Is the PAP test for cervical cancer screening being overused?

by Kristina Fiore

Physicians do not appear likely to reduce the frequency of cervical cancer screening — not even with the availability of the sensitive human papillomavirus (HPV) DNA test, researchers say.

When given a clinical vignette of a 35-year-old woman with a normal Pap test and a negative HPV test, only 19% of the more than 1,200 physicians surveyed said they would wait three years before conducting another Pap test, Mona Saraiya, MD, MPH, of the CDC, and colleagues reported in the June 14 issue of Archives of Internal Medicine.

Most said they would perform the test earlier than that.

“Until measures are in place to reinforce extended screening intervals among women with negative HPV and normal Pap test results, there is no advantage gained” with HPV co-testing, and, the researchers added “it is more expensive.”

U.S. Preventive Services Task Force guidelines recommend screening for cervical cancer among women 30 and up every three years. But the American Cancer Society (ACS) and the American College of Obstetrics and Gynecology (ACOG) have recommended three consecutive normal Pap tests before switching to screening less often than annually.

However, the addition of the HPV DNA test has resulted in stronger recommendations by ACS and ACOG to extend screening intervals to three years without prior normal Pap test results, the researchers said.

HPV testing has greater sensitivity to detect high-grade cervical precancers and cancers compared with the Pap test, according to background provided in the article. With a negative test result, clinicians can determine which women may be at low risk of developing high-grade precancer and cancer of the cervix for the next 10 years, the authors noted.

The USPSTF has not yet endorsed HPV co-testing, Saraiya and colleagues said, and many physicians still recommend an annual Pap test.

So to investigate whether the addition of HPV testing to routine screening for cervical cancer would prompt physicians to extend screening intervals among low-risk women, the researchers conducted a survey of 1,212 physicians between Sept. 1, 2006 and May 31, 2007.

They found that, overall, 82% of physicians recommended HPV testing. Most recommended an HPV test following an abnormal Pap test, with noticeable differences by specialty:

* General internists: 44.7%
* Family practitioners: 64.2%
* Ob/Gyns: 78.2%

Just a little over a quarter — 28.3% — recommended co-testing with HPV.

With regard to the clinical vignettes, only 31.8% said they would order the next Pap test in three years for a 35-year-old woman with three normal Pap test results.

More Ob/Gyns said they would conduct another Pap test in one year, compared with family practitioners and general internists, the researchers said.

In another vignette — a 35-year-old woman with a normal Pap test and a negative HPV test — only 19% reported that they would conduct the Pap test in three years.

Most — 78% — said they would conduct it more frequently. But this time, more Ob/Gyns recommended a three-year interval than did general internists and family practitioners (P<0.001).

Among the internists and family practitioners, “the addition of a negative HPV test result seemed to offer less security in recommending extension to triennial screening than a history of three previous normal pap test results and no new sexual partners,” they wrote.

“The most likely explanation for the changes by specialty may be lower familiarity with HPV and HPV testing guidelines among [internists] and [family practitioners], as found in other studies,” they added.

Generally, the researchers said they were surprised by the results, “given the endorsement of extension of screening intervals with HPV co-testing by two major guideline-setting organizations five years before our survey was fielded.”

They noted that the “financial incentive of annual testing” may also play a key role in yearly Pap tests, and added that the influence of opinion leaders within the local practice community is “essential” for behavior change.

Finally, they cautioned that cost-effectiveness models suggest the practices observed in the study “are likely to increases costs with little improvement in reducing cervical cancer incidence and increasing survival.”

The authors noted that the study was limited by self-report and by the fact that it used patient vignettes, not real cases.

Kristina Fiore is a MedPage Today staff writer.

Originally published in MedPage Today. Visit MedPageToday.com for more OB/GYN news.

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  • stargirl65

    A huge part of OBGYN income is the annual pap smears. If the annual pap smear was eliminated then many patients may not come in yearly. They may move their care to internists or family physicians. Of course moving the pap smear to every 3 years does not mean no exam is done. You still need to do exams for ovarian cancer, breast cancer, and general health risks. Many patients are so focused on the pap smear though that in their minds “no pap smear needed=no physical needed”. Patients need to understand that the pap smear is only PART of the exam.

