New Pap Smear Guidelines: The Right Care Or Rationed Care?
The American College of Obstetricians and Gynecologists (ACOG) recently reiterated their position that Pap smears should be performed on healthy women starting at age 21. This is different from the past which recommended screening for cervical cancer at either three years after the time a woman became sexually active or age 21, whichever occurred first.
How will the public respond to this change?
Over the past year there have been plenty of announcements from the medical profession regarding to the appropriateness of PSA screening for prostate cancer and the timing of mammogram screening for breast cancer. Understandably, some people may view these changes in recommendations as the rationing of American healthcare.
They should instead, however, welcome these advancements. Doctors are becoming even better at understanding which screening tests work and which ones don’t.
Doctors have discovered that for cervical cancer, which is detected by Pap smears, a significant risk factor in infection from the human papilloma virus (HPV). HPV is the most common sexually-transmitted disease and aside from causing cervical cancer are also the cause of genital warts. Women under age 21, who are healthy and do not have a compromised immune system from HIV or organ transplant, rarely develop cervical cancer from HPV infection.
Unlike the past when women needed annual pap smears, advances in screening with new liquid-based Pap smears as well as screening for HPV allows women to bechecked for cervical cancer every other year. Women age 30 and older who have had three normal pap smears in a row can have Pap smears every two to three years with a Pap smear or every three years with a Pap test and HPV DNA screening.
If all doctors recommended these interventions, this would reduce the number of Pap smears needed by 50 percent. The newest cervical cancer screening method would be far better as it identified which women were at risk with better precision and information than the past. By doing fewer unnecessary Pap smears, doctors are now free to address other problems as well as begin to take on the millions of Americans who will have health insurance due to reform.
The question is will they do it? Will women accept the new changes in screening intervals?
Research shows it takes about 17 years before results of studies and guidelines become commonly practiced in the community. One study showed primary care doctors were not particularly good at screening for colon cancer though new guidelines have been around for a decade.
It’s easy to blame doctors for being slow to change. It’s easy to blame patients for being slow to change. Many of my patients still demand an annual pap smear even though HPV DNA testing is something my colleagues and I have practiced for years.
The fact is that change is hard unless of course you are new to something. As my five year old daughter proudly told me recently there are exactly EIGHT planets not nine in the solar system.
For the next generation of women, they will not need Pap smears until age 21. They can be safely screened every other year. There is a chance that none of them will never develop cervical cancer as since 2006, HPV vaccines exist for individuals age 9 to 26 that immunize them from the subtypes of HPV that cause cancer.
These women won’t get upset. They won’t get worried. They know this is the right care. This is not rationed care. That is, of course, until the next revision in the guidelines and recommendations.
*This blog post was originally published at Saving Money and Surviving the Healthcare Crisis*
I think women have been trained to greatly fear this rare cancer – the pressure is enormous to have pap tests and even coercion is used to screen women. I have to remind myself that pap testing is an elective screening test that legally and ethically requires our informed consent. Instead women are denied the Pill if they refuse to screen and even denied all non-emergency medical care. There is an impatience from doctors when women exercise their legal right to decline. Men are treated very differently…
Women are also blamed if we don’t screen and get cc, doctors seem almost delighted and throw these women in our faces like a threat, yet a person who gets bowel cancer and didn’t have colonoscopies is not judged so harshly and unfairly. This screening is not cancer screening, it’s a systematic and deliberate abuse of our rights and bodies. We are provided with no real information and screening has always been reckless and excessive, harming far more than it could possibly help. A lot of the damage was avoidable…but excess and coercion generates vast profits and so its acceptable to treat women in this way. You only have to look at the Netherlands and Finland to see the harmful excess in the States, Australia and Germany. An in-tact cervix is uncommon in these countries – over-screening produces lots of false positives and potentially harmful over-treatment and unnecessary biopsies. Cervical damage can lead to infertility, premature babies, the need for c-sections, cervical stenosis, psych issues etc
The lifetime risk of this cancer is 0.65%, it was always rare and in natural decline – while the lifetime risk of referral is a whopping 77% for Aussie women and even higher in the States.
The Finns have the lowest rates of cc in the world and send the fewest women for biopsies and treatments (fewer false positives) – they offer 7 pap tests, 5 yearly from age 30 to 60. The Dutch have the same program, but will shortly move to 5 hrHPV primary triage tests offered at ages 30,35,40,50 and 60 and ONLY those positive will be offered a 5 yearly pap test.
Those negative may follow the HPV program or if monogamous or no longer sexually active may choose to forget all testing and revisit the subject if their risk profile changes in the future. Only 5% of women are HPV by age 40. This program will further reduce testing, over-treatment and is more likely to prevent these rare cases – the pap test misses 25% of squamous cell and 50% of adenocarcinoma. The Dutch are also using the Delphi Screener, the self-sample HPV device – many women who wish to test would welcome a self-sample option. HPV negative women don’t need pap tests, biopsies or damaging “treatments” – using the pap and HPV test together on all women just causes confusion and creates more re- testing and excess follow-up, it’s unnecessary.
Our program maximizes harm for no additional benefit, but is great for vested interests. Women are also being misled into routine pelvic exams when they are of poor clinical value in asymptomatic women and are far more likely to harm us – routine breast exams don’t help, but lead to excess biopsies. I think the greatest threat to our health is women’s “healthcare”…beware!
Only 5% of women are HPV POSITIVE by age 40, is what I meant to say…
Not sure if I can link articles, but if you search Delphi Screener, you’ll find more information. Also, the Health Council of the Netherlands website sets out the new HPV program – under “prevention” and the year, 2011. Also the HPV Today newsletter, special edition for the Netherlands, contains numerous articles on the new program.