Does one dare ‘smear’ the annual Pap smear?
DRUG BUST by Alan Cassels
Of all the medical screening programs offered to the population nowadays, which are the most valuable in terms of potentially saving a person’s life? Asked that question recently, I immediately answered “the Pap smear.” It’s a test that examines cells removed from a woman’s cervix for any signs of abnormality, a potential precursor to cervical cancer. While relatively easy to administer, many women find it rather invasive and unpleasant, even as it accomplishes what a good screening test should: it finds abnormalities in a relatively safe and efficient way before they develop into real health problems.
In the past, experts recommended women have a yearly Pap smear from the time of their “sexual debut” until old age, but how often do women really need it? This is a subject of some debate and Pap screening recommendations in Canada are all over the map. Health systems in Newfoundland and Alberta recommend screening every year; other provinces recommend longer periods – every two or three years. The Canadian Society of Obstetricians and Gynecologists recommend screening every three years after a woman has had two normal tests.
Changing recommendations around screening is always controversial, but I think it’s a good thing. After all, it may be due to the fact people increasingly recognize technology bites back and “good for one, good for all” thinking is problematic. The idea of selective screening for people at ‘high risk’ and not screening low risk people who stand little chance of benefiting is now gaining a foothold in the medical marketplace. In our modern, over-diagnosed world, administering medical procedures, drugs and tests wisely is all about constantly thinking about how not to overuse, underuse or misuse them.
One fact is unavoidable: not all women are at equal risk for cervical cancer. In Canada, older women (aged 40-59), immigrants, aboriginals and those from lower socio-economic strata are all at higher risk for cervical cancer and most cervical cancer deaths happen among those screened infrequently or not at all.
Where in the world is more cervical cancer-screening actually needed? In the poorest parts of the globe. This fact was recently reiterated when none other than former president George W. Bush announced the next phase of the Emergency Plan for AIDS Relief. In August, George W. announced a major push to expand the screening and treatment of women with cervical cancer, a laudable goal considering the majority of women dying of cervical cancer – more than 85 percent of cases – are in developing countries.
HIV positive women are especially at risk – up to five times more than women who are HIV negative. A woman’s risk of cervical cancer also rises with her level of sexual activity (number of partners) and so on.
In our corner of the industrialized world, we find groups like the American Congress of Obstetricians and Gynecologists proclaiming, “cervical cancer rates have fallen more than 50 percent in the past 30 years in the US due to the widespread use of the Pap test.” Really? Are we placing all the advances made in women’s sexual health in recent years at the foot of the humble Pap smear?
Undeniably, the Pap test can help pay the bills. One physician friend doing a stint at the U of T student health clinic told me about a student who wanted to renew her birth control pills without a Pap smear. The student, who had had only normal tests, said her previous doctor expected her to submit to a smear every time she wanted a new script for oral contraceptives. Which meant every three months.
Dr. Warren Bell, a family doctor in Salmon Arm, BC, recalls how recommendations around the Pap test have undergone sometimes boomerang-like changes. According to Bell, “about two decades ago, the BC Cancer Agency, which reviews all slides from Pap tests throughout the province, made the bold recommendation that, after a couple of initial normal Pap tests, and as long as your sexual partner did not change, Pap tests could be reduced to every two years. At age 35 or so, if the same conditions prevailed, they could be reduced to every three to four years. And after age 50 to 55, they could be reduced to every five years, and then ended completely after age 70.”
While most women would have welcomed these changes, Bell said the announcement “was greeted with howls of protest from the gynecological community.” The cancer agency backtracked, withdrew its recommendation and went back to pumping the annual Pap test – another example of ‘expert opinion’ slapping down common sense.
To answer the “do I need an annual pap test?” question, the answer is “it depends.” In Dr. Bell’s opinion, the recommendation for the Pap test shouldn’t just be based on a random time interval, but should also consider a woman’s socio-economic circumstances, lifestyle and sexual partners.
Dr. Bell recalls the most over-zealous Pap testing he’d encountered: an 82-year-old woman came to his office for her annual pap smear. He said his “jaw hit the floor with a thud” after the woman told him she had had the test every year, never shown any abnormalities and lived with the same partner for decades.
Physicians are convinced they need to be ‘doing something’ to prevent a disease that kills about 400 women a year in Canada. While cervical cancer still represents less than two percent of all fatal cancer deaths every year, it is still important to do what we can to reduce those deaths. One thing the medical community is ‘doing’ is embracing, researching and promoting the links between the human papillomavirus (HPV), an extremely common sexually transmitted virus, and cervical cancer.
Which brings us to Gardasil, the first vaccine marketed to prevent infections of HPV. If you haven’t noticed, it’s been back in the news recently, finding its way into the race for the nomination for the Republican presidential campaign.
US Representative Michele Bachmann recently attacked her opponent Texas Governor Rick Perry over the safety of the HPV vaccine. Mr. Perry, no doubt fuelled by campaign donations from Gardasil’s manufacturer, thought it was a good idea to issue an executive order requiring grade-six girls in Texas to be vaccinated for HPV. The twitterverse has been alight with the Perry-Bachmann banter on this exchange, yet here in Canada, we seem to have a decidedly more funny (not) take on HPV.
Late last summer, the province of Quebec funded and launched a campaign that probably rates as the most ludicrous example of cervical cancer mongering in history. This campaign glosses over the safety and effectiveness of the HPV vaccine and essentially says girls in Canada have a simple choice: They can either get the HPV vaccine or wear a chastity belt.
(http://www.vaccinvph.gouv.qc.ca/index.php?lng=en)
I couldn’t make this stuff up. And if I could, I’d be doing standup instead of writing columns.
Let’s face it folks; whether you are pushing the vaccine or the pap smear and whether you use political bullying or humour, denying the potential for their adverse effects and promoting them to everyone, everywhere, can only be called one thing: bad medicine.
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Alan Cassels is a drug policy researcher at the University of Victoria. Read more of what he’s writing about at www.alancassels.com
