张羽大夫的个人网站 zhangyupumch.haodf.com

本站已经通过实名认证,所有内容由张羽大夫本人发表

当前位置: 北京协和医院 > 张羽 > 文章列表 >ACOG2009宫颈癌筛查的最新指南意见

学术前沿

ACOG2009宫颈癌筛查的最新指南意见

发表者:张羽 人已读

美国妇产科大学(ACOG)发表于20091120日,关于宫颈癌筛查的最新指南意见

北京协和医院 张羽

    宫颈部位的恶性肿瘤称为宫颈癌,宫颈位于阴道的顶端,该生理解剖部位不像深藏在盆腔的子宫,也不像需要B超、CT才能看到的心脏,肺脏和肝脏,它非常容易通过医生简单的阴道窥具检查得以暴露和直视,所以定期进行宫颈脱落细胞的细胞学筛查实验,可以发现非常早期的癌前病变,并且通过现有的医疗技术彻底治愈癌前病变,从而防止宫颈癌的发生。近年来,随着国内医学领域的不断进步,广大人民群众健康保健意识的不断提高,以及广大医务工作者大声疾呼,很多成年女性都知道需要定期进行妇科检查,也知道妇科检查时需要进行宫颈的细胞学筛查。     北京协和医院妇科张羽

    以前,我在出门诊的时候,需要反复动员我的患者拿出150块钱,进行一次宫颈的“防癌”检查,很多患者根本不明白这是什么化验,自己从前也从来没做过,甚至没听说过,即使勉强答应,也经常会在知道了自己还需要等待一个礼拜才能拿到化验报告后,拂袖而去,拒绝检查。最近几年的情况好了很多,很多健康妇女会主动挂号,要求进行防癌检查,这也是近年来我们能够在临床上发现和诊断更多的早期病变的原因,作为一个妇产科医生,这是非常值得欣慰的社会现象,但是,临床中,也通常会有一些不适当的观念,例如,过于频繁的进行防癌检查,我见过每年要检查两次以上的健康妇女,或者短时间内在不同的医疗单位进行频繁复查的情况,或者认为一次防癌检查可以保护终生的想法,这些都是对宫颈癌筛查不正确的解读。

    今天读到美国关于妇女宫颈癌筛查的最新指南意见,发表于2009年11月20日,非常新的信息,所以今夜挑灯夜战,将其精华部分翻译出来,并且略加了一些能够让大众看懂的解释,发表在此,以飨读者。相信,在不久的将来,我们国家针对我们自己的国情,以及亚洲人宫颈癌疾病的特点也会很快更新和修订我们自己的指南意见,供广大妇女同胞参考。

Level A

1.宫颈癌的筛查应该从21岁以上的妇女开始,不要开始过早,以免在低危人群中带来不必要的恐慌,以及不必要的治疗。

2.21-29岁年龄段的妇女,应该每两年进行一次筛查。

3.30岁以上妇女,如果没有CIN 2 或者 CIN 3,不是艾滋病病毒感染者,不处于免疫抑制状态(例如免疫病或者器官移植后患者,需要长期服用免疫抑制剂),没有子宫内的DES暴露史(通常指,本人的母亲在妊娠期曾经接受过不适当的雌激素治疗病史),而且连续三次筛查结果都正常,可以将筛查的间隔改为每三年一次。

4.可以选择的筛查方法,包括TCT和传统的巴氏涂片。 

5.如果妇女因为良性病变(子宫肌瘤,或者良性的卵巢肿瘤)已经切除了子宫,而且既往没有高级别宫颈病变的历史,可以不再进行宫颈癌的筛查。

6.对于30岁以上的妇女,最佳的筛查方式是同时进行细胞学筛查(TCT)和宫颈HPV病毒检测,如果两项结果都正常,属于宫颈癌的低危人群,筛查的间隔最好在三年以上。

Level B

1.已经开始性生活,而且处于性活跃状态的21岁以下的青年女性,应该针对性传播疾病以及性行为的安全,避孕方法等进行咨询,不需要进行宫颈癌的筛查,如果没有症状,也没有必要使用窥具进行阴道检查。

2.对于65-70岁的老年妇女,如果连续三次筛查结果正常,而且在过去10年里,没有过异常的检查结果,可以停止宫颈癌的筛查。

3.既往有过CIN2-3或者宫颈癌的治疗病史的患者,应该坚持每年进行宫颈癌筛查,至少20年。

4.既往有过CIN2-3的患者,即使已经切除了子宫,仍应该坚持进行宫颈癌筛查。

Level C

1.即使不必每年进行宫颈癌的筛查,但是女性仍然应该每年进行一次妇科检查。

2.接种过HPV-16 和HPV-18疫苗的青少年,一旦开始了性生活,应该和未接种者一样,遵循以上的筛查指南。

 

原文如下,英文好的患者可以自己全面阅读。

 

ACOG Issues Revised Cervical Cancer Screening Guidelines

Laurie Barclay, MD

November 20, 2009 — First cervical cancer screening should be at age 21 years, and rescreening can be less frequent than previously recommended, according to newly revised evidence-based guidelines issued by the American College of Obstetricians and Gynecologists (ACOG). The ACOG\"s Committee on Practice Bulletins—Gynecology was posted online November 20 and will appear in the December print issue of Obstetrics & Gynecology.

Less Frequent Screening

The revised recommendations now call for cervical screening once every 2 years vs annually for most women younger than 30 years and once every 3 years for most women 30 years and older.

