Thursday, July 30, 2009

Pap Smears for Young Women: A Waste of Time and Money—or Not?

A new study from Queen Mary College, London, has found that Pap testing for sexually active young women may not be such a good idea—in fact “doing more harm than good.” But there are a few caveats that women might want to consider before following standard one-size-fits-all advice.

The researchers, curious about the effectiveness of aggressive treatment for low-grade lesions that often heal themselves in young women, compared 4,012 women aged 20-69 who had been diagnosed with cervical cancer with a matched group of 7,889 cancer-free women.

The study found three things:

· The outcome was no different for young women with abnormal cells whether they received a colposcopy—a microscopic examination of the cervix, possibly including a biopsy of suspicious cells—or whether they were told to come back later for more testing. Pap screenings didn’t reduce cervical cancer incidence over the next five years for women aged 22-24, but there was a 43-60 percent reduction in incidence for women aged 30-37.

· There was no difference in outcome for women who had a colposcopy and excision of abnormal cells and those who didn’t, although the surgical group suffered more problems such as bleeding.

· Immediate colposcopys did not prove any more cost-effective than ‘watchful waiting.’

“When you look at the balance of benefits and harms, surveillance does as well,” said Eduardo Franco, a professor of epidemiology and oncology who co-authored an editorial about the study in the British Medical Journal.

England’s recent policy of offering Pap smears only to women over 25 (women in Scotland, Wales and Northern Ireland can still get them at age 20) has been under fire ever since the furor over reality TV star Jade Goody’s untimely death from cervical cancer at the age of 27.

Goody’s tearful phone call with a doctor telling her she had cancer, on-camera during Big Brother filming, has been viewed millions of times over the internet. The progression of her illness—the cancer had metastasized to her bowel, liver and groin—was followed by a horrified international audience and there was an unprecedented rush for Pap smears in the UK. The surge in requests became known as ‘the Jade Goody effect.’

English health officials maintained that the new 25-and-over policy followed guidelines set by the International Agency for Research on Cancer. Cervical cancer in under-25s is extremely rare, officials said, but changes in the cervix are very common. Screening at 20 could therefore result in unnecessary interventions that could, indeed, do more harm than good. The new study appears to bear out this belief.

Currently women in the US are advised to begin screenings within three years of starting sexual activity or upon turning 21, whichever comes first. The American Cancer Society is considering revising its guidelines because of the Queen Mary College study.

But here’s what you should think about.

One size doesn’t always fit all. Although a huge percentage of tests and procedures in the US are known to be unnecessary and it’s important to rein in costs, as an individual you need to make informed choices. While raising the blanket testing age to 21 may well make sense, you yourself have to be totally and completely honest with your gynecologist about your personal life, including:

· Number of sexual partners. The more partners you have, the more varieties of the HPV virus (that causes most cases of cervical cancer) you will be exposed to. Studies have shown that people with more sexual partners are more likely to get cervical, anal and oral cancers. Young girls are particularly vulnerable to HPV because cervical cells are unstable and changing rapidly; protective cervical mucous is also not being produced as efficiently as in later years.

· Smoking. Smokers are 14 to 27 times (times, not percent) more likely to develop pre-cancerous lesions than non-smokers.
· Diet. People with a diet high in vegetables and fruits are at least 50 percent less likely to develop pre-cancerous lesions.

If your gynecologist doesn’t ask you about these issues, it’s up to you to bring them up and ask whether you should get earlier testing, plus HPV testing, if you have higher risks. You should also be aware that in Britain, at least, the incidence of cases of the highest grade of pre-cancerous change, CIN3, in 20-24 year-olds has risen from 15.8 percent of all cases in 1999 to 19.3 percent of all cases in 2004, suggesting that either HPV is becoming nastier or risky habits are making younger women more vulnerable.

If you and your gynecologist do decide on delaying testing to, or on ‘watchful waiting’—according to the study, possibly a better option if testing detects pre-cancerous cells—try to make healthy lifestyle choices such as quitting smoking if you smoke and including lots of vegetables and fruits in your diet. These changes will help to bolster your immune system so that you can shake off HPV.

