NEJM Makes No Sense Of New Cervical Cancer Screening Guidelines
In the December 8th issue of the New England Journal of Medicine in the Perspective section, there appears an article, “Making Sense of the New Cervical Cancer Screening Guidelines,” by Dr. S. Feldman. Dr. Feldman concedes that Pap smear sensitivity is poor, “roughly 50 to 60% [false negative]. She does not in her article explain the relatively poor sensitivity of the test but we can learn easily from other literature that a major contribution to the poor sensitivity of the test relates to improperly identified or interpreted smears.
While it is true that multiplying the frequency of smears increases the likelihood in spite of negligent readings that a cervical abnormality will be discovered while the disease is pre-invasive. There is no study randomized and prospective which proves that. Someone has simply picked out of a hat a frequency that they think is greater than needed and a frequency that is somehow lesser than needed and it comes to kind of a consensus that after age 21 every three years is frequent enough.
Cervical cancer is a very aggressive disease particularly in women who acquire the disease in their 30’s and 40’s. No intelligent woman knowing she possessed a cervical abnormality would decide to wait three years to do something about it. Where therefore does the pressure come from to reduce the frequency of looking? Most women considered healthy to have their gynecologist see them annually and Pap smears are done at this annual exam. Pap smears are relatively inexpensive. Of course, even something that is inexpensive becomes expensive when you multiply it by 100,000,000.
On the other hand, if a lab is getting $25.00 to $30.00 for every Pap smear it screens and requires the cytotechnologists (not doctors) who read the slides to read as many as 100 a day, one can see readily where the money is going.
I recently questioned during a deposition a cytotechnologist who had screened a slide with obvious severe abnormalities on it which she had in fact marked with screening dots. She doesn’t know why she put the slide back in the box but she did. She was having difficult times in her personal life which she had shared with her supervisors and others at the organization that was requiring her to perform as many as 96 screenings a day in spite of her obvious distraction.
While 4,000 to 5,000 women are needlessly dying of cervical cancer in the United States every year, cost efficiency is truly in the mind of the beholder.
In her article Dr. Feldman goes on to assert that HPV testing done with Pap smears, though recommended by the American Cancer Society every three years, is not recommended by anyone else including the United States Preventative Services Task Force.
It is well-know that women who are HPV positive are at much higher risk of developing cervical cancer in women who do not have this characteristic. It is also well recognized that any sexual encounter with a new person, particularly if it is unprotected sex could result in the transmission of HPV. Therefore, the fact that a person in a committed relationship is negative for ten years doesn’t mean that they are going to be negative for the next ten.
I keep on writing about this even though few hear what I have to say. It is simply that I am tired of watching my clients die of cervical cancer that was preventable if a person had been allowed to spend more than eight minutes reviewing their slide or were willing to endure the further expense of subjecting the slide to HPV testing. I wonder which committee of government or the prestigious professional organizations that direct these policies think they are in a position to decide what a woman’s life is worth. Perhaps if they watched more women die of cervical cancer as has been my unfortunate experience, they would find that testing every year rather than every three and adding HPV testing is cost efficient.
What do you think?
The way forward is to scrap population pap testing, it’s inefficient and unreliable, missing too many of these rare cancers and worrying and harming huge numbers with false positives, excess biopsies and potentially harmful over-treatment. The evidence based programs offer better protection for all women. The Dutch and Finns are the ones to watch…6-7 pap test programs, 5 yearly from 30 to 60, the Finns have the lowest rates of cervical cancer in the world, the Dutch no more than Australia and less than the States, but both countries refer far fewer women for excess biopsies/over-treatment. The Dutch are moving with the evidence yet again and the new program is 5 hrHPV primary triage tests offered at ages 30,35,40,50 and 60 and only the roughly 5% who are HPV positive and at risk will be offered a 5 yearly pap test. The vast majority of women will be HPV negative, not at risk and they will be offered the HPV primary triage testing program. Those HPV negative and no longer sexually active or confidently monogamous can forget further
testing…there is also a reliable self test option, the Delphi Screener. This program will save more lives and see pap testing and over-treatment plummet and it will save scarce health resources.
The pap test has been horribly over-used worrying and harming huge numbers of women, with testing too early and far too often…
Over-treatment can damage the cervix and lead to cervical stenosis, infertility, cervical incompetence, miscarriages, high risk pregnancy, cervical cerclage, the need for c-sections, premature babies etc…
There was no need to worry and harm so many, now there is no excuse…we can now identify the roughly 5% who are at risk and have a small chance of benefiting from a 5 yearly pap test.
Countries that seriously over-screen, that do not have evidence based programs may never introduce evidence based testing, women will have to demand smarter testing. Sadly, vested interests, profits, politics and high emotion control women’s cancer screening and misinformation and scare mongering is the norm; that’s a lousy and harmful deal for women. There has never been any respect for informed consent in women’s cancer screen and that must change…it is shameful that the lifetime risk of cc is 0.65% and the lifetime risk of referral for colposcopy/biopsy is a huge 77%…and probably even higher in the States.