Examining the Evidence
Q How many Ob/Gyns follow the new rules on Pap testing?
A A minority. Both Ob/Gyns and their patients prefer more frequent screening than the intervals advised by the American Cancer Society and other expert groups, 2 new studies found.
Less-than-annual screening in women over the age of 30, with 3 or more normal Papanicolaou (Pap) tests, is recommended by 3 expert groups: the American Cancer Society (ACS), the American College of Obstetricians and Gynecologists, and the US Preventive Services Task Force. Other expert groups additionally recommend that we stop screening women who have undergone total hysterectomy for symptomatic fibroids with no history of dysplasia, low-risk women over the age of 70, and virgin girls before age 21.
Neither Ob/Gyns nor patients, however, are inclined to follow these recommendations.
What women want
Most women prefer annual screening, irrespective of evidence. Sirovich and colleagues found that 75% of women 40 or older—most of whom had been regularly screened—prefer annual testing. Once informed of the evidence, 69% said they will persist with annual screening. About half said they will continue being screened up to and after age 80 despite no evidence of benefit.
Only 43% knew of the updated guidelines, and only 10% were being screened at the recommended intervals of 2 to 3 years.
These findings were via a survey conducted concomitant with the 2002 ACS guidelines, and published in February 2005. The nationally representative sample was questioned in a random-digit-dialing telephone survey with a response rate of 75%.
While 40% of the women understood that overscreening is wasteful and might lead to unnecessary further testing and treatment, 50% believed the primary motivation for recommending less frequent screening was cost.
What Ob/Gyns are doing
A majority of Ob/Gyns will screen women annually and indefinitely despite lack of evidence of benefit, Saint and colleagues found. They surveyed 355 randomly selected US Ob/Gyns, with a response rate of 60%.
More than 70% plan to continue screening in a 70-year-old woman with 30 years of negative Pap tests and no sexual intercourse for the past 10 years, and 60% of Ob/Gyns plan to carry on annual screening in a 35-year-old woman with 3 or more consecutive normal tests.
This is surprising, given that 82% of respondents use liquid-based Pap tests and 34% employ combined Pap–human papillomavirus (HPV) testing.
A failure to ask the simple question: “Why?”
It would be fascinating to learn why physicians persist with annual screening. Unfortunately, Saint and colleagues did not ask this question. As is the case in much recent clinical research, we rarely ask the “why” questions that seek to make sense of outcomes analyses. A simple query at the end of the survey asking, “If you screen low-risk patients annually, what is your rationale?” would have helped clarify the issue. The answer probably has little to do with scientific evidence and much to do with tradition, meeting patient expectations, maintaining trust, and possibly fear of litigation from misdiagnosis.
A matter of time
Patients expect the best, and in this competitive era physicians will do what it takes to keep a patient satisfied. If that means annual cervical cancer screening, so be it.
Perhaps the issue boils down to a matter of time. After all, we spent 50 years teaching doctors and patients the importance of annual screening, so it will be no surprise if it takes a long time for both Ob/Gyns and patients to trust that “less is more” in low-risk women.
Change may also hinge on the medical marketplace. Women who expect annual screening link it to more than cervical cancer prevention. They want their Ob/Gyns to focus on the entire health spectrum and will seek other physicians if their expectations are not met.
Despite breakthroughs in cervical cytologic sampling and DNA testing, the new technologies have not yet inspired broad confidence that less frequent screening is good health care.
And a matter of cost
Over the long term, however, paying for the more costly tools and interventions in screening and triage will be possible only with longer screening intervals for screen-negative women.