One last caveat: don’t think you’re safe if you’ve had the Gardasil vaccine against HPV. It protects against only four HPV viruses out of more than 100, at least 40 of which are known to be cancer-causing, and has proved to be 17-45 percent effective against pre-cancerous lesions. Its eventual effectiveness against cervical cancer is still unknown and replacement disease, where other strains of the virus fill the void left by vanquished strains, is a real possibility. Don’t forgo your annual visit to your gynecologist, and above all, be honest when you do go.


Anonymous said...

I'll never understand why American women think they need to see a gynecologist every year.
It's no doubt the reason you have the highest hysterectomy rate in the world - a horrifying 600,000 every year or one third of all women at age 60.
I've never had a routine breast, pelvic or rectal exam. Our doctors say they are of poor value in a symptom-free woman and expose you to the risk of false positives and even more useless testing.
When I lived in the States, I saw the misery these exams unnecessary. I also saw the risks with one woman having a healthy ovary removed after a Dr thought she felt something...
Pap smears are more useful for some, not for others.
I'm in a lifetime mutually monogamous relationship and chose not to have smears. The risk of false positives is high and the threat of this cancer is low, even for a high risk woman - my risk is near zero.
Many women over-estimate the risk from this cancer. Only 0.65% of women benefit from smears, so 99.35% derive no benefit at all...too much screening and too early exposes you to high risks.
The lowest rates of cervical cancer in the world and they also have the lowest number of colposcopy/biopsies is Finland - 5 yearly from 30 - 5 to 7 tests in total.
My host family were great - the poor mother had already had 50 smears at 55 - just ridiculous. It is taking advantage of women for no benefit and so harmful.
She now tests 5 yearly after speaking to my Dr over the phone.
There is a great site moderated by a Dr...Dr Joel Sherman's Medical Privacy and under Women's Privacy Concerns you'll find a host of great information.
Good luck everyone...
Stats taken from an article by an American pathologist, Richard DeMay - reference is at Dr Sherman's site.

Kristin Johns said...

Interesting comment. Although I'm well aware that Americans test too much--in fact the guidelines for Pap smear testing have just been revised--I can't say I agree with you that testing is unecessary. I also can't see why a 55-year old woman would have had 50 smears unless she had active cancer--and even then, 2 a year is crazy. At 51 I've only had about 20(there was a gap when I moved to a new town and found that lots of women just loved the local OB/Gyn because he was just "so great with my hysterectomy!" I waited til a new doc moved to town).

I can tell you, though, that the exams never caused me any misery and as someone who doesn't have regular physicals I felt good that once a year, someone was checking my BP and giving me a thorough once over, including catching a severe iron deficiency.

I also knew a woman who left her two young kids orphaned; right after her jusband had a heart attack she found she had stage IV cancer that a mammogram could have found in time--and another friend discovered a tiny but vicious cancer at a stage where she could fight it. Yep, I get the check-ups. I have kids I need to be around for.

The rate of cervical cancer plumetted by 80 percent after regular Pap smears were introduced. Look at the rates of cervical cancer deaths in the developing world if you believe that check-ups aren't necessary. And I'd never recommend that women wait until 30 for a check-up; not when the highest grade of lesions are becoming found far more frequently in younger women.

I'm a big fan of controlling your own behavior so that your risk of cervical cancer,and indeed other cancers, is reduced. But would I rely totally on a good diet, a healthy immune system, and a totally faithful marriage? No. At least every couple of years, I'd get the smear.

Liz said...

Not sure whether you're aware the American and Canadian annual gyn exam is not evidence-based and so it's not recommended in many countries.
I know routine pelvic exams are never recommended unless you have symptoms. You would only be referred to a gyn if you had a problem or were pregnant.
It is entirely a matter for you whether you have pap smears, but informed consent is a legal requirement for all cancer screening and not just for men.
More women are starting to question the fact risk information has been withheld and the risk from this cancer has been greatly exaggerated.
You may care to look at this so-called massive drop in the death rate since screening. The numbers are very small and this cancer was in decline before screening started...there are other factors that impact on the death rate like the fact many more women have had hysterectomies these days.
I heard Dr Angela Raffle being interviewed a couple of years back - this Dr is a leader in the field of cervical screening. Her research showed that 1000 women need regular screening for 35 years to save one woman from cervical cancer. The stats were published in the BMJ.
Over those years one woman would die anyway (regardless of smears - false negatives) and many hundreds are referred for colposcopy/biopsies - some are left with health problems as a result.
Screening is not black and white and more women are asking questions...which is only right.
It is never right or wrong to screen.

