The Pap Smear – Not Too Many – Too Few

According to the American Cancer Society’s most recent estimate for 2009, 11,270 new cases of invasive cervical cancer will be diagnosed and 4,070 women will die from the disease.

Prior to 1955 cervical cancer was one of the most common causes of cancer death for American women. As a result of the development of the Pap smear screening test between 1955 and 1992, the cervical cancer death rate declined by 74%.

Since half of the cervical cancer cases arise in patients who have never had a Pap smear or whose last Pap smear preceded diagnosis of invasive cancer by more than five years, the problem is not that too many Pap smears are being done but that not enough Pap smears are being done.

Nevertheless, the guidelines for screening of Pap smears have resulted in fewer Pap smears being done. For a test that is misinterpreted when it shows abnormalities between 20 and 40% of the time, frequent repetition of the test is needed to assure one appropriate interpretation. Even when an appropriate interpretation of Pap smears is made and abnormalities are found which require treatment, the appropriate treatment is not given 10% of the time.

For a test associated with little cost, and which is essentially risk free, the pressure to limit the performance of even this test is clearly present.

Matthew Mintz, M.D. writes at KevinMD.com medical web blog on November 17, 2009, “Why Doctors are Doing So Many Unnecessary Pap Smears.” In his opinion piece, Dr. Mintz asserts that the Pap smear is a symbol of our healthcare system’s problems, yet the only evidence he quotes in support of this proposition is a study from the Annuals of Internal Medicine which demonstrates doctors are doing more frequent Pap smears on women than some guidelines recommend.

The fact that more Pap smears are being done does not mean that they are needless and they certainly are not harmful.

When even well-informed physicians can reach such wrong-headed conclusions it is not surprising that it is so difficult to fix the healthcare system.

Where is the alarm about the high rate at which Pap smears are wrongly interpreted as negative when in fact they show ominous changes?

Not all screening tests have been as successful as the Pap smear. The fact that we could have for example better screening tests for breast cancer than a mammogram does not negate the importance of women having an option to have a mammogram. We should be searching for better screening tests improving the performance of existing texts and not failing to screen with the tests available simply because the tests are imperfect.

With such controversy swirling about healthcare reform it is difficult to hear the truth in the midst of all the noise that is being made. Staying well informed and being skeptical is the safest approach to receiving appropriate medical care.

All articles in this blog are the collaborative effort of attorneys Jerry Meyers, Brendan Lupetin, and Gregory Unatin.

11 thoughts on “The Pap Smear – Not Too Many – Too Few

  1. Pap smears are not harmful – what a statement!
    Many women find a pap smear an ordeal and some women refuse to have them at all. Aside from that, pap smears are unreliable and lead to over-treatment with LEEP and biopsies. The risk of this cancer and the benefits of this testing have been completely misrepresented to women.
    I think this shows a disgusting lack of regard for women and their rights.

    This cancer is uncommon, always was – look at the figures. Don’t talk in terms of “75% reduction” or “deaths halved”, talk about absolute risk.
    This is an unreliable test that with annual testing sends almost all women for biopsies in her lifetime, with only a very small number having any sign of malignancy. Two yearly testing sends 77% of women for biopsies, three yearly – 65% and even 5 yearly is 55%.
    Your chance of unnecessary and potentially harmful biopsies is FAR greater than the low risk of cancer. (near zero for a low risk woman)
    Some of those women will be left with continuing health problems.
    Overscreening and screening women under 25 causes lots of damage for very little benefit. Young women produce VERY high numbers of false positives simply because their bodies are changing and these changes are interpreted as abnormal – these young women don’t need medical intervention. it is to protect these young women from harm that countries like the UK don’t screen before 25 and the Netherlands and Finland, not before 30.
    Finland has the lowest rates of cervical cancer in the world and sends the smallest number of women for biopsies – they offer screening from age 30 and then 5 yearly to 60. My low risk Finnish friend does not have screening at all.
    Angela Raffle, UK cancer screening expert released some figures that puts the risk into perspective – 1000 women need regular screening for 35 years to save ONE woman from cervical cancer.
    When the risk of this cancer in an unscreened population is about 1.58% and a low risk woman has a near zero chance of getting this cancer AND this test so often leads to over-treatment…only one person can make the decision to accept those odds – the woman herself.
    Of course, the benefits of screening have always been exaggerated as well as the risk of this cancer & the risks have been concealed…
    There is no respect for a woman’s right to choose – whether she wants testing. Informed consent is totally disregarded and more than that, women are pressured and coerced into testing. Coerced by the unethical tying of birth control with cancer screening. They have nothing to do with each other – this is a tactic to FORCE screening. Even the medical associations, WHO and the USF&DA all say this test is not needed for the initiation and continuing use of the Pill. Can you imagine compulsory rectal exams for all men wanting Viagra or antibiotics? No say in whether they want testing. Yet that is accepted in women’s health – screening is demanded with no risk or unbiased information, it is never offered…
    We need a major change in women’s health – it’s time for honesty and some respect.

    1. You wrote “This is an unreliable test that with annual testing sends almost all women for biopsies in her lifetime, with only a very small number having any sign of malignancy. Two yearly testing sends 77% of women for biopsies, three yearly – 65% and even 5 yearly is 55%.”

      Where did you get these numbers? Colposcopy should only be performed when a high grade lesion or atypical cells suggesting a high grade lesion is found. This is an in frequent event. Further, colposcopy does not result in any biopsy unless evidence of a precancerous lesion is confirmed. 90% of these precancerous lesions will progress to invasive cancer if not treated.
      The reason that relatively few cases of cancer are diagnosed each year in America (15,000) each year is because of the success of treating precancerous lesions found by pap smears.

