Posted on 06/22/2004 9:26:20 PM PDT by neverdem
As many as 10 million women who have had hysterectomies and who no longer have a cervix are still getting Pap tests, a new study finds.
The screening Pap test looks for precancerous cells in tissue scraped from a woman's cervix and can prevent what would otherwise be a common and deadly cancer. But testing most women without a cervix makes little sense, leads to false positives and wastes money, said Dr. Brenda E. Sirovich, a research associate at the Outcomes Group at the Veterans Affairs Medical Center in White River Junction, Vt., and the study's lead author. Each test costs $20 to $40, she estimated.
The women in question do not include the 1.1 million who had a hysterectomy and still have a cervix, which is at the base of the uterus, nor the 2.2 million who had their uteruses and cervices removed because they had cancer or precancerous cells in their cervix. (Doctors occasionally leave the cervix behind in hysterectomies, although a large study found no particular advantage to doing so.) In both of these groups, Pap tests are warranted. But most women who have their uteruses and cervices removed do so for reasons other than cancer, like noncancerous fibroid tumors, Dr. Sirovich said.
Dr. Sirovich said she was taken aback by her study's findings.
"We were actually quite surprised," she said. "These women are being screened for cancer in an organ that they don't have."
The 10 million women having unnecessary Pap tests constitute about 12 percent of the 85 million women currently being screened, Dr. Sirovich said.
No one is suggesting fraud or mendacity on the part of the doctors or laboratories. Instead, Dr. Sirovich and others say, the situation seems to reflect doctors' habits and women's expectations.
In their paper, published today in The Journal of the American Medical Association, Dr. Sirovich and her colleague, Dr. H. Gilbert Welch, analyzed national data on Pap testing and on hysterectomies over 10 years.
Not only are most women who have had hysterectomies having Pap tests, they found, but the proportion having them also held steady, at 68 percent, from 1992 to 2002. No professional organization recommends Pap tests for most women without a cervix.
The screening guidelines "either have not been heard or have been ignored," the investigators wrote.
When a woman does not have a cervix, a doctor scrapes cells from her vagina instead, sending them off to be examined. And that, cancer experts say, is problematic.
Vaginal cancer is exceedingly rare, and tests of vaginal cells are much more likely to result in false positives than they are to find vaginal cancers. A result is unnecessary vaginal biopsies that can result in their own false positives. As a result, women can end up having vaginal tissue removed to treat a cancer that is not even present.
Dr. Alfred Berg, chairman of the department of family medicine at the University of Washington and the former chairman of the U.S. Preventive Services Task Force, which issues medical practice guidelines, said Pap tests in women without a cervix had been "a longstanding issue." Since 1988, Dr. Berg said, the task force has issued more and more adamant statements against it, to little avail.
"We're all fascinated as to why this should be," Dr. Berg said. In part, he said, it might be because the American public is convinced that cancer screening is an unmitigated good, making women and their doctors reluctant to give up a test as simple and popular as the Pap.
"We have a thing in this country about cancer screening," Dr. Berg said. "It has a deep social value, and when evidence points in another direction, people are very skeptical."
Another possibility, Dr. Sirovich said, is that evaluations of doctors and health care systems count the percentage of women who have Pap tests, giving little incentive to advise against the tests.
Gynecologists are also puzzled.
"It's kind of hard to figure out," said Dr. Kenneth Noller, who is professor and chairman of obstetrics and gynecology at Tufts-New England Medical Center. Dr. Noller is an author of the cervical cancer screening guidelines issued by the American College of Obstetrics and Gynecology, which does not recommend Pap tests for most women who have had hysterectomies.
Dr. Noller said he suspected that a reason the test was being done in these women anyway was that doctors were used to it.
"It's a relatively cheap and easy procedure," he explained. "It's sort of become a habit."
Dr. Alan Waxman, another author of the obstetricians and gynecologists' guidelines and an associate professor of obstetrics and gynecology at the University of New Mexico, said women expected the test.
"Many women equate the Pap test with the pelvic exam," Dr. Waxman said. "So they come in every year for their Pap test even if they don't need it any more."
He spelled out a scenario. "The woman didn't need to be tested," Dr. Waxman said. But she had a Pap test anyway. "The test shows a mild abnormality. Then she gets treated, just to be on the safe side." Now the woman is labeled as a cancer patient. "It all adds anxiety, discomfort, and expense," he said.
