10 Million Women Who Lack a Cervix Still Get Pap Tests

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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. "

 

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