  2. I was diagnosed with advanced invasive cervical cancer (squamous cell, stage 2B with metastasis to two pelvic lymph nodes – 50% 5-year survival rate) after having a solid history of negative pap smears. I became sexually abstinent in 1996, but continued getting routine pap smears. I may have skipped a year once or twice, but I did have at least 3 normal pap smears in a row in 2003, 2004, & 2005. Then in 2006, my Dr. found a large tumor. I believe that if I had not gone to have a pap smear in 2006, I would not be here today. In fact, although I have been “cancer-free” (no evidence of disease”) for 3 years now, I still have a 50% chance of surviving the next two years. I want to advise every woman who has EVER been sexually active to continue getting ANNUAL pap smears even if the results are always negative (“normal”). I know they say that it is rare for this to happen (cervical cancer), but when it happens to you, it doesn’t really matter how rare or common it is. I know of at least 2 other women who had a history of normal pap smears prior to a cervical cancer diagnosis which was made too late, and those women are no longer alive. After suffering through chemotherapy, radiation, along with the horrible and some long lasting side effects that come with treatment, becoming infertile, and being put into instant menopause at the age of 38, I can assure you that the discomfort and financial cost of a pap smear pales in comparison.

    1. I’m very glad that you decided to share with our readers your comments. It is very easy for a woman who has never shared your experience or known anyone in your circumstances, to minimize the importance of early diagnosis of cervical cancer.

      I find it interesting that you described negative Pap smears on more than one occasion prior to the Pap smear which led to your diagnosis. In your remarks you refer to others whose diagnosis also followed negative Pap smears and who were less fortunate, and that their disease was advanced at the time diagnosis was made.

      Though Pap smears have dramatically reduced deaths from cervical cancer, interpretive errors with respect to the reading of the Pap smears has on occasion resulted in needless delay in diagnosis.

      I have represented numerous women who after investigation were proven to have had an avoidable delay in diagnosis. It is my experience in these cases that makes me so sensitive to your remarks.

      Thank you again for commenting.

      For further information please read the articles appearing at my web site.

  3. Where did you get these numbers? Colposcopy should only be performed when a high grade lesion or atypical cells suggesting a high grade lesion is found. This is an in frequent event. Further, colposcopy does not result in any biopsy unless evidence of a precancerous lesion is confirmed. 90% of these precancerous lesions will progress to invasive cancer if not treated.
    The reason that relatively few cases of cancer are diagnosed each year in America (15,000) each year is because of the success of treating precancerous lesions found by pap smears.

    This is false. I had mild dysplacia and my doctor wanted to do a colposcopy and biopsy immediatly. When I refused, she sent me a certified letter demanding I get this procedure even though she admitted this would “probably clear on its own”. This test is over-sold. Doctors are too biopsy-happy. Had I known the overall risk of this cancer, I never would have put myself through this in the first place.

    1. Your Dr. did not act in accordance with recommended practice unless you are also HPV positive. Your experience does not justify the conclusion you reached. It is true that mild dysplasia does most often clear on its own. That’s why colposcopy is not recommended for that finding.

      1. Mr. Meyers,
        For the past 15 years, I have been “tortured” by doctors who have done colposcopies for CIN I, II and III that did not exist. After my last pap in June of 2012 my gyno called very excitedly and said I had Cin III (I’ve heard that one before) and said I should have that hysterectomy now. I answered her by saying that I assumed she would want to do a colposcopy and that I was not available for at least 2 weeks because I was enrolled in a summer adult ed class at a local university and then my family and I were going on vacation for a week. There was an audible uptake in her breath and she said someone would call me. The nurse called and I made an appointment for Sept. You might think this is crazy but I have been through this so many times in the last 15 years and I have had HPV tests showing that I do not have the HPV that causes cancer. I have trouble believing her and any other doctor. My colposcopy showed metaplasia yet again. I have moved in the past 15 years so this is not the first doctor to do this to me.

        1. Elaine,
          Colposcopies are not indicated for low grade lesions, CIN I, particularly where one is HPV negative. Your experience does not reflect the experience of the majority of women. 1/1,000 Pap smears show CIN III. If colposcopy showed nothing to biopsy that certainly would be consistent with you having been subjected to too many colposcopies. Metaplasia is a cytologic finding made on inspection of pap smears and not a diagnosis made by biopsy. Many tousands of women have died be cause of not having regular pap smears and appropriate followup. You should discuss your concerns with your gynecologist.

  4. My other question to you is this – the reduction in deaths – it does not appear that the “74% reduction” includes the increased number of women getting hysterectomies (600,000 a year or 1 in 3 women by age 60) most of which are for benign conditions. I’m an auditor and am very concerned that this numbers aren’t properly being represented to women.

    1. You are mixing apples and oranges. The reduction in the rate of death is not due to the number of hysterectomies performed. Pre-invasive cervical cancer and high grade intraepithelial neoplasia are most often treated with cryo-therapy or cone biopsy, not hysterectomy. Further, preinvasive cervical cancer and high grade intraepithelial neoplasia are not benign conditions. On the other hand, there are benign conditions which justify hysterectomy in women past child bearing age. Prolapsed uterus, etc. Please tell us where you obtained a statistic which suggests that 600,000 hysterectomies are performed because of abnormal pap smears where cancer or a high grade neoplasia was not present. the value of pap smears in reducing death from cervical cancer is real. Whether unnecessary hysterectomies are being performed for other reasons is certainly a matter worth looking into.
      Thanks for your interest.

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