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?
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Definitely paranoia, but I don’t blame women, I think we’ve been groomed to greatly fear this rare cancer, always rare by the way and in natural decline before testing even started…
I think you may be interested to know that Finland and the Netherlands have evidence backed programs – less is more with pap testing (but now population pap testing is outdated)
Both countries have 6-7 pap test programs, 5 yearly from age 30 to 60 and the Finns have the lowest rates of cc in the world and the Dutch have no more than Australia (and probably less than the States and Canada) but just as importantly, both countries refer FAR fewer women for colposcopy/biopsy – their programs produce far fewer false positives, which can lead to excess biopsies and potentially harmful over-treatment.
The Dutch are moving again with the evidence and the Health Council of the Netherlands has recommended a new program – 5 hrHPV primary triage tests offered at ages 30,35,40,50 and 60 and only the roughly 5% who test HPV positive will be offered a 5 yearly pap test, these are the only women who can benefit from a pap test and even they, only have a small risk as the lifetime risk of cc is 0.65%…
Those HPV negative, most of us, are not at risk and cannot benefit from pap testing, biopsies etc – these women will be offered the remaining four HPV primary tests. Those women HPV negative and confidently monogamous or no longer sexually active can forget all further testing. There is also a self-test device, the Delphi Screener, already in use and also available in Singapore, Italy, Malaysia etc for those women who wish to test, but find the invasive test unacceptable/uncomfortable/painful etc
This is smarter testing – it identifies the small group of women at risk and is more likely to save lives/prevent this cancer and it spares those not at risk from unnecessary pap testing, biopsies etc – that means fewer women with damage to the cervix after over-treatment – fewer premature babies, c-sections, miscarriages, less infertility, fewer high risk pregnancies etc…cervical stenosis and cervical incompetence are a risk especially with cone biopsies, laser treatment or after multiple procedures.
It will also save money in the long run…with far fewer women testing and having excess biopsies/treatments etc For too long those not-at-risk have suffered at the hands of population pap testing, made much worse by early screening and over-screening.
Here in Australia we are some of the most over-screened and over-treated in the world…and the damage is horrible and tragic as most of this worry and damage was avoidable with screening in ethical and responsible hands, but now there is no excuse at all…we can identify the small number of women at risk. As a low risk woman, my risk of cc is near zero, the risks were too high for me and I have always declined to test.
I think it may take other countries a lot longer to reach evidence based testing – some may never offer this sort of program to women – i think women will have to take the lead here and demand better information and smarter testing.
http://www.hpvtoday.com/webEng/material.html (Registration is free and No 24 sets out the new Dutch program in great detail)
http://www.sciencedaily.com/releases/2011/10/111020163909.htm
Nice post on an important topic! Two quick thoughts come to mind:
– Definitely, reminder systems are important, for q3y Pap tests as well as other screening exams (which we’re increasingly realizing may not need to be revisited yearly). The potential role of electronic medical records here is largely unharnessed; I agree the initial implementation of these systems may be costly, but there’s evidence they are likely to pay for themselves in the long run.
– “Sexual frivolity” is a somewhat stigmatizing way to describe behaviour, but I’m glad you raise the point that there is a lot of variety in sexual activity (frequency, partner change, concurrency within sexual networks, etc). The variation within clinical populations is one reason that guidelines are not (or shouldn’t be) the final word in clinical decision-making — if they were, our jobs would be much simpler. Examining the assumptions implicit in guidelines (e.g. adherence, ‘average’ risks, etc) is critical to understanding the margins where their application is less certain. This post (and the commenters) open an interesting conversation.
Thanks for writing on this. I’ll look forward to future posts!
In my opinion additional factors need to be considered here, i.e. individual risk. HPV infection for example and lifestyle parameters that may indicate if HPV status is likely to change, HPV vaccination status, family history etc. Using such parameters to separate “high” risk from “low” risk populations, each group could receive personalized screening schedules. A 3+ year interval seems inappropriate for a high risk population, while it may be appropriate for the low risk group. In addition, I feel that the intervals should be tapered, i.e. after 10 years of once yearly normal pap smears and in absence of major risk factors one may consider tapering intervals to the once every 3 year schedule. So there are middle ways to consider and hopefully we can find an appropriate shade of grey. Overall I agree with the opinion stated by others that erring on the side of caution may be preferable in case of these screenings. When detected early, cervical dysplasia or cancer are very treatable even with the option of preserving womens’ ability to have children, warranting hypervigilance. As always, if detected too late treatment options are very limited.
On the personal side of things (i.e. acceptance of the yearly cytologies): Perhaps we need to consider how we as individual women fit into the grander scheme of things. Is it worth it to endure the suffering inflicted by a scare and accept a higher number of false positive results due to higher number of screenings in order to save other womens’ fertility or their lives?
I agree completely that three years seems a stretch. What the author does not point out is that having redundancy built into the system – ie an annual Pap – minimizes the effects of lab errors. If the Pap reading machine goes on the fritz unnoticed for a month, many women will be affected. If their next Pap is in three years, a tumor will have six years to grow.. Seems unwise. Different situation for annual paps.
In addition, if I’m doing a speculum exam anyways, why bother NOT doing a pap? Huge potential return – life saved, usually in years where a woman’s contributing a lot to society thru motherhood, child and elder care, taxes, etc – and minimal marginal cost, once the system is up and running.
I presume numbers have been crunched to address these concerns…
Until gov starts to make me personally pay for Paps more frequent than guidelines, think I’ll just sneak in an extra one here and there, specially in women who are high-risk. And when Gov starts to ding my own wallet without providing a recall system(like the mammogram one which works well) well then it’s the patient’s buck that will get spent, creating inequity.
The inequity already exists, of course cuz SOGC recommends HPV screening not cytology but MOHLTC cannot afford that, so only hi-income women are screened via HPV screening.
I cannot help questioning the role our dismal provincial economics plays in this decision. It will decrease colposcopy costs, cut Pap reading costs by 1/3-1/2, and, well, truth be told, the small increment of women with invasive cervical cancer this strategy will produce don’t generally cost too much before they die.
Such is medicine in Ontario in 2012.
I have no source data to back this up, but when I was working on the website of the BC Cancer Agency we did a small-sample survey of website users, and discovered that most women don’t associated pap smears with cancer. (They wouldn’t naturally go to the ‘Cervical Cancer Screening’ section of a website to find information about Pap smears.) It’s more seen as a general health check-up, something to get done regularly because doctors say we should. So from a patient’s perspective, the Pap test is not a source of paranoia, but is definitely a source of peace of mind. Having said that, the clinical and well-being issues around false positives and compliance with regular testing remain.