The tendency towards “over-screening” for disease in this country is a hot topic as healthcare costs continue to spiral upwards and overall health of the average citizen has not improved accordingly. I would like to address the traditional “annual pap smear” in light of high quality new evidence.
For decades, women have been seeing their health care provider every year primarily to obtain a pap smear, which is a screening test for cervical cancer. The test was originally developed by George Papanicolaou, a Greek physician who published results of his study in 1943: by taking samples from the cervix and looking at the cells under a microscope, we could screen women for cervical cancer. The now famous “pap smear” is the most common screening test for cervical cancer worldwide. The risk of dying of cervical cancer has decreased accordingly. However, it is only recently that high quality studies have determined how often women should be screened. Fifty years ago, the practice of the “yearly pap” was established. Why yearly? Completely arbitrarily, which means this was essentially a best guess.
Dr. Papanicolaou, when he made his original discovery, had no idea of the following: all cervical cancer is caused by particularly bad, or “high risk” strains of human papilloma virus, which is sexually transmitted. Eighty percent of Americans are exposed at some point in their lives to HPV. Condoms do not prevent transmission. It is virtually impossible to avoid, except through vaccination of children prior to intimate or sexual contact of any kind. Interestingly, HPV is like other viruses, in that our immunity can clear it from the system over time, though it can re-express itself unpredictably.
It makes sense to include screening for the virus when we screen for cervical cancer. In fact, screening for the virus alone may at some point completely replace the pap smear itself. So what is new now?
Finally, high quality studies that assessed thousands of women have been done to help guide us on this issue. In April of this year, the American Cancer Society and the U.S. Preventive Services Task Force published new guidelines for cervical cancer screening based on these studies.
A brief summary: women under 21 should not be screened at all. Women from 20-30 years of age should have the pap alone every 3 years. Women ages 30-65 should be offered what is called co-testing: the pap itself AND the test to look for high risk HPV. If both are negative, her pap can be repeated in five years. For women who do the pap alone, they can be re-screened in three years. Women who have had 3 consecutive normal pap smears and are now 65 or older do not need any more pap smears for the rest of their lives. Unlike breast cancer, cervical cancer is not a disease of elderly women. Women who have had a hysterectomy with the cervix removed do not need any more pap smears, regardless of age.
There are exceptions of course, for women with a history of “pre-cancer” of the cervix and previously abnormal pap smears. These women will have screening individualized by their provider, but over years may return to “routine screening” if their abnormalities resolve.
You might ask, well what’s wrong with more frequent screening? Won’t we pick up more cancers? The answer is no. What we will pick up is more “pre-cancer” on the cervix, also called dysplasia. Mild forms of dysplasia are essentially a transient HPV infection, and most will resolve on their own. The problem is that over-screening leads to many unnecessary procedures, visits, and further testing that do not decrease the risk of cancer. I like to call this the “burden of HPV disease,” and it is a major reason to pursue vaccination of children with the HPV vaccine.
Most women who actually have an invasive cervical cancer have not had pap smear screening in several years, and these women often were never screened for HPV at any point in their lives. The odds of a woman who has had regular screening all of a sudden developing cervical cancer in the course of a year is very rare.
The new recommendations are refinements of prior recommendations and are good news for women and their health care providers. The new options are simpler, less frequent, and offer women outcomes that are as good as or better than current screening recommendations for detecting both severe dysplasia and invasive cancer.
They also will help women avoid harms such as unnecessary procedures for “pre-cancer” and potential problems with future pregnancies. It is great news for uninsured women, who do not need to pay for unnecessary pap smears, and the burden on the health care system is significantly lower. Simplified, less frequent screening will simplify access for currently unscreened groups of women.
The problem for healthcare providers is in trying to dissociate cervical cancer screening from the “annual preventive visit.” A woman is much more than her cervix! Doing fewer pap smears will allow us to spend more time on other important issues: breast cancer screening, weight loss counseling, safe sex practices and STD screening, depression screening, contraception counseling, family planning, vaccination options, menstrual issues, and menopause assessments to name a few. There are many components of the well-woman visit and far too little time to focus on them. The decreased requirements for cervical screening create a tremendous opportunity for us to be more effective in all of these other counseling and management responsibilities. Clearly, performing less frequent pap smears does not in any way lessen the importance of the annual well-woman visit.
Women need to hear the message regarding the pap smear with HPV co-testing that “less is truly more.” Many of my patients are already nervous about less frequent testing. They do not need to be. With co-testing, they are getting two tests instead of one. And, there is high-quality evidence that co-testing is just as effective at preventing cervical cancer as the “annual pap.”
The American College of Obstetrics and Gynecology is continuing to evaluate the evolution of HPV and cervical cancer screening as well as the life-long periodic health assessment for women. Watch this space for updates as we continue to evaluate this continuing transformation of cancer screening and accordingly revise recommendations. Ask your healthcare provider for more information.