    Insurance companies get measured on HEDIS and other measures and these need to be in line with the recommendations. Doctors don’t want poor scores by doing less and following current guidelines.

    • MarylandMD

      Stargirl65, you make some good points, but are you sure that Ob-Gyns make a majority of their income from annual exams? Given our current system that is heavily skewed towards procedures, it is my impression that the majority of their income is from deliveries, C-sections, surgeries, and other procedures, NOT from annual evals or other office visits. Do you have data to back up your assertion on sources of the incomes of Ob-Gyns?

  • patient

    And I don’t want a yearly Pap test as I am low risk, and they hurt, expose me to the risks from unclean hands and equipment when I don’t really need the exam.

    I’m no longer a birth control pill hostage, which is nice.
    But I don’t see why I should play income stream when what I’m paying for is my own interest in my own health.

    • doctor

      So don’t “play” income stream and don’t be a “birth control pill hostage”. Don’t go to the doctor. If you really are “low risk” and know all the answers, you have nothing to worry about, right?

  • MarylandMD

    Nearly all of my new female patients are quite surprised when I report to them that they don’t need annual Paps, so it is clear to me that many other doctors, including many Ob-Gyns, still insist on doing the Paps every year. I don’t know exactly why this is, but I think there are 2 reasons:

    1) It takes some extra work to go over the patient’s history and risk factors, check when the last Pap was, and discuss all this with the patient and come up with a mutual decision on whether to screen or not on that particular visit. The doctor says to his or herself: “Heck, I will just recommend a Pap and I won’t have to worry about all that nonsense.” Since patients are used to annual Paps, they don’t question it. In other words, it is the path of least resistance. When you are busy and behind schedule, the path of least resistance is very, very tempting.

    2) When I have a patient in for a physical, I really don’t know when, if ever, I will see her for her next physical. Here is an example: Today, I see a patient who is low risk and 2 years out from her last Pap. I review the chart, I have the proper assessment and discussion on screening frequency, and I decide with the patient to do Paps every 3 years. Then, the patient doesn’t show for another 3-4 years. When she finally comes in, I do a Pap that is positive for invasive cervical cancer. Unless I am very good about documenting today’s visit, including the assessment, discussion, and the patient’s decision on screening frequency, I am vulnerable to getting nailed for failure to diagnose because I could have done a Pap today and didn’t–even if I was following the guidelines. If you work with a population that is especially transient, you are going to work with a “strike while the iron is hot” approach to doing Paps, and this approach can carry over to most or all of your patients.

    Many of the screening guidelines seem to assume you have all the old medical records available at the time of the visit and you are working in a long-term doctor-patient relationship with medically savvy, motivated patients who show up regularly and schedule their physicals on time. Unfortunately, all this is true probably only with a minority of patient visits.

    It is my strong impression that most women expect Paps every year. Surprisingly, the majority of women who have had hysterectomies for bleeding (or other reasons that are not cancer related) are surprised to find out from me that they don’t need Paps at all! Until most women expect that they DON’T need Paps every year, you will not get the pushback from patients that will keep many doctors from just going the easy route and doing annual Paps.

  • Melissa

    So much of this outrages me. Women NEED YEARLY paps, no matter what the age!! I have had a pap done every year since the age of 16. I am now 23, missed one pap in 2009, and am now one stage away from developing cervical cancer. I am facing having to have a hysterectomy. I now have to have paps every 3 months for the next year or so.

    Imagine what could have happened if I would have missed my pap for 2010?
    Imagine what could have happened if I WOULDN’T have missed ONE.

    • stargirl65

      Studies support that your pap smear has a high probability of returning to normal without any treatment. (I cannot confirm this 100% since I do not have your exact pap smear report or previous reports. I also do not have your medicine list or list of other medical issues.) Also the every 3 year recommendation is for women over 30, in monogamous relationships, with a hx of normal pap smears for the last 3, no hx of cervical cancer, and no other factors to increase their risk such as long term prednisone or AIDS.

  • melissa

    I’m a stage 3, it will not go away on its own. My entire cervix is affected after less than two years.
    And its not just women over 30, they are stating women age 21-29 only need paps every two years. Well, look what happens after two years. I’m sorry, I’d rather go through the minor discomfort of having a pap every year than to go through what I am now. I missed one, now I get to have one every three months instead.