You also can't assume that cancer is always picked up in a mammogram or that the cancer would have progressed. We now know about 40% of older women have DCIS - a slow moving cancer that rarely bothers a woman...a bit like the slow-moving type of prostate cancer.
If I were high risk for cervical cancer, which is basically a 1% risk, I'd probably have 5 yearly smears from 25 or 30...NEVER before 25. (unless you want to have unnecessary treatment and biopsies) Some high risk women are put off screening after a very early bad experience.
I think all women should look at these issues with an open mind - it can protect your health.
I've also looked at Dr Sherman's site, which is excellent and his article at the Kevin MD site called, "Informed consent is missing from cervical screening."
Staggering it's taken so long for someone to notice!
Sadly, there are few sites that seek to inform women.
Re: the lady with 55 smears
Dr Sherman's own wife has had more than 50 normal smears...she called a stop to them recently, not her Dr.
Also, many American doctors ignore the revised guidelines and continue to over-test. I know one woman who was refused birth control until she agreed to a whole host of unnecessary exams and tests. I'm told that's a common thing.

You cannot compare cervical cancer in the third world with developed countries.
It's comparing apples with horses - totally different.
In the third world many women become sexually active at 9 or 10, have early and multiple pregnancies, use newspapers, mud and other things during menstruation, have impaired immune systems and poor diets...the list is long.
It is entirely a matter for every woman whether she wants smears or mammograms, but I think it's unwise not to make it an informed decision.

I'd recommend to any woman thinking about breast screening and it's a big Q as breast cancer is common...take a look at an unbiased summary at the Nordic Cochrane Institute website - "The risks and benefits of mammograms".
It was produced as the NCI were concerned about the misleading and inadequate information being released to women.
I don't know when it became okay to give women half the story and put a line through informed consent.
Screening under 25 is very risky for no benefit - the risks exceed the benefits. This was reviewed in the UK recently and the screening start age remains at 25.
(for those who want screening)
Australia is expected to make that change later this year....years overdue.
Interesting article!

Liz said...

By the way, 2 yearly screening carries a lifetime risk of 77% for referral for colposcopy and usually some form of biopsy.
It's considered over-screening and increases the risks of over-treatment.
With screening your risk of cervical cancer is 0.35%, without screening around 1%. (much lower for low risk women)
Not hard to see why some women accept a small or tiny risk rather than a high risk of over-treatment.
Even 5 yearly screening carries somewhere between 30-55% lifetime risk of over-treatment.

See: Dr Laura Koutsky, Cancer Prevention, Fall 2004, Issue 4 and
Violet to Blue blog on screening.

Kristin Johns said...


Great comments--thanks. I completely agree that informed consent is the thing, and frankly, I'm appalled that none of us insist on it--in fact, I wrote about that very thing recently.

Unfortunately, health care's a bit like taking your car to the mechanic. Unless you have training, you assume that your mechanic's advice is the way to go. It is intimidating to ask questions of busy doctors and if you're older, that was just not done in the past. My 88-year old mom in the UK would think it insulting to question her doctor and refuses even to take her a list of supplements like CoQ10 to ask about, let alone research likely treatments ahead of time.

Me, I'd kill any doctor like that. My OB/GYN is decent; she's mainstream but at least will discuss things like Gardasil--she doesn't agree with me that my daughters shouldn't get it, but respects the fact that I've researched it rationally. And she has talked ME out of tests I'd inquired about.

Few of us are comfortable with 'watchful waiting;' we're worry-warts, and we need to learn that it's OK to wait and see before treating sometimes.

