Friday, April 20, 2012

To Pap or NOT to Pap?

Choosing Wisely is a wonderful campaign aimed at increasing discussions between doctors and patients about tests and procedures, and what is expected versus what has been shown to be effective. I am starting my focus on this campaign with highlighting the recommendations of my academy- the AAFP (American Academy of Family Physicians.) So far, I've discussed back x-rays, sinusitis treatment, bone density tests and EKGs, and today I would like to address Pap tests.

Pap tests do a wonderful job in helping us detect cervical cancer in early, very treatable stages. With our increased understanding of this disease being caused by HPV (the Human Papilloma Virus) as well as improving technology that allows us to detect the specific strains of HPV that are high risk for cancer, we are changing the recommendations for Pap tests on what seems like an annual basis. This recommendation focuses on two parts: Girls under the age of 21 and women who have had hysterectomies for reasons other than cancer (such as fibroids or heavy bleeding) do NOT need Pap tests. Evidence has shown that the vast majority of teens who are infected with HPV will not progress to cancer, but instead effectively "clear" the infection within a few years (meaning the HPV lowers to an undetectable level, though it still may be present.) Likewise, the incidence of cancer in women who have had their uterus removed for non-cancerous reasons is so small that there is little evidence for improved outcomes.

As a major proponent of sexually transmitted disease awareness, however, I want to be crystal clear that women under the age of 21 STILL NEED TESTING for STDs if they are having sex! No Pap does NOT equal no testing or no exam.

BOTTOM LINE: Pap testing recommendations are changing frequently- please talk with your doctor about the most current recommendations and do not be surprised if you do NOT need one this year!


Eliz52 said...

I think the lack of respect for informed consent in cervical and breast cancer screening is scandalous. Women get orders and misleading information, men get offers and real information plus respect for informed consent.
Cervical cancer was always rare and in natural decline, now thanks to the unreliable pap test and it's reckless overuse huge numbers of women are subjected to potentially harmful over-treatment after false positive pap tests. An industry in the over-treatment of CIN has been created...
As a low risk woman I rejected pap tests almost 30 years ago...yet so many years later, women still get orders and misleading information and are being seriously over-treated...damage to the cervix is linked to infertility, cervical stenosis, cervical incompetence, high risk pregnancy, premature babies, the need for c-sections etc...the lifetime risk of referral after an abnormal pap test in Australia is a huge 77% for a cancer with a 0.65% lifetime risk.

Finland has the lowest rates of cc in the world and refers far fewer women, they offer 7 tests, 5 yearly from 30 to 60. There is no difference in terms of benefit between annual and 5 yearly testing, but shorter intervals are associated with very high numbers of false positives and over-treatment. No country in the world has shown a benefit testing those under 30, but this group produce the most false positives.

The Dutch have the same program (7 tests) but the Health Council of the Netherlands have recommended a 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, about 5% of women. Those negative can follow the HPV test or test themselves using the Delphi Screener or if negative, monogamous or no longer sexually active, can forget all testing. This will greatly reduce pap testing, false positives, over-treatment and is more likely to prevent these rare cancers....of course this also means profits for the medical profession will plummet.

I believe both breast and cervical screening are largely controlled by vested and political interests and do not operate in the best interests of women.
Breast screening is little or no benefit with a serious risk of over-diagnosis, but without the amazing Nordic Cochrane Institute most women would still be in the dark. The dishonesty, lack of proper ethical standards, the absence of informed all very worrying. It certainly is not ethical cancer screening. I greatly respect the few doctors prepared to fight for women...Prof Michael Baum, Angela Raffle, Muir Gray, the NCI, Margaret McCartney and Gilbert Welch...they haven't forgotten the motto: first do no harm.
The situation in the States is shocking....women being coerced into screening in exchange for birth control and being pressured to have routine breast and pelvic exams, neither helpful and exposing women to risk...excess biopsies, unnecessary surgery etc thankfully, neither exam has been recommended for some time in the UK and Australia. Dr Carolyn Westhoff has been brave enough to step forward and inform American women. More than ever before, women need to do their reading, it is dangerous to assume our doctors are acting in our best interests.

Ticked said...

A high school student could have looked at the error rates of a pap smear and concluded that annual testing, statistically speaking, made zero sense (false positive problem). How convenient that this testing regimen generated so much extra business for the industry? And testing technology for home hpv testing (superior to Pap) exists today if the FDA would stop practicing "doctors protecting doctors".

And now that the testing interval is lengthened (3 years is still far too aggressive, particularly for neg HPV, neg Pap), women are told they still need annual pelvic exams. They do not. This examination does not have any zcientific support whatsoever. It is NOT a screen for ovarian cancer.

And this leaves us with Clinical Breast Exams which are worthless in mammogram populations (and lets remember that the average age at diagnosis for breast cancer is 59 and that 0.5% of cases occur pre-40).

The whole industry is theater. This needs to stop... wastes resources and traumatizes women. These practices were put in place for the benefit of the, power, sex (titillation).