  • am

    Melissa,

    When speaking about medical guidelines, discussions should revolve around scientific studies and scientific evidence. You are presenting an anecdotal example which is pointless to discuss. Physicians should make decisions based on large population studies conducted in a very rigid manner. Although your story is upsetting it has no place for discussing recommendations for a population.

    To further support your points of view please present scientific studies.

  • http://pulse.yahoo.com/_SQVOWLFFBQ32YWRTFB5KBENIVE Eliz52

    I don’t think there is any doubt this test is being greatly over-used and this means more false positives, lucrative over-treatments and unnecessary biopsies. It also leaves some women with continuing problems with cervical weakness and scarring – premature babies, infertility, miscarriages, cervical stenosis etc
    Women under 30 DON’T benefit from pap testing, but carry the highest risk for a false positive  – which means worry or being referred for excess procedures. The rare case that happens to a young woman is usually missed by pap testing. (probably because they are usually adenocarcinoma and the pap test often misses this even rarer form of cc)
    Women at 30 could simply have a HPV test and if negative to high risk HPV and in a monogamous relationship (or no longer sexually active), could forget pap testing. Women could reconsider testing if there risk profile changes in the future.
    At the moment women are given no options, we’re all “assumed” to be at risk – to have the same risk – this approach is paternalistic and unacceptable and it risks the health of vast numbers of women.
    You don’t have to take my word for it: See: “Cervical cancer screening” in “Australian Doctor” July 2006 by Assoc Prof Margaret Davy, Director, Gyn-Oncology, Royal Adelaide Hospital and Dr Shorne (on line, a download)

    The women who test positive for high risk HPV should be offered the Finnish and Dutch program which carries a lesser risk of false positives – they offer 5 to 7 tests in total, 5 yearly from age 30 to 60. Women could keep testing for HPV, most women will eventually clear the infection. The referral rate with the Finnish program is 35% to 55% – the US rate is 95% (according to pathologist, Dr Richard DeMay, “Should we abandon pap smear testing” – online), 77% in Australia.

    This testing has always been used with reckless indifference to the vast majority of women – their health and rights – the more than 99% who’ll never have an issue with this rare cancer. In my opinion, this testing has been used to control women, keep misguided gender and other pressure groups happy, gain political advantage and maximize profits.
    When you have a rare cancer in natural decline and an unreliable test – it is probably an unacceptable mass screening test because you worry and harm many to “possibly” help very few…there are no randomized controlled trials for pap testing, so we’ll never know for sure whether it helps anyone, but if it does, it must be fewer than 0.45% – 0.65% is the lifetime risk of cc, take out the false negative cases and consider other factors are at work – more hysterectomies, better condoms, better hygiene, less STD (the last two mentioned by Dr Gilbert Welch in “Over-diagnosed”), fewer women smoking etc
    It makes me shudder to think so much damage, fear and pain could have been caused for very little or no benefit.
    Dr Welch also mentions that stomach cancer has fallen by a similar (or greater) margin with no screening test, but you can be sure if there was a screening test, they’d be grabbing all of the credit.

    Look beyond the hype and spin and make an informed decision based on your level of risk. I also know there is a blood test available for HPV, but it’s not offered to women in this country in place of pap testing. It’s a more expensive and more reliable test – you don’t want women demanding that when you’ve set up a hugely expensive pap testing program.
    As a low risk woman, I have always declined pap testing and more recently, on turning 50, rejected breast screening (false positives, over-diagnosis) – both decisions made on the basis of information that is not released to women.
    Also, see: “Time to scrap breast screening” by Prof Michael Baum that appeared in the “Guardian” recently – a response to more alarming evidence that the fall in the death rate from breast cancer is about better treatments, and not screening.
    There are serious question marks hanging over these screening programs and keeping women ignorant and complaint is not informed consent – it is unethical not to properly advise women of risk and benefit.
    A double standard exists in cancer screening – women get puff, spin and an order to screen (even coercion), men get facts and have a say in screening. Not good enough….
    http://www.guardian.co.uk/commentisfree/2011/aug/02/breast-cancer-screening?INTCMP=SRCH
    http://www.bmj.com/content/343/bmj.d4411

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