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New recommendations call into question annual Pap test

For many women, getting a Pap test, which screens for cervical cancer, is an annual ritual.
Perhaps no longer.

For many women, getting a Pap test, which screens for cervical cancer, is an annual ritual.

Perhaps no longer. According to new guidelines issued today by the American College of Obstetricians and Gynecologists (ACOG),

  • Women between the ages of 21 and 30 should have a Pap test every two years
  • Women aged 30 and older who have had three consecutive negative Pap tests may be screened every three years; and
  • Women aged 65 and older can stop getting a Pap test if they’ve had three negative tests in a row and no abnormal tests results for 10 years.

Furthermore, the ACOG recommendations suggest that women receive their first screening at age 21. Previous recommendations had called for young women to be screened within three years of becoming sexually active or at age 21, whichever came first.

Cervical cancer is caused by a very common sexually transmitted virus known as the human papillomavirus (HPV). The American Cancer Society reports that about 11,000 new cases of cervical cancer will be diagnosed this year, and about 4,000 women will die from it.

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First, do no harm

According to ACOG, the purpose of the new guidelines, which were published in the December issue of Obstetrics & Gynecology, is to reduce unnecessary testing — and to prevent the potential harm and anxiety that many women experience from unnecessary treatments.

In a press release, Alan G. Waxman, MD, the University of New Mexico physician who led the ACOG committee that revamped the guidelines, made the following statement: “The tradition of doing a Pap test every year has not been supported by recent scientific evidence. A review of the evidence to date shows that screening at less frequent intervals prevents cervical cancer just as well, has decreased costs, and avoids unnecessary interventions that could be harmful.”

The potential harm from over-testing is particularly high for young women.They’re more likely to develop cervical abnormalities that look precancerous, but that frequently go away on their own. Yet, if these abnormalities are found on a Pap test, physicians are likely to recommend that they be removed — a process that may damage the cervix and cause problems later when the woman becomes pregnant, including an increased risk of premature birth.

A coincidence?

Yes, it may seem strange that these recommendations came out during the same week as the U.S. Preventive Services Task Force’s (USPSTF) highly controversial recommendations for breast cancer screening.

But, no, there was no conspiracy. And these recommendations have nothing to do with any hidden agenda to ration healthcare. Reports the New York Times:

[T]he timing was coincidental, said Dr. Cheryl B. Iglesia, the chairwoman of a panel in the obstetricians’ group that developed the Pap smear guidelines. The group updates its advice regularly based on new medical information, and Dr. Iglesia said the latest recommendations had been in the works for several years, “long before the Obama health plan came into existence.”
She called the timing crazy, uncanny and “an unfortunate perfect storm,” adding, “There’s no political agenda with regard to these recommendations.”

Furthermore, ACOG strongly rejected the USPSTF’s mammography recommendations of earlier this week.

Curiouser and curiouser

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I suspect that these new Pap guidelines will cause very little controversy, particularly as many physicians have been informally following them for several years.

Yet I also find it curious that the same evidence-based arguments being used to support these guidelines — “new medical information,” “unnecessary testing,” “harmful unnecessary interventions” — are being accepted for cervical screening but not for breast cancer screening.

In fact, for those people so concerned about health-care rationing, ACOG clearly states that the cost of Pap testing was a factor in its recommendations. Cost was not a consideration in the USPSTF’s mammography recommendations.

In a very curious interview this morning on CBS TV, Dr. Bernadine Healy, now health editor for U.S. News and World Report, claims the ACOG guidelines are “prudent and sensible” while the USPSTF ones on mammography are “an assault on patient-doctor choice.”

Furthermore, she made the even stranger statement that a woman’s Pap decision “needs to be a choice between a woman and her doctor. That [decision] should not come from the White House.”

Healy doesn’t explain why she believes the Pap guidelines would not get between patient and doctor while the mammography recommendations would. Both guidelines are issued as recommendations, not policy.

And, as I’ve pointed out before, USPSTF is not a government agency. It’s a panel of independent experts — just like the ACOG panel.

Both groups looked at the scientific evidence and came to their best-judgment conclusion. Women can now use that information to decide how they want to individually proceed with cancer screening.

Yet the political posturing and fear-mongering regarding the proposed changes in mammography screening continues.