After the recent controversy over new breast cancer screening guidelines, the recommendations issued today by the American College of Obstetricians and Gynecologists (ACOG) to do fewer Pap tests may seem like another blow to women’s health. But the truth is, it isn’t.
The leading experts and gynecologists who care for women recommend the following:
1) All women should begin receiving a Pap test at age 21.
2) Women ages 21 to 30 should have a Pap test every other year.
3) Women ages 30 and over should have a Pap test (with the addition of an HPV test done at the same time as an option) every three years.
THE GOOD NEWS ABOUT WAITING UNTIL AGE 21
Waiting to first test women with the Pap test until they are 21 will protect so many young women from unnecessary anxiety, biopsy of their cervix, and potentially harmful treatment. We now know that most of these abnormal Pap tests in young women are caused by one of the many strains of the human papilloma virus (HPV) and will go away on their own without treatment in 1-2 years. Furthermore and even more important, women who are aggressively treated for an abnormal Pap test have a much greater risk of premature birth and other pregnancy complications. I have cared for many women over the years who had prior cone biopsy’s and other treatments to their cervix which led to difficult pregnancies.
MY BIG CONCERNS ABOUT LESS FREQUENT SCREENING
I am worried, however, that by reducing the interval for Pap tests to every 2-3 years, depending on a woman’s age, will lead to many women falling through the cracks of healthcare. The annual Pap test has been an important part of woman’s health for so many years and most women view the annual Pap test with the annual visit… a right of passage each year. In truth, so much more goes on when a woman comes in for a regular check up including a breast, rectal and pelvic exam along with a check of blood pressure, heart risk factors, and so much more.
I also wonder who will manage all of the Pap test results for women? Women frequently move and change doctors and practitioners. I worry that it will be difficult to know exactly which woman has had three negative Pap tests in a row unless a woman keeps those records for herself. As I have said over and over in the past that women should manage their own health records. They should give their practitioners a self-addressed stamped envelope at each visit and keep original copies of their test results. They can then make this information available to any future practitioner.
And of course I wonder how insurance companies will react to this? Almost certainly they will start covering fewer Pap tests, which makes sense. However how will they know when a woman has had three negative Pap tests in a row – or that a woman may have had an abnormal Pap test or positive HPV test or symptoms that need closer follow up?
A LITTLE BACKGROUND
Until the Pap test was widely adopted in the United States in the late 1940’s, cervical cancer was the number one cause of cancer death in women. After the widespread use of the Pap test however, cervical cancer cases dropped by 70%. This is a huge success story. (By the way, it remains the number two cause of death worldwide and in very poor countries it tops the list of deadly cancers because many countries cannot afford the costs associated with Pap tests.)
By 1999 the World Health Organization concluded that there was a single cause of cervical cancer – the Human Papilloma Virus (HPV). HPV is a simple double-strand of DNA enclosed in a protein capsule that resembles a soccer ball when viewed under a special microscope. Although there are over 100 types of HPV, only about fifteen types are linked to cancer. These fifteen types are commonly called “high risk strains” of the virus.
Soon after the discovery of HPV as the cause of cervical cancer, a DNA test to look for the high risk strains of HPV was developed. This simple test is done using the same scraping of cells used for the Pap test. Although most women are exposed to HPV at some point in their lives (which is why we suggest that all women undergo cervical cancer screening), most women will fight off the virus within a year or two and the virus either disappears altogether or remains dormant. Only about five per cent of women will not fight off the virus and these women will continue to test positive with the HPV test and may eventually developing precancerous cell changes and cancer if these cell changes aren’t treated.
The Pap test looks for cell changes under the microscope caused by the virus and is not foolproof. On occasion the cell changes are not discovered and cervical cancer is eventually discovered. One of my sisters was diagnosed with cervical cancer earlier this year despite previously normal Pap tests. On the other hand, there are other causes of a mildly abnormal Pap test besides HPV, such as low estrogen in women after menopause. I had an abnormal Pap test after menopause which was from low estrogen and not from HPV.
Here is a quick review of what I would recommend:
1) All young girls and women should begin an every other year Pap test starting at age 21.
2) Any inconclusive or mildly abnormal Pap test result should lead automatically to an HPV test. Women who have a mildly abnormal Pap test and also test positive for high risk HPV need more testing such as a colposcopy and closer follow up. Women who don’t have high risk strains of the virus and therefore test negative with an HPV test can simply have their Pap test repeated in 6-12 months.
3) Starting at age 30, women who have had three consecutively normal Pap tests can have a Pap test every three years ( they can ask to have an HPV test at the same time as their Pap test). If they have a normal Pap test and no high risk strains of HPV, they can safely have a repeat check for cervical cancer every 3 years. It takes about 3 years from the time a woman is exposed to HPV to develop serious cell changes that can be detected with the Pap test.That doesn’t get women off the hook for the all important regular check up including a pelvic exam however.
4) Women who have had a hysterectomy and their cervix removed for benign conditions such as fibroids or heavy bleeding can stop having Pap tests altogether.
5) Women who have had a hysterectomy for cancer should continue with regular Pap testing. The vulvar, vaginal and rarely anal tissues can also develop precancerous cell changes and even cancer from high risk strains of HPV.
6) Women who remain sexually active should continue to be checked regularly, although most experts agree that if Pap tests remain negative, they could be stopped by age 65 or so. As always, I welcome your thoughts and suggestions.
Marie Savard, M.D.
ABC News Medical Contributor
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