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Why Did The USPSTF Change The Pap Test Guidelines For Women?

Women have been told they should have screening for cervical cancer with a pap test every year.  The visit to the gynecologist or internal medicine physician has been a right of passage for most young women and most are very compliant with that annual visit throughout their lives.

Well, the times they are a-changin’ because new guidelines issued by the US Preventative Services Task Force and the American Cancer Society say women should undergo screening NO MORE OFTEN than every 3 years starting at age 21.  To further strengthen this recommendation, even the American Society for Clinical Pathology (those folks that read the pap smears) agrees with the recommendation.  They also recommend stopping routine pap smears after age 65 for women who have had 3 negative Pap test results in the past 10 years.  These women are just not at high risk.

So why the change?

The pap smear is a screening test for cervical cancer.  Evidence shows that more frequent screening than every 3 years doesn’t find more cancer and we now know that cervical cancer is the result of infection with Human papillomaviruses (HPVs).  Women that have not been exposed to HPV are not at risk of cervical cancer.  Furthermore, out of 150 related viruses, of which 40 are sexually transmitted, only certain ones are high-risk, oncogenic (or carcinogenic) HPVs.  Persistent infections with these high-risk HPV types can cause cell abnormalities that are picked up on pap tests.  But the majority of infections with even high-risk HPV types go away on their own and do not cause cancer.  Two types of HPV (types 16 and 18) cause 70% of all cervical cancers and they are very slow growing.

When a pap test detects cervical cell changes, an HPV DNA test is usually done.  If the HPV test is negative, a women is safe from cervical cancer for many years.  Even if a pap test shows equivocal changes, if the HPV test is negative, it is recommended she be re-tested in 3 years.

Despite these recommendations, annual testing remains a common practice in most gynecology offices.  Even in women who have been tested for HPV and found negative, less than 15% of physicians recommended that patients wait 3 years before repeat testing.  Women are still being told to come back annually.

Why?

Some doctors may not know about the guidelines, even though they are also supported by the American College of Obstetricians and Gynecologists.  Doctors as well as patients are in the habit of “the annual pap test”.  Doctors are also concerned that if they don’t recommend pap smears, women will not come in for an annual exam and other preventive screening.   But doing unnecessary testing is not a way to have women come in.

For most women this will be a welcome change.  Stretching out those gynecologic screening exams will save time, money, false positive tests and unneeded follow-up.   Keep in mind this only refers to non-symptom screening.  Women who have any gynecologic symptoms (unusual bleeding, discharge, pain, pressure) or any other  concern or questions should see their physician.

*This blog post was originally published at EverythingHealth*


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2 Responses to “Why Did The USPSTF Change The Pap Test Guidelines For Women?”

  1. Michael Mirochna, MD says:

    This isn’t new. ACOG wrote these new guidelines in December 2009. They didn’t receive much attention as they were hidden behind the mammogram changes from the USPSTF a month or two earlier.

  2. Elizabeth (Aust) says:

    None of this is new, in my opinion the changes were only made because more women were getting to the facts and it became unsafe for doctors to continue with reckless over-screening. Other countries have always put women first and screened responsibly – Finland for example has the lowest rates of cc in the world and just as importantly refers the fewest women for colposcopy/biopsies. (fewer false positives) When you over-screen the benefits don’t change, but risk goes WAY up – of course, over-screening leads straight to over-detection and potentially harmful over-treatment – all highly lucrative for doctors, pathologists, labs, day procedures centres etc

    Finland offers 7 pap tests, 5 yearly from 30 to 60 – no country in the world has shown a benefit pap testing women under 30, but all have evidence of harm. Just look at the number of US and Australian women who’ve had “treatment” on their cervix – it’s telling when the lifetime risk of this cancer is only 0.65% – it’s rare, and always was…both countries over-screen, so both have hidden and shameful over-treatment rates.
    Aussie women have a 77% lifetime risk of referral, the States, even higher – almost all referrals are unnecessary.

    The Dutch have the same 7 pap test program and will shortly 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. Only 5% are HPV positive by age 40. Those negative can follow the HPV schedule (if they choose) or if monogamous or no longer sexually active, might choose to stop all testing and revisit the subject, if their risk profile changes. This program will greatly reduce the amount of testing and over-treatment and that means fewer women with cervical damage – fewer premature babies, c-sections and women with health issues after over-treatment, like depression, psych issues, scar tissue/infertility etc
    The Dutch are also using a self-sample device to test for HPV – the Delphi Screener.
    Countries like the States and Australia have IMO continued to over-use the pap test to maximize over-treatment and there is one group who don’t benefit – women. When more than 99% of women can never benefit from testing, it is disgraceful and unethical that no attempt has been made to protect them from worry and harm – and it also shows a cavalier disregard for our bodily privacy – no women needs more than 7 pap tests.
    There has never been any respect for informed consent, our legal right. I think pap testing shows paternalism is still alive and well in medicine – doctors and others believe they can safely use women for our own benefit. The abuse of proper ethical standards is also quite disturbing – making something elective, compulsory for women – if they want the Pill or pre-natal care or in some cases, any non-emergency medical care.
    Of course, pap testing is elective, it can never be compulsory, legally or ethically, but doctors have created their own boycotts to force women into testing (usually over-testing) and left them with the negative consequences. FAR more women have been harmed from this testing, than could possibly be helped…
    The consequences of these boycotts – unplanned pregnancies, abortions, miscarriages, ectopic pregnancies and then doctors have the audacity to say they FORCE women to have elective cancer screening “for their own good”. These things carry far more risk than rare cervical cancer – far more!
    Screening is OUR decision, just as men are entitled to consider, accept or reject screening. Rectal exams are not compulsory for Viagra. Doctors do not have the right to make decisions for women or accept risk on our behalf and they should not be permitted to behave unethically and illegally.
    I hope there is some justice for the vast numbers of women harmed by this testing and all with no informed consent. The message has always been – doctors can behave with no ethical standards if female patients are involved – anything goes…that attitude must change.
    I have always rejected that offensive thinking…and as a low risk woman have always declined testing.

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