The article series, Data Driven Docs, is designed to provide a behind-the-scenes view into a few areas of medicine that should be driven by data or best practices and for whatever reason are not. Sometimes our practices are driven, as mentioned in previous articles, by third parties or regulation agencies. Sometimes we ignore best practices because our patients ask us to.
As a guest writer, I will make a departure from the glamorous world of aesthetic and flight medicine and delve into something as mundane as the Pap smear. Men – you are not yet welcome to put the paper down and leave. I’m going to talk about something you might find interesting as well if you are a bit of a science nerd. Ladies – I know that Pap smears are something that you have historically felt were your annual duty. Skip them and you could be sure to feel the wrath of your disapproving provider and potentially even have to beg for your birth control. Take heart, times are changing.
Described initially by Dr. George Papanicolaou in 1943, the Pap smear has been the single most life saving screening test we as a species have ever dreamed up. Cheap, easy, fast and readily available; it is performed around the world more often than any other cancer screening test in existence. Is it perfect? No. Is any screening test? No. We have, however, gotten much closer to perfect since 1943. I’ll explain. A Pap smear consists of cells from the cervix taken during a pelvic exam being evaluated under a microscope to see if they have any characteristics of cancerous cells. That was, until 1999, the best we could do. In 1999, the FDA approved a molecular test to diagnose the viral infection (human papilloma virus or HPV) that caused cervical cancer. The test was not easy to use until Pap smear collection changed a bit and we could test for the virus without a second visit or second pelvic exam. After a few years with the HPV testing technology and some more studies, we began to understand more fully the progression from viral infection to cancer. We began to see that most of the women who had this virus got rid of it all by themselves in a year or two. In 2006, the Pap smear screening intervals changed as women were risk stratified by their age. Our management of borderline Pap smears changed to include HPV testing. In 2012, the recommendations changed again to further extend the screening interval to five years.
Five years?!? I have many patients who don’t believe it and feel that skipping their Pap smear is akin to a death wish. I have heard a number of times “I know about the new recommendations but I would feel better if you just went ahead and did my Pap smear.” Before you start to feel like five years is long enough to slip through the cracks consider that screening tests are a balancing act. They don’t diagnose anything. It takes more testing, more expense and more emotional trauma to make the diagnosis and the job of the screening test is to help us determine when further testing is warranted. The new guidelines were designed to get more bang for our buck. If you have an abnormal pap smear in 2012 we are already much closer to a significantly risky diagnosis than we were with an abnormal Pap smear in 1998. I am in no way arguing that abnormal Pap smears should not be investigated appropriately. In some cases this includes repeating the test in a year. In some cases, this includes a diagnostic test called a colposcopy. In some cases, the Pap smear is significantly abnormal enough to warrant skipping the diagnostic test and going straight to treatment. In NO cases does it ever include repeating the Pap smear in few months and believing a better result. At your next visit, ask where you fall on the screening interval spectrum. Ask where you are spending your healthcare dollar. Let’s make them count.
Disclaimer: Dr. Keri Rath, MD, FACOG is a board certified Ob/Gyn in Ruidoso, New Mexico. She finds molecular diagnostic technology exciting as she was originally a biochemistry and genetics nerd and will be happy to whip out a flow chart or draw an explanation on exam table paper for you if you want one. Comments or questions? Email Contact@FusionMedicalSpa.net.