Bradley J. Monk, MD:
Dr. Jin, thank you.  That was very, very succinct.  You obviously put in a lot of time to teach us about the new guidelines.  As you were saying all that, it struck me, why do we need new guidelines?  What was wrong with the old guidelines? Give us a little bit of the rationale as to why all of this works, why we are here today, why new guidelines?  

Xian Wen Jin, MD:
That is an excellent question.  In the last decade, we have had a growing body of evidence that suggests that HPV is the cause of cervical cancer.  By adding HPV testing to screening, it really added the value of high sensitivity to detect precancerous lesions, and it offers a very excellent negative predictive value.  

As you mentioned earlier, if there is no HPV in the cervix, then the risk of having cervical cancer is basically not there.  Therefore, the new guidelines are based on the large evidence of science.  

It also leads us to conclude that less is more.  

• We start screening later, at the age of 21.
• We will screen women from 21 to 29 years old every 3 years instead of two.
• Then in women age 30 all the way to 65, if both tests are negative, the screening interval can be extended to every 5 years.
•  Women over age 65 really should not continue to have cervical cancer screening if prior adequate screening has been done.  
  

So that is why we have this new set of updated guidelines. 

Bradley J. Monk, MD:
And I guess the way I look at it, as I hear you talk, is that the older, previous guidelines were that if you had a negative Pap and a negative HPV, you could wait three years.  But these data, these large randomized trials that you so nicely reviewed, have matured and we have found that the protection is longer than 3 years.  So, if you are age 30 and older, you can now have 5 years of protection rather than 3.  In my mind, that is probably why these guidelines needed to be updated.

The thing that impressed me personally is also that we brought people together.  You know, the cervical cancer screening world is not always in agreement, but here it is.  The American Cancer Society, U.S. Preventive Services Task Force, American College of Obstetricians and Gynecologists, ASCCP, ASCP.  Everybody agrees.  So, I think now that we have consensus, we can really begin to save money, and also save lives.  

Xian Wen Jin, MD:
Correct.  This is the first time these organizations have come together and issued basically a Consensus Guideline as of March 2012.

Bradley J. Monk, MD:
I had another question.  You said that HPV testing is better than the Pap, right?  I mean, I think so.  So, if HPV testing is better than the Pap, do we need to do both?  Maybe we just need to move to HPV testing, forget about the Pap and that would save more money.  What do you think?

Xian Wen Jin, MD:
That is another excellent question.  I think that we need to understand the HPV test is better in terms of sensitivity of detection of CIN 2 or worse lesions…  

Bradley J. Monk, MD:
The lesions that we would treat; the lesions that cause cancer, right?  

Xian Wen Jin, MD:
Yes.  However, the HPV test does not have excellent positive predictive value.  In other words, if you test HPV positive, it does not say this woman is going to have disease.  In contrast, our cytology Pap smear has a very high specificity, which means that if we see some abnormal changes that really means something.  

Therefore, at the present time, our best screening strategy is to rely on both.  Take advantage of the high sensitivity of HPV testing, and the high specificity offered by cytology.  That seems to be the best approach.  

Nancy R. Berman, MD:
Dr. Jin, the guidelines were first published after approval in March 2012.  How have you found implementation in your setting to go?  We know that there can be resistance among both patients and clinicians to do less screening.

Xian Wen Jin, MD:
Absolutely, Nancy.  You brought up a very good point because the guidelines are very new.  As a matter of fact, at the Cleveland Clinic, we are just in the process of implementing the new guidelines, and it takes time.  Certainly,  implementation of the new guidelines will raise new questions from both providers and our patients. Education and effective communication are the key elements in implementation of any new practice guidelines.  

Nancy R. Berman, MD:
Do you see that patients are accepting when they come in and you tell them, ”I will not be doing a Pap this year.  You do not need it.”  Are you getting resistance?

Xian Wen Jin, MD:
Certainly there are women that have those questions.  They are so “trained” to have an annual Pap smear.  And some of our providers are so used to practicing the way they we have practiced for many, many years.  But I think there is ample opportunity for a clinician to educate patients,  and talking about what scientific evidence has taught us in terms of:  1) how we risk-stratify women; 2) not wanting to find and treat transient infection - a low-grade lesion that may go away by itself.  We certainly want to identify those women who at risk down the road for developing cervical disease or cervical cancer by the best screening strategy.