Saturday, December 10, 2011

Women Don't Need As Many Pap Tests

Women have been told they should have screening for cervical cancer with a pap test every year.  The visit to the gynecologist or internal medicine physician has been a right of passage for most young women and most are very compliant with that annual visit throughout their lives.

Well, the times they are a-changin' because new guidelines issued by the US Preventative Services Task Force and the American Cancer Society say women should undergo screening NO MORE OFTEN than every 3 years starting at age 21.  To further strengthen this recommendation, even the American Society for Clinical Pathology (those folks that read the pap smears) agrees with the recommendation.  They also recommending stopping routine pap smears after age 65 for women who have had 3 negative Pap test results in the past 10 years.  These women are just not at high risk.

So why the change?

The pap smear is a screening test for cervical cancer.  Evidence shows that more frequent screening than every 3 years doesn't find more cancer and we now know that cervical cancer is the result of infection with Human papillomaviruses (HPVs).  Women that have not been exposed to HPV are not at risk of cervical cancer.  Furthermore, out of 150 related viruses, of which 40 are sexually transmitted, only certain ones are high-risk, oncogenic (or carcinogenic) HPVs.    Persistent infections with these high-risk HPV types can cause cell abnormalities that are picked up on pap tests.  But the majority of infections with even high-risk HPV types go away on their own and do not cause cancer.  Two types of HPV (types 16 and 18) cause 70% of all cervical cancers and they are very slow growing.

When a pap test detects cervical cell changes, an HPV DNA test is usually done.  If the HPV test is negative, a women is safe from cervical cancer for many years.    Even if a pap test shows equivocal changes, if the HPV test is negative, it is recommended she be re-tested in 3 years.

Despite these recommendations, annual testing remains a common practice in most gynecology offices.  Even in women who have been tested for HPV and found negative, less than 15% of physicians recommended that patients wait 3 years before repeat testing.  Women are still being told to come back annually.

Why?

Some doctors may not know about the guidelines, even though they are also supported by the American College of Obstetricians and Gynecologists.  Doctors as well as patients are in the habit of "the annual pap test".  Doctors are also concerned that if they don't recommend pap smears, women will not come in for an annual exam and other preventive screening.   But doing unnecessary testing is not a way to have women come in.

For most women this will be a welcome change.  Stretching out those gynecologic screening exams will save time, money, false positive tests and unneeded follow-up.   Keep in mind this only refers to non-symptom screening.  Women who have any gynecologic symptoms (unusual bleeding, discharge, pain, pressure) or any other  concern or questions should see their physician.

7 comments:

Dr Paula said...

Good post. ACOG published these guidelines in December, 2009 but there are still a lot of unnecessary tests and procedures.

There is confusion among patients who believe they do not have to come in at all but this is remedied with a little education.

Anonymous said...

Fascinating post. I didn't know this and have been going to gyne every year for decades!!!! Never had an abnormal pap.

Margaret Polaneczky, MD (aka TBTAM) said...

Great post, Toni. I love that we are backing off on one size fits all gyn screening. And not doing paps on teens.

Liz said...

i call this good news.

http://pocketshrink.blgospot.com

Linda F Slawson said...

And women who have had a hysterectomy with surgical removal of the cervix do not need Pap screening either. Vaginal cancer is very low risk especially in women who have not been exposed to HPV and are in stable relationships.

Anonymous said...

when women are told not to come in or come in every three years the testing is pushed aside. this is the same for all types of tests,example when men needed a PSA test for prostate screening.
when its down to money,liability and good preventive medicine,the money wins out.
all they had to do was limited the claims on liability since a pap is a screening process and limit the cost of insurance on OBGYN DOCS.

they refused and the government fell down on its part of the equation....a total failure.
so who cares if women come down with tumor..will cut it out and burn the tissue. the patient will comeback or visit the obgyn doc with a more severe lesion

Elizabeth (Aust) said...

Our program is now more than a decade behind the evidence and is harming women. It is awful to watch doctors knowingly risking their patients health and then collecting target payments for their trouble. Most women are unaware their doctor has a potential conflict of interest. These payments IMO are unethical - if you don't feel you can tell women about them, get rid of them!
American women now need to take a close look at the well-woman exam - it's of poor clinical value, it's not evidence based and exposes you to RISK - they lead to excess biopsies and other potentially harmful procedures. Many of your doctors are trying to change things, which is promising, especially your Dr Carolyn Westhoff.
http://www.mailman.columbia.edu/academic-departments/epidemiology/research-service/routine-pelvic-examination-obsolete

When you look at countries like the Netherlands and Finland, you see the harmful excess and unnecessary procedures caused by our program. You don't need to worry and harm so many women in an attempt to help the 0,65% who'll have an issue with this cancer.

The Finns have the lowest rates of cc in the world AND send the fewest women for colposcopy/biopsies, they offer 5 to 7 pap tests, 5 yearly from 30. The more often you test, the more false positives you produce, for no additional benefit. The Dutch have the same program, but will shortly move to 5 hrHPV PRIMARY TRIAGE tests offered at 30, 35, 40, 50 and 60 and only those positive will be offered a 5 yearly pap test (or until they've cleared the infection) - those negative will be offered the HPV program or if monogamous or no longer sexually active can forget all testing and revisit the subject if their risk profile changes. By age 40 only 5% of women are HPV positive, so this program will GREATLY reduce the amount of testing and over-treatment. It is also more likely to catch the rare cases, including adenocarcinoma, missed by pap testing in at lest 50% of cases.

The absurd thing in this country is we only offer women HPV AFTER they've had treatment for an abnormal pap test. A HPV negative woman doesn't need treatment, but IMO, this practice preserves the profits from over-treatment. Most women here have been deceived and around 60% are still being over-screened by their doctors - we're also still testing young women, and some "doctors" are testing teenagers...the worry and harm is awful and completely unnecessary.

I'm not sure what's happening in this country, but our program is certainly not in the best interests of women - it's harmful and IMO working for the benefit of vested and political interests.
I should add the Dutch also use the Delphi Screener, a self-sample HPV device. I doubt Aussie women will see HPV primary triage testing or the Delphi Screener, those things would reduce testing and over-treatment and profits for all of the vested interests would fall, that would never do...so when I hear them say our program is saving lives - nothing could be further from the truth, they are knowingly harming women and IMO, we'd also have a few deaths that could have been prevented by HPV primary testing as well.
As a result of over-treatment we have lots of women with cervical damage and psych issues - lifetime risk of referral is a massive 77% here (the States also has high referral rates) - this can lead to premature babies, cervical stenosis, the need for c-sections, infertility etc.

Our Govt has said there is no point HPV testing women as there is no cure for it and most women clear the infection, of course, this is misleading and deceptive - HPV negative women don't need pap testing - they can simply re-test for HPV infrequently - these comments IMO, are about protecting our harmful program, not women.
It's shameful and they claim women have equal rights.

http://www.sciencedaily.com/releases/2011/10/111020163909.htm
http://www.delphi-bioscience.com/Delphi-Screener/Paginas/default.aspx