Flap about Pap

Is an annual exam needed?

The test is familiar to almost every woman who has visited a gynecologist. To take a Pap smear, the doctor inserts a metal device that enables him or her to see into the vaginal tract. Then he inserts a swab or spatula, scrapes some cells from the cervix and smears them on a glass slide, which is then sent to a laboratory for microscopic examination. A few days later, the doctor receives a report indicating whether the cells are normal, atypical or malignant. The patient gets a bill for about $6.

American women have been urged since the early 1950s to have an annual Pap (named for its inventor, Dr. George Papanicolaou) smear as a screening test for cervical cancer. That recommendation has now been challenged. Public Health Researcher Anne-Marie Foltz of New York University and Epidemiologist Jennifer Kelsey of Yale University charge that the test became entrenched as a yearly health measure before its merits could be established. At best, they say, institution of the annual Pap test has been "a dubious policy success."

Although cancer specialists point out that the incidence of invasive cervical cancer has fallen by more than 50% since yearly screening became widespread, they have no hard evidence to link the drop to the test. The decrease might be explained by other factors like the increasing number of hysterectomies, in which the cervix is usually removed. The true efficacy of the test is also clouded by the fact that though half the adult women in the U.S. have Pap smears annually, relatively few of the tests are on women who run the highest risk of developing cervical cancer. The disease is most prevalent among women in low-income groups, as well as those who begin having sex at an early age and have multiple sex partners.

Then too, say the critics, the test is not highly accurate. Primarily because the physician may take an inadequate smear, some 20% to 30% of tested women who may have an atypical or cancerous condition erroneously receive a normal report. One study shows that because the condition of the cells is sometimes misinterpreted by the laboratory, another 7% of tested women who are in good health are told they have suspicious smears, after which a biopsy is often recommended. To Foltz and Kelsey, such statistics at the very least indicate that the Pap test is being overused at considerable expense to the public; the cost of mass annual screening, including office visit charges for women seeing their gynecologists solely for the annual test, runs in the millions.

Beyond U.S. borders, others have come to similar conclusions. A medical task force in Canada studied the effects of the annual Pap smear and two years ago reported that the results did not warrant the costs. Their recommendation: at age 18 any woman who has had sex should have her first Pap test. If it is negative, she should wait a year and have a second test. If that too is negative, then she should be screened only once every three years until age 35, then once every five years to age 60. If the test is still negative, there is no need for further exams.

Though U.S. doctors took scant notice of the Canadian report, America's policy-making health institutions have tacitly begun to concede that it may make sense. The American Cancer Society, which launched an all-out drive in the 1950s to get the Pap test itself accepted by a reluctant medical establishment and urged that it be performed annually, two years ago subtly changed its recommendation; it now advises "periodic" or "regular" testing.

The National Cancer Institute is also hedging. Says Dr. Margaret Sloan, of NCI's division of cancer control: "We recommend annual Pap smears starting at age 20 or the beginning of sexual activity. That is the optimum schedule. But, if funds are limited, once you have done two or three negative Pap smears within a year of one another, you can relax and have them at a three-to five-year interval." More specific guidelines may be in the works: NCI will hold a meeting this week to discuss cervical cancer screening. Says Foltz: "The time for a policy change is long overdue."

This file is automatically generated by a robot program, so viewer discretion is required.