"The tradition of doing a Pap [Papanicolau] test every year has not been supported by recent scientific evidence," lead author Alan G. Waxman, MD, from the University of New Mexico in Albuquerque, said in a news release. "A review of the evidence to date shows that screening at less frequent intervals prevents cervical cancer just as well, has decreased costs, and avoids unnecessary interventions that could be harmful."

Either the standard Pap test or liquid-based cytology is suitable for all cervical cancer screening. Instead of annual screening, the ACOG now recommends that women aged 21 to 30 years who not at high risk be screened every 2 years and that women 30 years and older may be screened once every 3 years if they have had 3 consecutive negative cervical cytology test results.

Risk factors that may indicate the need for more frequent screening include HIV infection; immunosuppression; diethylstilbestrol (DES) exposure in utero; and treatment of cervical intraepithelial neoplasia (CIN) 2, CIN 3, or cervical cancer.

ACOG\"s earlier recommendation was to begin cervical cancer screening 3 years after first sexual intercourse or by age 21 years, whichever occurred first. To avoid economic, emotional, and future childbearing implications of unnecessary treatment of adolescents, ACOG has now moved the baseline cervical cancer screening to age 21 years.

The rationale is that invasive cervical cancer is very rare in women younger than 21 years, although the rate of human papillomavirus (HPV) infection is high among sexually active adolescents, because the immune system in most adolescent women clears the HPV infection within 1 to 2 years. In addition, adolescents have a higher incidence of HPV-related precancerous dysplasia because the cervix is immature, but most of these lesions resolve spontaneously without treatment.

Women treated with excisional procedures for dysplasia have recently been shown to have a significant increase in premature births.

"Adolescents have most of their childbearing years ahead of them, so it\"s important to avoid unnecessary procedures that negatively affect the cervix," Dr. Waxman said. "Screening for cervical cancer in adolescents only serves to increase their anxiety and has led to overuse of follow-up procedures for something that usually resolves on its own."

Regardless of age, women who have had a total hysterectomy for benign conditions and who have no history of high-grade CIN should discontinue cervical cancer screening.

The upper age limit for discontinuing cervical screening remains the same in the revised ACOG\"s guidelines, which recommend stopping cervical cancer screening at age 65 or 70 years for women who have at least 3 consecutive negative cytology results and no abnormal test results in the previous 10 years.

Women vaccinated against HPV should follow the same screening guidelines as unvaccinated women, according to the revised guidelines.

Revised Guidelines

Specific ACOG recommendations in the updated guidelines, based on good and consistent scientific evidence (level A), are as follows:

  • Cervical cancer screening should begin at age 21 years and should be avoided at younger ages, when it may result in unnecessary and harmful workup and treatment in women who are at very low risk for cancer.

  • For women aged 21 to 29 years, cervical cytology screening is recommended every 2 years.

  • The interval between cervical cytology examinations may be extended to every 3 years for women at least aged 30 years who have had 3 consecutive negative cervical cytology screening test results and who have no history of CIN 2 or CIN 3, HIV infection, immunocompromised state, or DES exposure in utero.

  • Acceptable screening techniques are liquid-based and conventional cervical cytology methods.

  • Routine cytology testing should be discontinued in women who have had a total hysterectomy for benign conditions and who have no history of high-grade CIN.

  • For women older than 30 years, an appropriate screening test is cytology combined with HPV DNA testing. When both these test results are negative in a low-risk woman 30 years or older, rescreening should be performed no sooner than 3 years later.

Specific ACOG recommendations in the updated guidelines, based on limited and inconsistent scientific evidence (level B), are as follows:

  • Sexually active women younger than 21 years should be counselled and tested for sexually transmitted infections and should be counselled regarding safe sex and contraception. Cervical cytology testing is not necessary, and speculum examination need not be performed in asymptomatic women.

  • Cervical cancer screening can be discontinued between the ages of 65 and 70 years in women who have 3 or more consecutive negative cytology test results and no abnormal test results in the past 10 years because cervical cancer develops slowly, and risk factors decrease with age.

  • Women previously treated for CIN 2, CIN 3, or cancer remain at risk for persistent or recurrent disease for at least 20 years after treatment and after initial posttreatment surveillance. This group should therefore continue to be screened annually for at least 20 years.

  • Even after the period of posttreatment surveillance, screening should continue for women status post hysterectomy with removal of the cervix who have a history of CIN 2 or CIN 3, or in whom a negative history cannot be documented. In this patient group, there are no good data to support or refute discontinuing screening.

Revised ACOG recommendations, based primarily on consensus and expert opinion (level C), are as follows:

  • Physicians should inform their patients that annual gynecologic examinations may still be appropriate regardless of the frequency of cervical cytology screening, even if cervical screening is not performed at each visit.

  • Women who were vaccinated against HPV-16 and HPV-18 should follow the same screening guidelines as nonvaccinated women.

A proposed performance measure recommended by ACOG is the percentage of women aged 21 to 29 years who have received a Pap test within the past 2 years.

Obstet Gynecol. Published online November 20, 2009.

问医生

与医生电话交流 开始

网上免费问医生开始

预约就诊

发表于:2009-11-25 23:10

张羽大夫的信息

  • 感谢信: 0 感谢信 礼物: 0 礼物
  • 贡献值: 0

张羽大夫电话咨询

张羽大夫已经开通电话咨询服务
直接与大夫本人通话,方便!快捷!

网上咨询张羽大夫

张羽的咨询范围: 子宫腺肌症、有出血/疼痛/压迫症状/有备孕计划的子宫肌瘤

咨询张羽大夫