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.