As discussed earlier, the high rates of HPV and abnormal cytology in adolescents began the movement to screen all sexually active women including young adolescents in the United States (9-11). The guidelines also proposed that once screening was initiated, if three consecutive annual Pap smears were normal, screening intervals could be extended to every 3 years except for "high risk" women who should be screened annually. All adolescent women who are sexually active are often considered high risk (9) because adolescents have the highest rates of STIs including Neisseria gonorrhoeae and C. trachomatis (3,47,48). The low sensitivity of a single smear fueled the recommendations for early and frequent screening (49). However, new data suggest that even if adolescents are not screened within 3 years after the onset of sexual activity the chances of any HPV progressing to carcinoma-in situ are extremely rare. Whereas, screening and discovering abnormal cytological smears create unnecessary referrals.
Although, most care providers agree that cervical cancer screening in adolescents yield low benefits, the age limit to begin screening remains controversial. The American Cancer Society's Committee upper age limit of 21 years was primarily based on expert opinion. Using mathematical modeling as reported in Saslow's report for the American Cancer Society (12) the most cost effective HPV testing strategy is to start screening 3 years after the age of sexual onset, with a cap at 25 years. In theory this would catch more than 97% of young women. In the United States, 21 years of age was considered a more realistic age for compliance and access to patients, particularly, in the absence of an organized screening system. The safety net is there for providers who do not ask and for young women who do not answer the question about when they initiated sexual intercourse. In countries with organized screening, such as the United Kingdom, new recommendations where to start screening at 25 years (49a). In contrast, Australia recommends a screening interval of 2 years for women who have had no symptoms or history suggestive of abnormal cytology commencing between the ages of 18-20 years or 1-2 years after first sexual intercourse, whichever is later (49b). Clearly, some cases of invasive cancer are missed when screening begins after 20 years of age.
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