Posted on 06/22/2004 9:26:20 PM PDT by neverdem
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."
When doing a pap, isn't the doc LOOKING in that general area? I would think that one would recognize a cervix vs no-cervix.
I had a student attempt to perform a pap on me once. Hurt me terribly while "looking around" and then announced she couldn't find my cervix. As far as I know, there aren't any bends or curves there, so how hard is it?
But the legal system has set up a "standard of care" or be sued system until recently. And the "Standard of care" system called for pap smears in post-hyster women.
Would you be willing to be the maverick?
In medicine sometimes they (the insurance companies) drew the line, sometimes you drew the line.
Bottom line, if you were worth your salt, you fought for the best you could give and then some. That was and is risky business.
When doing a pap, isn't the doc LOOKING in that general area? I would think that one would recognize a cervix vs no-cervix. ......... I had a student attempt to perform a pap on me once. Hurt me terribly while "looking around" and then announced she couldn't find my cervix. As far as I know, there aren't any bends or curves there, so how hard is it?
Just to clarify, my earlier post had to do with the manual exam that "feels" for masses and not the speculum exam that "looks".
As to your question, yes, it is very easy for an inexperienced student, who has not had much "hands on" experience with female anatomy to get lost.
Get a man's sock, hold it between your thumb and the other four fingers, point the sock hand straight towards the floor and then slide your other hand into the sock and straight towards the floor.
The other hand slides right in to the end of the sock without much problem.
Now, hold the sock hand at an angle that is not pointing straight towards the floor and try to slide the other hand in. Since you have the angle wrong, your hand is catching the sides of the sock and getting stuck. The harder you push, the more "stuck" it gets.
The same thing happens to the inexperienced student. They get the speculum angle wrong, they are catching the sides of the vagina and they push harder because they think the problem is that they are not deep enough. Eventually, if they ever S-C-R-A-P-E their way to the end, the cervix will eventually "pop" into the end of the speculum.
It could be worse.
I once had a resident call me into his barium enema study to ask why the rectum looked so funny and why the barium would not flow any further.
I replied that it probably had something to do with the fact that he had just performed a barium study on a normal vagina.
Experience........There is no substitute for it but, unfortunately, we are not born with it.
"We were actually quite surprised," she said. "These women are being screened for cancer in an organ that they don't have."
Why surprised. Former abortion provider Carol Everett used to explained at length how they would sell abortions to women who weren't pregnant.
Just lie about the test results. Of course it was all about fraud and money.
In this case, just order the tests and don't ask questions.
And that is exactly what it FELT like she was doing! LOL! I've only had students practice procedures on me a few times. They've got to learn somehow, so I try to be understanding. But that hurt like a son of a gun!
Here's an idea for you! Can you invent a speculum that doesn't make that hideous screwing-into-place noise? That really is one of the worst sounds (and feeling, since I can feel the vibration) in the world to me.
Fewer Pap Tests Urged
By Melissa Tennen, HealthAtoZ writer
Not all women need yearly Pap smears, the American Cancer Society (ACS) says.
Seeking to prevent needless anxiety among women and unnecessary procedures, the ACS, with input from the National Cancer Institute and other leading medical institutions, developed new guidelines for doctors and health care providers.
The norm for the past 15 years has been for all women older than 18 to get a Pap smear. However, the ACS, basing its guidelines on evidence collected in the past several years, says a blanket guideline for all women isn't necessary.
The new guidelines say women older than 70 with normal Pap smears throughout life and those between the ages of 18 and 21 may not need the test. Women should begin getting the test within three years of the start of sexual activity but no later than age 21. And those who have had hysterectomies where the cervix has been removed for reasons other than cancer don't need to be tested. Historically, Pap smear tests have been continued for women who've had hysterectomies because there's no guarantee a hysterectomy removes all cervical cells.
Screening should be done every year for the traditional Pap tests or every two years with the newer liquid Pap test. At or after age 30, women who have had three normal test results in a row may get screened every two to three years. But if a woman has human immunodeficiency virus (HIV) or a weakened immune system, a doctor may suggest yearly tests.
"[The guidelines] are going to be effective in reducing costs but won't compromise women's safety," says Diane Solomon, M.D., senior investigator of the division of cancer prevention at the National Cancer Institute. "The guidelines strike a nice balance between detection sensitivity to protect women and avoiding over-treatment."
