Pap smears: are we doing a good job?

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Public health screening tests for things like Breast Cancer, Prostate cancer and Cervical cancer are never far from controversy. And NO screening test is a 100%, gold-plated certainty to pick up all the cases of cancer that it is designed to detect. Also, more and more malignancies are being found to have some form of environmental link -

• Smoking and lung cancer
• Alcohol and bowel/breast cancer
• Hepatitis C and liver cancer
• Papilloma viruses and Head and neck plus Cervical cancers

   so prevention is a much better approach than shutting barn doors after horses have bolted!

Also, although we tend to assume that Pap smears are a simple procedure, like getting your passport checked at immigration, from a practical point of view - both for the patient and the practitioner - they are sometimes far from easy to perform!  For instance, strange though it may seem, the Cervix is not always easy to locate by an inexperienced Practitioner who does not have their examination room set up to perform them on a routine basis. Anatomically, in a woman who is overweight and not very "agile", and who has lax pelvic structures,  it can be very difficult to directly view the cervix as it is doesn't come with a label, nor is it distinctly a different colour to the rest of the surrounding vaginal structures!

But even in those cases where the experienced person can perform the screen and send the "smear" off for cytological examination, again the results cannot be claimed to be 100% certain. However, there are certain broad guidelines that are used to reduce the risk of missing early, treatable Cancer of the cervix, and these guidelines are based on age. BUT EVEN THEN THESE GUIDELINES MUST BE TAILORED TO THE INDIVIDUAL NEEDS OF EACH WOMAN.

In 2012, the U.S. Preventive Services Task Force, American College of Obstetricians and Gynecologists and American Cancer Society recommended that:

1. Cervical screening should begin at the age of 21
2. Screening should be every 3 years and not annually.
3. Screening is NOT necessary for women who have had a Hysterectomy for non-cancerous reasons.
4. Screening is not necessary for women over 65 who have had several previously normal Pap smears.

Current national policy in Australia is:

1. Routine screening with cervical smears should be carried out every two years for women who have no symptoms or history suggestive of abnormal cytology.
2. All women who have ever been sexually active should commence having a cervical smear between the ages of 18 and 20 years, or one or two years after first intercourse, whichever is the later.
3. Cervical smears may cease at the age of 70 years for women who have had two normal cervical smears within the last five years. Women over 70 years who have never had a smear or who request a cervical smear should be screened.

From a recent CDC report, it appears that many women - 22 million in fact - may have had unnecessary Pap smears. The reasons behind this massive failing are probably not limited to the US: they're just far more honest about it!

My take on all of this? Sex is literally in our DNA, but we have to be aware that casual sex can cause permanent damage! As far as cancer of the cervix goes:

• We need to improve our rates of vaccination with the most effective HPV vaccines currently available. 
• We need to educate the most vulnerable groups on how to best protect themselves with vaccination and condoms. 
• We need to screen those groups who are known to be more at risk (and at this stage I would tend to favour the American guidelines over the Australian ones). 
•  Finally, those who are screening for Cervical cancer should only be screening those at risk and there should be no place for "over-servicing" of inappropriate cases.

references:
CDC
RACOG

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