The thought of the annual Pap smear causes me as much discomfort as it does any young woman. When I read the new guidelines for cervical cancer screening in Ontario, reported in last month’s issue of Journal of Obstetrics and Gynaecology of Canada, I was slightly relieved at the recommendations being put forth. Rather than an annual Pap smear, the new guidelines suggest that Pap smears be performed every three years for those with normal cytology. Smears would initiate at 21 years of age and continue until a woman is 70. The recommendations then go on to list six screening considerations for those with special circumstances, including women who have been previously treated for dysplasia and women who are immunocompromised (both of whom should be screened annually). Perfect! I thought to myself, less smears, less pain, less follow-up.
Although some part of me is comforted by the absence of the spectacular speculum, another part of me is wondering if this guideline, in particular, is a little too good to be true. Unlike several guidelines which recommend over-screening, as written by Shelagh McRae in a January posting, this guideline seems to break the pattern of hypervigilence. Yet, I wonder, can a three year interval for what used to be an annual test do just as well in identifying cervical cancer cases?
As I recall, cervical cancer has declined since regulated screening processes began, a process that was abetted by mandating the annual Pap smear. Half of the cancers of the cervix that are diagnosed in Ontario are in women who have had Pap smears. Then again, perhaps the frequency of the annual Pap was unnecessarily identifying too many false positives. False positives can themselves be harmful to patients, causing psychological distress, worry, and loss of work days, not to mention the impact on public health care dollars. Any screening process that alleviates this, is, in my books, a good screening process.
On the other hand, the sensitivity and specificity of a test, will never achieve perfection, nor can one be increased without decreasing the other. If that is the case, then the new clinical guidelines may be decreasing unnecessary testing but at a cost of missing out on the true positives. A recommendation for the Pap every three years means that most patients and their physicians will not follow up on their smears as stringently as before. In my own personal experience, an annual visit to the dentist rarely happens. It is more likely that I will visit every two years, at worst. If I am a representative of other women out there, women who are busy, otherwise healthy, and uncomfortable with the Pap, then the recommended frequency of every three years, may only be achieved every five years. The thought of this is particularly alarming to today’s society, one that is driven by sexual frivolities, and the guidelines do not seem to take into consideration the vast number of sexual partners some people can have in a three year time period.
Speaking with Dr. Jennifer Blake, a gynaecologist who also works in the colposcopy clinic, she shared similar concerns. She is aware of research that shows that annual Paps are done every year and a half to two years, and the three year interval is not based on telling women to go every three years. For that to happen, she believes we would need a recall system, and those are costly, and hard to maintain. Her suggestion for success? If you want a three-year interval ask women to attend every other year. (Born in an even numbered year, attend in even numbered years; born in an odd-numbered year, attend in odd numbered years). If the desired interval is five years, that is easily done; start screening at 21, establish a negative series of Paps, then from age 25 go every 5 years. She agrees that, with HPV vaccination and HPV testing, we can reduce screening intervals, but says that we need a system that works with women’s busy lives.
Therefore, while I praise the new guideline for helping me avoid the Pap, I can’t help but fear the number of women who may go without getting screened, or followed up with. I suppose the question remains, is the annual Pap smear a source of paranoia or peace of mind?