Millions of women have abnormal Pap results every year. But fewer than one half of one percent of abnormal Pap smears show cancer. These are causing unnecessary anxiety and fear among some women who don't understand these odds, Solomon says.
Doctors who have no objections to the new ACS guidelines in principle may have a more practical reason for continuing to do annual screenings.
"If your talking about cervical cancer, that makes sense, but if you're talking about overall health, that doesn't make sense," Scott A. Dinesen, D.O., in private practice in Doylestown, Pa., says of the recommended cutbacks.
Dinesen said he was concerned that the reduced recommendations might discourage women from getting a full pelvic examination every year. Whether or not an individual needs a Pap smear every year, he still believes some kind of yearly gynecological exam is indeed necessary for early detection of other cancers and other conditions which occur in that zone of the body.
"People tend to take their cars in for service more often than they get themselves to a doctor," Dinesen said.
Cervical cancer mortality has decreased by more than 70 percent in the past 50 years, according to ACS. Cervical cancer was once the number one cancer for women in the United States. It now ranks 13th in cancer deaths for women. In 2002, about 13,000 cases of invasive cervical cancer were diagnosed and an estimated 4,100 women died from this disease. However, when this very slow growing disease is caught at an early stage, the five-year survival rate is about 92 percent.
Infection of the cervix with human papillomavirus, a sexually transmitted disease, is the most common cause of cervical cancer. And many women have it. However, the vast majority of women with the infection do not develop cancer.
Most cervical precancers grow very slowly. And the majority of (HPV) infections go away on their own without causing cancer.
ROFLOL!
Kidding! LOL!
What can be done for those of us who suffer extreme side effects from HRT? I've had a complete hysterectomy, and the gastro-intestinal side effects from the HRT was horrible so had to stop the HRT.
Thanks for the comments.
That certainly is true and can happen....but is extremely rare and unusual...any little remnant left behind could undergo malignant degeneration. It is tragic when that happens because the odds of diagnosing this in a timely manner is even less than the low liklihood of finding a primary ovarian malignancy in a "normal" ovary.
Talk to your doctor about alternative routes of administration -- estrogen patches or injections may be tolerable where oral adminstrations is problematic.
If no estrogen is tolerable, or is contraindicated for other reasons such as venous thrombosis, breast malignancy etc other meds to combat the symptoms can be tried, including SSRI's such as prozac, or such meds as bellaspas, catapres in pill/patch form. Some woman try herbal remedies, the most frequently used one is black cohosh, but I don't have much luck with the herbal remedies.
Gynecologists are all perverts?
The genetic markers can be used, but you have to ask yourself what you will do with the answer...a positive test doesn't guarantee you will get the cancer, and a negative doesn't guarantee you won't.....Some women will proceed with bilateral oophorectomy if the genetic markers are positive for the piece of mind....others would just use this data to be more diligent in screening. The exact mechanisms of this screening isn't dogmatically scribled in stone...but generally would be a yearly pelvic exam, probably a pelvic sono every few years and anytime a question is raised by the exam....and a CA - 125 every couple years.....some would do this more often.
But I do still have my ovaries. That doesn't make a difference, does it?
The Pap does not detect diseases for the ovaries-it's strictly for the cervix.
I guess so, and Obstetricians too. No, just kidding. Family Practioners do it too. It's probably partly being so busy they can't keep up with the literature and standards of care, part greed for a few more sheckles, part defensive medicine, part patient expectations and part patient ignorance about their own surgical history, let alone a complete medical history.
Although I've had other ladies tell me that gas, acid and sluggish bowels are common problems for them who are on HRT. My GYN didn't want to believe me. Within 30 days of dropping the HRT all the 'new' problems disappeared. There is no other medical reason not to use HRT. I'm 57 and other than OA and Fibromyalgia healthy. BP averages out at 118/85.
Since you are being so nice about answering questions, I have a strange one for you.
I had my hysterectomy 9 years ago. My surgeon said he left one ovary to avoid the menopause problems. The GYN said I should still have paps even tho the cervix was gone, but I only went one year, didn't make sense to me.
Now....2 years ago, I went to a gyn about some hormone questions. He does an ultrasound in his office and low and behold I have 2 ovaries. He said that they can regenerate. I guess I have to believe either that or my surgeon lied to me. Any guesses??? I'm feeling like a lizard or an alien or something regenerating parts....
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