Despite a near-unanimous consensus among authorities that Pap smear testing for cervical cancer should be conducted only every three years, most physicians apparently prefer to do it at shorter intervals, according to a new study released Monday. And if you add in HPV screening, which makes the assays even more sensitive, even fewer doctors adhere to the recommended guidelines, according to a report in the Archives of Internal Medicine. The results are "discouraging," wrote Dr. George F. Sawaya of UC San Francisco in an editorial accompanying the report, because frequent screening exposes women to more hazards without providing any significant benefit. The excess screening also costs the healthcare system additional money, not only for the extra tests but for follow-up procedures and further tests. The tests also cause pain and anxiety for the women subjected to them.
Last year a federal panel called for less frequent mammograms to look for breast cancer, a call that drew widespread criticism from both patients and physicians, who viewed it as an attempt by officials to save money while needlessly endangering women's health. But calls for less frequent cervical cancer screening have been less controversial, largely because there is overwhelming evidence that yearly screening is unnecessary. Current guidelines by the U.S. Preventive Services Task Force, the American Cancer Society and the American College of Obstetrics and Gynecology call for screening at three-year-intervals once a woman has had three consecutive negative tests.
Recently, physicians have also begun testing for the human papilloma virus (HPV), which is now known to be one of the major causes of cervical cancer. A negative HPV test is considered an even more powerful predictor of risk, and guidelines call for three-year intervals between HPV tests without the need for an initial three negative tests.
In an effort to determine how well physicians are complying with the guidelines, Dr. Mona Saraiya of the Centers for Disease Control and Prevention and her colleagues sent out a short questionnaire to 1,212 primary care physicians, presenting them with two scenarios. One scenario was for a 35-year-old woman with three consecutive negative Pap tests. The second was for a 35-year-old woman with one negative Pap test and a negative HPV test. The doctors were asked how they would conduct future screening in each scenario.
In the first scenario, about a third of doctors said they would give another Pap test in one year, a third said they would do it in two, and only a third said they would follow guidelines and give it in three years. In the second scenario, only 19% of clinicians said they would follow the guidelines, while 60.1% said they would give both Pap and HPV tests yearly.
"A negative HPV test means a lot, the chance of a tumor developing in the next three years is extremely low," Saraiya said in an interview. "There is really no reason to do an HPV test every year.... The new guidelines are definitely not doing the job they were intended to do."
The researchers are not sure why they got the results they did. For one thing, Saraiya said, it generally takes five to 10 years for new guidelines to be widely implemented. Also, many doctors may be confused about the guidelines, as was apparent from the response to the second scenario. Finally, there is a strong financial incentive: Many physicians have expressed concern that the Pap smear has become so closely linked to the annual physical examination for women that they will skip the exam if they don't get the test.
For now, the CDC and the National Cancer Institute are preparing new informational materials for both women and physicians to emphasize the importance of the guidelines. The researchers will also conduct another survey in a couple of years to see if adherence has gotten any better.
-- Thomas H. Maugh II
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