As for the over-testing, I think it's up to an individual to figure out what she's comfortable with. I have understood for a long time that I could probably go every three years rather than every year (because my gyno is popular it's usually more like 18 months between visits) but I'd personally be uncomfortable with that. That's in part because she serves as my GP--I rarely go to the real one! There is more to an annual exam than a Pap smear.

With regards to the statistics, I'm picky. For instance, statistically my kids are very unlikely to have an adverse reaction to Gardasil, but if one of them does have one--that's MY child. So I looked at the touted benefits of Gardasil, the risks of cervical cancer, the potential of a healthy lifestyle to brush off HPV, and decided that the statistically unlikely risk of a side effect, however small, isn't worth it--for MY children.

Similarly, I read the statistics you posted about the likelihood of a colposcopy with overscreening and I believe them--and yet I'll still go regularly for my exam and mammogram, because I've known women who've died from cancers going undiagnosed, including my grandmother, and that isn't going to be me. I also feel comfortable with my doctor and the likelihood that if anything comes up, she'll discuss the options rationally and with respect. That's important.

If you come back to this site, email me- it would be fun to write a post about this subject.

Anonymous said...

I've chosen not to screen after looking at the pluses and minuses of this test and they were hard to find. Almost all of the information easily found is inaccurate and misleading....some actually contains lies.
Many of the medical journals are only accessible if you pay a hefty subscription fee. My partner and I thought it was worth the money and spent $500 on subscriptions. I became concerned after my older sister had several miscarriages due to damage to her cervix following treatment for abnormal smears in her late teens. (two conizations)
All of the tissue was normal even though the smears showed highly abnormal changes.
Things may not work out for my sister...the damage is done. The last miscarriage happened at 16 weeks after her cervix failed despite a cervical cutelage. (I hope I've got that word right)
Her gyn said an infection is also a risk as the cervix no longer seals the uterus off from the outside world.
Now she was never asked whether she wanted the test and got no risk information.
She wanted the birth control pill and her doctor refused her a script unless she agreed to a smear.
The pain and grief is awful and it breaks my heart to see my sister struggling to come to terms with her future childless life.
I think we need, as healthy women, to demand more respect from the profession. We are not children, but adult women who can make their own decisions.
I will make my own decisions and will never allow a doctor to push me into anything.
Please be careful with this test, especially if you're very young.
My sister just called and she and her husband are hoping to adopt a Chinese girl!

Anonymous said...

They are more than a waste of time and money...they risk your health.
Women under 25 have a 1 in 3 chance of an abnormal smear and being referred for treatment or biopsies. Yet cancer in this age group is very, very rare.
Also, the smears they produce can appear very abnormal, but are nothing to worry about.
There is a lot of evidence to suggest also that the unlucky women who get this cancer as young women are usually not helped by smears.
A 21 year old girl was diagnosed with cervical cancer in Victoria last year, the youngest case in this State, yet her pap smear a few months before diagnosis was normal.
That can put a woman in a risky position if she's falsely reassured by the normal result and delays seeing a Dr...she may face a later diagnosis.
I've never understood the faith women have in this test, wrong so often and healthy women being "treated" and it lets one third of the few women who get this cancer them normal results. I think few women really understand and if not for my father, I'd probably be in the same position. I've heard women say this cancer is the most common cancer and that the test checks for ovarian and uterine cancer as well...there is a lot of incorrect information published about this test and the cancer and that doesn't help anyone.
I was lucky enough to have a father who worked in the field. I had one smear at 40 and won't have any more. I choose to live with the minute risk of cancer and spare myself LEEP or a cone biopsy. I've also always put prevention of HPV first.

Anonymous said...

My daughter won't be having smears until she's 30 and then only if it's her decision.
We have lived in the Netherlands for the last 5 years and their medicine is evidence based and you find remarkable honesty from their doctors. My daughter would have fearfully agreed to smears from around 20 and then probably annually and that would have endangered her health.
She now has the information she needs to make the best decision for her body.
She also refused Gardasil after seeking advice from our amazing Dutch doctor. It was a weighing-up process and I support her decision because I know her Dr wasn't pushing one way or the other.
Why can't American doctors do that?
I'm afraid to trust their advice on screening, they are all extreme and excessive and that ends up hurting us.

Kristin Johns said...

