AEGiS-GMHC: Screening for Cervical Cancer

Important note: Information in this article was accurate in 1994. The state of the art may have changed since the publication date.

Screening for Cervical Cancer

Gay Men's Health Crisis "Treatment Issues" Vol. 8, No. 11 - December 1994
Amy Fusselman

Defining the best way to screen HIV-positive women for cervical cancer has long been a matter of debate. Medical reports through the years have documented that women with HIV have a greater risk of cervical cancer and that such cancer progresses more rapidly and tends to recur after treatment. The standard method for detecting abnormalities that might develop into cervical cancer is the Pap smear, a simple procedure consisting of swabbing the cervix to obtain a sample of cells which are then examined under a microscope. Unfortunately, the accuracy of Pap smears has been called into question, particularly in the case of women with HIV. These women frequently have lower genital tract infections that may obscure Pap results. One 1991 report1 from the State University of New York Health Science Center in Brooklyn found not only that the incidence of cervical tissue abnormalities increased with worsening immunosuppression but that Pap smears detected these abnormalities in only three of the 32 women in the study. Colposcopy, a more discriminating procedure, detected cervical problems ranging from inflammation to precancerous lesions in another 22 of the women.

In colposcopy, a low-power microscope (colposcope) is used to examine the cervix, and if suspect tissue is observed, small pieces are removed (biopsied) for further evaluation. Although colposcopy traditionally serves only as a corroborative test in women with abnormal Pap smears, the authors in 1991 urged that "cervical colposcopy be part of the routine management of HIV-seropositive women" regardless of the findings of previous Pap smears.

Colposcopy versus Pap Smear

When the Centers for Disease Control and Prevention (CDC) began drafting gynecological guidelines for HIV-positive women last year, the CDC's advisory group had to choose between a schedule of regular Pap smears and/or colposcopy. The agency settled on recommending repeat Pap smears as a way of countering false-negative individual Paps. The CDC said that care providers should perform a baseline Pap smear as part of the initial gynecological exam for women with HIV. If the results are normal, another Pap smear should be performed in six months, and after that, annually. If the results of the baseline Pap are abnormal, the CDC still recommended that women wait another six months for another Pap. If a woman's second Pap smear also is abnormal, providers should refer the woman to a trained clinician for colposcopy.

Upon hearing the guidelines, many AIDS activists feared that HIV-positive women who had to wait six months or more for testing of abnormal Paps would risk contracting life- threatening cervical cancer -- now regarded as a totally preventable disease. In the effort to ensure prompter, more effective care, many activists insisted on colposcopy examination for all HIV-positive women.

Three medical studies published this year, though, have found that Pap smears in HIV-positive women are just as accurate as those in HIV-negative women. When properly conducted, Pap smears furthermore seemed almost as accurate as colposcopy in detecting the early signs of potential cervical cancer, even in women with HIV. The largest of these recent studies2 was reported in October. It involved 398 women with HIV and 357 without. Twenty percent (70) of the HIV-positive women had precancerous cervical lesions compared to five percent (fifteen) of the HIV-negative women. Fifteen of the women with HIV had lesions detectable only by colposcopy and biopsy. The other two smaller studies found similar results.[3,4]

Strategy over Technique

But the issue is deeper than just one tool versus another. In the Abner Korn study cited above, twelve of 38 HIV-positive women with scheduled appointments for further gynecological care never showed up and were lost to follow-up. Such poor relations between doctors and their patients cast doubt on the practicality of the repeat Pap smear approach.

Howard Minkoff, M.D., a gynecologist at State University of New York's Brooklyn center commented "I don't think the case is proven that regular pap smears are less effective than colposcopy Any surveillance system will work as long as it is rigorous and regular."

Marion Banzhaf executive director of the New Jersey Women in AIDS Network, had a suggestion for how "rigorous and regular surveillance" could be better assured. "I don't want to abandon the fight for colposcopies," she said, "but at the same time, we're still at square one in dealing with access. The women I work with have a hard enough time getting gynecological care in the first place." The first item Banzhaf would address is "incorporating GYN into HIV primary care -- basically giving a more realistic approach to the body."

Risa Denenberg, a family nurse practitioner in the AIDS Clinic at New York's Bronx Lebanon Hospital, extended Banzhaf's remarks: "Cervix cancer, like PCP, is a preventable disease. And like PCP, a case of cervix cancer represents not an individual failure, not a medical failure, but a system failure. We need to work towards a consensus that all women should receive their gynecological care in the context of receiving their primary care. And for HIV-positive women, we must agree that the appropriate standard of care is having a Pap smear every six months, and that all HIV-positive women with abnormal Pap smears need to receive colposcopy immediately. That is, within six weeks. We are no way near achieving this standard."

Denenberg continued, "If we now demand that all HIV-positive women receive a colposcopy as a screening test for cervix cancer, we fail women in two very important ways: one is that we are letting primary care providers who don't want to do Pap smears anyway off the hook; and, two, we will make HIV- positive women -- who are at the greatest risk of cervix cancer -- wait even longer for an evaluation."

Colposcopy requires specialized training as practitioners must attain the skill to visually recognize diseased tissue through the colposcope lens. There are not enough expert colposcopists at present to regularly examine every women with HIV, and this exam will always have to take place separately from other medical procedures. As a practical matter, it may be more effective to educate women to demand and create the best conditions for successful use of the low- tech Pap smear than to pour resources into the more sophisticated colposcopy technique. (See box, page 5.)

References

1. Maiman M et al. Obstetrics and gynecology. Jul 1991; 78(1):84-8.

2. Wright TC et al. Obstetrics and gynecology. Oct 1994; 84 (4 part 1):591-7.

3. Korn AP et al. Obstetrics and gynecology. Mar 1994; 83(3):401-4.

4. Brosgart C et al. Tenth International Conference on AIDS. Aug 1994; I(abstract 079B):26

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