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.

Why Don't Adults Get Vaccinated?

It's kind of depressing to keep reading about how our healthcare system fails to do the basic preventive tests and interventions that doctors and researchers know that can keep us healthy and lead productive lives. Here's another example in Time magazine's article Why Don't Adults Get Vaccinated?

A survey of 7000 adults found that most could only name the flu vaccine and that the hepatitis A, B, the shingles vaccine, the pneumococcal vaccine, the diphtheria, tetanus, and pertussis vaccine, weren't mentioned as easily.

Excerpts from the article:

• Just 2% of adults have had the new combo shot for tetanus, diphtheria and pertussis (better known as whooping cough), even though pertussis rates in adolescents and adults have soared in the last 20 years. The disease, a major child killer before the childhood vaccine was introduced, can cause coughing so forceful it breaks a patient's ribs or leaves him vomiting.
• Despite clamorous public debate and high-profile media coverage about the first cancer vaccine, which protects against the human papilloma virus, only about 10% of young women reported receiving at least one dose of the three-dose vaccine.
• Vaccines should be a cornerstone of preventive medicine. "They can prevent serious illness and death. They can save money and help keep us healthy, and at work and able to take care of our families, says Schuchat, who is also director for the CDC's National Center for Immunization and Respiratory Diseases. "We obviously have a lot of work to do and it involves literally rolling up our sleeves."

What perhaps is more disturbing is that many adults aren't vaccinating their children.

These reports only illustrate the increasing importance that you must take charge of your health and ask and even demand preventive tests and interventions you need to stay healthy and live longer as it is clear that our healthcare system won't do it for you.

Better Screening Test for Cervical Cancer - Are Pap Smears Obsolete?

Very exciting news about the war against cancer. A published article in the New England Journal of Medicine found that screening for the human papilloma virus (HPV) was far more accurate in detecting cervical cancer than the current PAP smear.

Highlights from the article.

The HPV test, which looks for the virus that causes cervical cancer, correctly spotted 95 percent of the cancers. The Pap test, which checks for abnormal cells under a microscope, only found 55 percent, according to researchers at McGill University in Montreal.

The Canadian study, which was government-funded, included 10,154 women ages 30 to 69 in Montreal and St. John's, Newfoundland. The women got both tests. Still to be determined is the best way to start using the HPV test by itself and what follow-up action to take after positive results, the researchers said.

Dr. Carolyn D. Runowicz, who wrote a journal editorial, noted that the two studies used a different kind of Pap test, not the liquid-based technology used in the U.S, which may be more sensitive The results of a British study that used liquid Pap are due to be presented in November.

"We're not ready for prime time. We're moving in that direction. But we're not there yet," said Runowicz, a former president of the American Cancer Society.

Troubling Trend of Avoiding Vaccinations in Children

A recent article noted how more parents, skeptical about the value of vaccinations and worried about the linkage of immunizations with other problems like autism, are using religious grounds to be exempted from mandatory childhood vaccinations.

This troubling trend is fortunately relatively small. Highlights from the article.

• The number of exemptions is extremely small in percentage terms and represents just a few thousand of the 3.7 million children entering kindergarten in 2005, the most recent figure available.
• In 1991, a religious group in Philadelphia that chose not to immunize its children touched off an outbreak of measles that claimed at least eight lives and sickened more than 700 people, mostly children.
• And in 2005, an Indiana girl who had not been immunized picked up the measles virus at an orphanage in Romania and unknowingly brought it back to a church group. Within a month, the number of people infected had grown to 31 in what health officials said was the nation's worst outbreak of the disease in a decade.

I understand the parents' concerns. I also am more concerned that people have forgotten how many of these illnesses, like polio, measles, mumps, were debilitating and devastating in the past and that generations of adults, through the use of vaccines years ago, have avoided those complications or premature and preventable deaths.

This past winter, I saw first hand how powerful and effective vaccinations are. When I examined one patient, in his late 30s who was vaccinated against influenza, he felt well in a day or two despite having the flu. This was in stark contrast to other patients in their early 20s, who weren't vaccinated, felt miserable, stayed in bed for days, and wanting to die (they didn't of course). If you've had the flu, you know what they mean, fever often up to 103 to 104 F and every muscle, joint, and bone aching relentlessly. On follow-up months later, the latter group all without hesitation planned on getting the flu shot this fall, even though they are not required to based on current vaccination guidelines.

With recent reports about the rise of bacteria that are resistant to all antibiotics resulting in 19,000 deaths and the findings that cervical cancer is caused by the human papilloma virus (HPV), individuals skipping vaccinations maybe missing opportunities to stay healthy.

Those who cannot remember the past are condemned to repeat it.
* George Santayana (1905) Life of Reason vol. I, ch. XII Charles Scribner's Sons