This is really interesting--I'd never realised there was much controversy about Pap smears apart from the usual problem that they're over-used in the US (IF you have insurance, of course).

To me, again, it boils down to women being responsible and thoughtful about their own health. If a doctor tells you there's a problem, ask questions. Is it appropriate to look at watchful waiting? etc. etc. Do research and get a second opinion.

Interesting about that younger girl getting cervical cancer--it bears out the stats in the UK and the US. People are getting the persistent infections and lesions younger. I'd guess it's because of the increasing disrespect that younger generations are showing their bodies (and that's quite something for a wild child of the 70s to say) in terms of number of partners, diet, sleep, etc., but who really knows?

Anonymous said...

I agree.
I think there should be more attention on prevention of HPV.
It is possible to minimize the risk by starting your sex life later when your cervix is more mature, limit partners and always use condoms. Condoms give you sound protection, at least 70% less HPV infections with condom-users and possibly higher with perfect use.
These things make a huge difference when our top risk from this cancer is a small 1%.
I wasn't a wild child, two shy virgins met and got together at mid 20's. I've never had screening due to my very low risk of infection with HPV.
Why is there no HPV test for men?
Women could protect themselves and forget about smears and we wouldn't end up over-treating vast numbers of women.
I worry that all the money that is made from smears, over-treatment (worth one billion dollars a year in the States) and all the previously healthy women left with health problems after excessive treatments, might mean a HPV test for men never appears.
We need to push for that test...currently a virgin can ask a man with sexual history to get STD checks, but they can't test for HPV. What then?
All you can do is assess his level of risk - how many partners, condom use, if infection is likely - insist that condoms are always used or take your chances without condoms - with or without smears. Smears only offer partial protection and the risk of over-treatment.
I know the male Pill was developed many years ago as I know a scientist who worked on the project. He was told it wasn't commercially viable and men preferred to leave contraception to the woman.
I think many men and women would like the option of the male Pill.
Sadly, many of these developments never get to the public.
I hope a HPV test for men is not far away.

Kristin Johns said...

Bernice--well, there may be no HPV test approved for general use in men, but they can certainly test--otherwise we wouldn't be seeing all these articles about how uncircumcised men have a higher risk of persistent infection etc. I assume (perhaps wrongly) that they don't just make those statistics up.

On the other hand, I strongly believe in strengthening the host rather than focusing on going after the invader in this case. As you say, being intelligent about your sex life helps--not that kids are often intelligent about their sex life.

Eating and sleeping well and not smoking (smoking is a huge risk)would save a lot of grief in my opinion. Prime HPV prevention, with a bonus good effect on your entire physiology.

Anonymous said...

As I understand it they can check men for a current HPV infection, but a negative test result is not a guarantee the man isn't infected with HPV, he might be asymptomatic and still able to transit the infection.
The HPV that causes herpes is not the HPV associated with cervical cancer as well, BUT is a serious problem all the same. I wouldn't have sex with a herpes sufferer, although it can be treated, it's never cured and you have outbreaks throughout life.
My friends married when they were virgins and after a mid-life crisis my friend had a fling that ended her marriage and gave her herpes. She forgot about condoms because she was past childbearing age, but totally forgot about STI's as they were not something she ever needed to think about with her only other sexual partner of 26 years.
Prevention is a thousand times better than smears or anything else. To me it's a bit like bolting the door after the horse has bolted...I heard one Dr say that women might have a higher risk of cervical cancer if they take the Pill (of course that may be because these women often don't use condoms and the cervix is exposed and not have anything to do with the actual Pill) but "don't worry we'll pick it up in your smears"...
Great, what a cavalier attitude and a reckless one when you think that one third of women who get cervical cancer have had one or more normal pap smears and adenorcarcinoma is rarely picked up by smears. (which is linked to HPV infection as well)
Why do we rely so much on this imperfect test? and sensible sex preferably after age 16, limit partners, use condoms until you're sure of his HPV etc status, don't smoke, basically look after your body including your cervix.
Instead of a cervical cancer awareness week concentrating on the pap smear, we need a "protect your cervix" week and teach women to protect themselves from these things that can negatively affect their entire lifes.