Monday, July 26, 2010

New Pap Smear Guidelines - Rationing Healthcare or the Right Care?

The American Congress of Obstetricians and Gynecologists (ACOG) recently reiterated their position that Pap smear should be performed on healthy women starting at age 21. This is different from the past which recommended screening for cervical cancer at either three years after the time a woman became sexually active or age 21, whichever occurred first.

How will the public respond to this change?

Over the past year there have been plenty of announcements from the medical profession regarding to the appropriateness of PSA screening for prostate cancer and the timing of mammogram screening for breast cancer. Understandably some people may view these changes in recommendations as the rationing of American healthcare.

They should instead, however, welcome these advancements. Doctors becoming even better at understanding which screening tests work and which ones don't.

Doctors have discovered that for cervical cancer, which is detected by Pap smears, a significant risk factor in infection from the human papilloma virus (HPV). HPV is the most common sexually transmitted disease and aside from causing cervical cancer are also the cause of genital warts. Women under age 21, who are healthy and do not have a compromised immune system from HIV or organ transplant, rarely develop cervical cancer from HPV infection.

Unlike the past when women needed annual pap smears, advances in screening with new liquid-based Pap smears as well as screening for HPV allows women to be checked for cervical cancer every other year. Women age 30 and older who have had three normal pap smears in a row can have Pap smears every two to three years with a Pap smear or every three years with a Pap test and HPV DNA screening.

If all doctors recommended these interventions, this would reduce the number of Pap smears needed by 50 percent. The newest cervical cancer screening method would be far better as it identified which women were at risk with better precision and information than the past. By doing fewer unnecessary Pap smears, doctors are now free to address other problems as well as begin to take on the millions of Americans who will have health insurance due to reform.

The question is will they do it? Will women accept the new changes in screening intervals?

Research shows it takes about 17 years before results of studies and guidelines become commonly practiced in the community. One study showed primary care doctors were not particularly good at screening for colon cancer though new guidelines have been around for a decade.

It's easy to blame doctors for being slow to change. It's easy to blame patients for being slow to change. Many of my patients still demand an annual pap smear even though HPV DNA testing is something my colleagues and I have practiced for years.

The fact is that change is hard unless of course you are new to something. As my five year old daughter proudly told me recently there are exactly EIGHT planets not nine in the solar system.

For the next generation of women, they will not need Pap smears until age 21. They can be safely screened every other year. There is a chance that none of them will never develop cervical cancer as since 2006, HPV vaccines exist for individuals age 9 to 26 that immunize them from the subtypes of HPV that cause cancer.

These women won't get upset. They won't get worried.

They know this is the right care. This is not rationed care.

That is, of course, until the next revision in the guidelines and recommendations.

1 comment:

Anonymous said...

It is rationed care to some extent. It's not BETTER to detect cervical cancer by getting tested every three years. It's still BETTER for a patient to be tested every year. Even with the new pap smears and HPV testing, the sensitivity of a pap is low (hence there are many false negatives). Specificity is high - very few false positives. It's a VERY cheap test. I'd rather not get a false negative and then wait three years. I don't care if I get a false positive. I am sick of MDs misrepresenting stats and saying "Paradoxically, the more you get the Pap, the more likely you are to get a false positive". Of course that's true of ANY test that has any chance of false-positives. But the far bigger risk here is a false negative! Given the specificity, false positives are rare, and in the case of a positive, they can RERUN the CHEAP test. Cervical cancer is deadly. It can grow a lot in 6 years. And with low sensitivity, it's not BETTER to get it every three years. It's a CHEAP test, and my life matters. By the way, I have a PhD in math and work in biostat. So I've read the research papers on this topic. Standard textbooks in 2006 talk about how cheap a pap is. It's still cheap. My life isn't.


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