with cervical intraepithelial neoplasia may have an aggressive cell type
can unprogress rapidly and undetected if screeing is delayed. The axact incidence and natural
history of aggressive disease in young women remains incertain, however.
Another reason given for early screening the concern that the incidence of cervical dysplasia in
young women appers to be on the rise, concident with the increasing sexual ativity of adolescents.
On these grounds, testing should begin by age. Screening in the absence of a history of sexual
intecourse may be justified if the credibility of the sexual history is in question.
When screening is initiated, it is frequently recommended that the first two to three smears be
obtained one year apart as a means of dedecting aggressive tumors at a young age. There is little
evidence to suggest, however, that young women whose first two test are separated by two or three
years, rather than one year, have a greater mortality or person-years life lost. Recomendations to
perfom these first tests annually are basesd primarily on expert opinion.
Elderly women do not appear to benefit from Pap testing if repeated cervical smears have
consistently been normal. Many olden women have had inadequate screening, howeve;nearly half
of women over age 65 have never receinved a Pap test and 75 percent have not receiver regular
screening. Screnning beyond age 65 in this group of older women is important and has been shown
to be cost-effetive.
The effectiveness of cervical cancer screening is more likely to be improved by extending testing
to women who are not currently being screened and by improving the accuracy of Pap smears than
by increasing the frequency of testing. Studies sruggest that those at greatest risk for cervical carcer
are the very women least likely to have access to testing. Inadequate Pap testing is most common
among blacks, the poor and the ininsured, the elderly and those living in rural areas. Inaddition,
many women who are tested receive inaccurate results because of interpretive or reporting errors

made by clinicians. The failure of some physicians to provide adequate follow-up for abnormal Pap
smears is another source or delay in the management of cervical dysplasia.
Clinical Intervention
Regular Pap smears are recommended for all women who are or have beer sexually active.
Testing should begin when the woman first engages in sexual intercourse. Adolesents whose sexual
history is thought to be unreliable should be presumen to be sexually active at age 18. Pap tests are
appropriately performed at an interval of one to three years, to be recommended by the physician on
the basis of risk factors (e.g., early onset of sexual intercourse, history of multiple sexual partners,
low socioeconomico status). Pap smears may be discontinued at age 65, but only if the physician
can document previous Pap screening in which smears have been consistently normal. Physicians
should submit specimens to laboratories that have adequate quality control measures, to ensure
optimal accuracy in the interpretation and reporting of results should also be ensured.