Sign Out: If it ain't broke, why are we fixing it?

October 1, 2007

If the message is you don't need a Pap smear, many patients will hear: you don't need a visit.

CERVICAL CANCER AT ONE TIME was the leading cause of death for American women. The Pap test is rightly credited with a significant reduction in morbidity and mortality since it was introduced over 50 years ago. Throughout the world there are still over 200,000 deaths per year due to cervical cancer. The American Cancer Society estimates that in 2007 approximately 11,150 cases of cervical cancer will be diagnosed in the United States and approximately 3,700 of these diagnosed women will die from the disease. Realize, however, that between 1955 and 1992 deaths from cervical cancer in the US dropped by 74%!

Clearly these statistics show that getting a regular Pap smear is important to a women's health and has been one of medicine's greatest success stories. Sadly, about half of the diagnosed cervical cancers in the US are in women who have never presented themselves for a Pap smear. In addition, another 10% occur in women who have not had a Pap smear in the past 5 years. Finally, a significant number of women fail to follow-up on an abnormal Pap smear result.

The introduction of liquid-based cytology and imaging systems has further improved Pap testing. Liquid-based cytology was introduced in 1996 and since then large independent trials have evaluated its advantages over traditional Pap testing. No doubt these studies have been responsible for the fact that about 90% of all Pap tests are now done with this technology. When the FDA approved liquid-based Pap tests, they noted that it was significantly more effective than a traditional Pap at disease detection, to have improved specimen quality and adequacy, to improve detection of glandular lesions, and to have the ability to test for HPV, chlamydia, and gonorrhea directly out of the vial within 3 weeks of specimen collection. This has proved to be especially valuable in the group of women with ASCUS cytology but found to be negative for high-risk HPV DNA.

Why widen the testing intervals?

Despite all these positive developments, I'm very concerned about the guidelines to widen the Pap smear screening intervals. It is a very inexpensive test to perform, especially as the patient needs to present herself for an annual exam. Furthermore, even now as we encourage women to come in yearly for their exam, we know that the interval between exams turns out to often be longer. Many physicians are rightly concerned that if you encourage extending testing intervals even further a woman's actual interval may also extend even beyond that.

Many women have come to equate the annual visit with the Pap smear. If the message is you don't need a Pap smear, I fear that many patients will hear: you don't need a visit. Many of the new screening guidelines from the American Cancer Society and ACOG make sense, such as no longer doing Pap smears of the vaginal cuff in women who have had hysterectomies for benign noncervical reasons, or not initiating Pap smear screening in women until age 21, or 3 years after sexual intercourse. However, many of the other recommendations that deal with reducing intervals and combining non-reflex testing for high-risk HPV DNA, will, in my opinion, confuse patients as well as clinicians.

IN SUMMARY, Pap smear testing has been one of the finest accomplishments of modern medicine. Liquid-based technology and reflex HPV testing has fine-tuned the procedure even further. Since the majority of cancer cases occur in women who fail to present themselves or fail to follow-up on abnormal results, our effort should be to reach these women rather than change the rules for those in whom the system has worked so well. In short, if it ain't broke, why are we fixing it?

DR. GOLDSTEIN is Professor of Obstetrics and Gynecology, Director of Gynecologic Ultrasound and Co-Director of Bone Densitometry, New York University School of Medicine, New York, NY., and a former editorial board member for Contemporary OB/GYN.