The Pap Smear – Not Too Many – Too Few
According to the American Cancer Society’s most recent estimate for 2009, 11,270 new cases of invasive cervical cancer will be diagnosed and 4,070 women will die from the disease.
Prior to 1955 cervical cancer was one of the most common causes of cancer death for American women. As a result of the development of the Pap smear screening test between 1955 and 1992, the cervical cancer death rate declined by 74%.
Since half of the cervical cancer cases arise in patients who have never had a Pap smear or whose last Pap smear preceded diagnosis of invasive cancer by more than five years, the problem is not that too many Pap smears are being done but that not enough Pap smears are being done.
Nevertheless, the guidelines for screening of Pap smears have resulted in fewer Pap smears being done. For a test that is misinterpreted when it shows abnormalities between 20 and 40% of the time, frequent repetition of the test is needed to assure one appropriate interpretation. Even when an appropriate interpretation of Pap smears is made and abnormalities are found which require treatment, the appropriate treatment is not given 10% of the time.
For a test associated with little cost, and which is essentially risk free, the pressure to limit the performance of even this test is clearly present.
Matthew Mintz, M.D. writes at KevinMD.com medical web blog on November 17, 2009, “Why Doctors are Doing So Many Unnecessary Pap Smears.” In his opinion piece, Dr. Mintz asserts that the Pap smear is a symbol of our healthcare system’s problems, yet the only evidence he quotes in support of this proposition is a study from the Annuals of Internal Medicine which demonstrates doctors are doing more frequent Pap smears on women than some guidelines recommend.
The fact that more Pap smears are being done does not mean that they are needless and they certainly are not harmful.
When even well-informed physicians can reach such wrong-headed conclusions it is not surprising that it is so difficult to fix the healthcare system.
Where is the alarm about the high rate at which Pap smears are wrongly interpreted as negative when in fact they show ominous changes?
Not all screening tests have been as successful as the Pap smear. The fact that we could have for example better screening tests for breast cancer than a mammogram does not negate the importance of women having an option to have a mammogram. We should be searching for better screening tests improving the performance of existing texts and not failing to screen with the tests available simply because the tests are imperfect.
With such controversy swirling about healthcare reform it is difficult to hear the truth in the midst of all the noise that is being made. Staying well informed and being skeptical is the safest approach to receiving appropriate medical care.