10 Million Women Without Cervix Still Get Pap Test??

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10 Million Women Who Lack a Cervix Still Get Pap Tests

 

http://www.nytimes.com/2004/06/23/health/23PAP.final.html?th

 

June 23, 200410 Million Women Who Lack a Cervix Still Get Pap

TestsBy

GINA KOLATA

 

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. "

 

Copyright 2004 The New York Times Company