"Many physicians don't consider the consequences of false positives," Dr. Waxman said.
Instead, he explained, they worry about the consequences for themselves if they counsel against a Pap test for the rare woman who turns out to have vaginal cancer. "If the doctor didn't do a Pap test, then there's the litigation threat," he said.
Dr. Noller said he tried to dissuade women who do not need Pap tests.
"I will present the facts to them," he said. "I will try to talk them out of it."
But, he said, "if they still insist, I would probably do it."
PING
Good info for the uninformed.
Here is a related story about the Washington State Patrol's free Pap Smear with a DUI arrest.
http://www.kingcountyjournal.com/sited/story/html/164441
This must be the part where I show this to the "View" gals and say "But you think they don't need to see an ultrasound before they have an abortion because they know all the facts, right? Because women, yes all of them you said, aren't stupid and know their own bodies?"
I just don't understand anyone who insists on testing a part of their body that isn't there.
(sigh...)
I never could understand why I would be admonished so severely for not getting pap smears. I couldn't understand why it was necessary, since I had a hysterectomy in 1968. So thanks for posting this. It confirms that I was right and not the doctors (again!).
But I do still have my ovaries. That doesn't make a difference, does it?
My best friend insisted they always left the cervix and I should get a Pap smear....I am happy to say I knew my own records and have not had a Pap smear since surgery....The doctors should be ashamed.
No
Thanks. The medical personnel have always confused me on this issue.
Ovarian cancer has nothing to do with cervical cancer. As long as you had a total hysterectomy which includes the cervix, according to the article these guidelines have been in effect since 1988. Tell your doc you want free pelvic exams if your getting annual physical exams. Just hold that Pap test.
If the ovaries are left behind...a manual pelvic exam should be done...as ovarian cancer can occur and is difficult to detect in early stages. As a non-gyn, I try to convince my patients that if they need a hysterectomy, they should have the ovaries removed, as in all liklihood, the only thing they will accomplish in the future is bad for their health. The hormones the ovaries produce can be replaced for the necessary duration to treat the menopausal symptoms that will occur after removing functional ovaries.....of course the feminist patients retort that they will have that done as soon as their doctor has his testicles removed!!! But testicular cancer is much rarer and easier to detect - and generally less deadly! There are no easy definitive answers in medicine - that is why it is still an art as well as a science.
A big chunk of malpractice suites are based on what is termed "standard of care" i.e. if everyone else is doing it you better be doing it no matter how stupid it sounds. Standard of care until lately was giving pap smears to post-hyster ladies. If you didn't do and the women did come down with very, very rare case of cervical cancer, the doc would be so hosed.
Part of this practice was raking in change but part of it was still getting women to check out parts that still should occasionally be checked out when most other docs won't go there.
It has been ~YEARS~ since I've had a pelvic exam. Doctors don't seem to do that any more - not even when I would go in for physicals.
I'm going to go to a new doctor in a month or so. I'm going to ask her to do it.
You can't have cervical cancer without a cervix...and only women who have their cervix removed in a hysterectomy have no need for a Pap smear....They still perform the Pap smears on women who have no cervix..
How much do you want to bet a lot of this takes place for the simple reason the insurance plan covers it every year?
Remember a while back, I think I read it on FR, that a biological male in Britain who had had a sex change operation was demanding a Pap smear?
The doctor was refusing and the case ended up in Court. The Court decided that the he-she was entitled to a Pap smear and the doctor sarcastically asked for guidance on how to perform an exam on a body part the the patient had never had. :-)
The folks across the pond think we're unsophisticated rubes and cowboys. I think they're more stupid and/or evils than our rats.
Even if the patient has had a TAH/BSO, a pelvic exam should be done.
One of my most tragic cases was a personal acquaintace that had had a TAH/BSO. I found a pelvic mass that turned out to be ovarian carcinoma from an ovarian remnant.
Any comment on current blood screenings? Any faith in the gene methylation screening I'm reading about?
Is hormone replace as effective as natural hormones for women with with a family history for arterial scelorsis?
Yikes, sorry to bug you, but curiosity is getting the best of me.
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