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Do doctors screen for cervical cancer too often?

Survey finds that physicians recommend testing more often than guidelines suggest

By Marissa Cevallos, Orlando Sentinel

12:12 AM EDT, June 15, 2010

It sounds like the breast- cancer debate all over again: A new study has found that doctors have been overzealous in advising women to be screened for cervical cancer.

Although physician groups and federal guidelines recommend that women older than 30 get a Pap test every three years, a survey of more than 1,200 doctors in the Journal of the American Medical Association released Monday found that about two-thirds would recommend that patients be screened more often.

The report cautions that if doctors disregard the guidelines, it will be difficult to control the cost of screening the more than 100 million women in the U.S. for cervical cancer.

And now, as policy-makers try to cut health-care costs, doctors worry that discouraging women from making regular gynecological appointments could mean fewer opportunities to screen them for other deadly diseases such as breast and ovarian cancer.

Waiting three years between Pap tests is too long, say some local health-care providers who have urged patients to be screened every year.

"So many things can change in three years," said Shari Layton, a nurse at a private practice in downtown Orlando who has performed Pap smears for nearly 30 years. Women can meet new sexual partners and contract genital human papillomavirus, or HPV, the sexually transmitted disease that can cause cervical cancer, she said. "I don't think there's any risk in testing every year."

Some doctors say that many women consider their OB-gyn their primary-care physician, and may not have medical care other than their annual Pap test.

"If they don't bring a woman in on an annual basis, they think they will lose the women for other reasons," said Dr. Mona Saraiya, the study's lead author. "The Pap test was sort of the hook."

When a federal task force last year urged doctors to stop ordering mammograms for women under 50 who were at low risk for breast cancer, doctors were deeply divided about whether to adopt the new guidelines. But the three groups that issue cervical-cancer guidelines — the American Cancer Society, the U.S. Preventative Services Task Force and the American College of Obstetrics and Gynecology — all agree that women don't need testing every year. Doctors just don't appear to be following the guidelines.

"Physicians have been slow to adopt the new guidelines," said Dr. Veronica Schimp, a gynecologic oncologist at Orlando Health. One reason, Schimp said, is that doctors may not understand how slowly HPV causes cancer in the cervix, sometimes taking several decades after infection.

Physicians who have always advised their patients to get an annual Pap smear are reluctant to suggest that patients be less vigilant about the screening, even though more-frequent testing hasn't been shown to reduce cervical-cancer deaths.

By some estimates, 20 million Americans are infected with HPV. Last year in the U.S., 11,000 women were diagnosed with and 4,000 women died from cervical cancer. Doctors test for cervical cancer by performing a Pap smear in which they scrape cells from the cervix and look for any abnormalities. Another type of screening, called an HPV test, is performed in the same way but looks for the virus that can cause cervical cancer.

The issue is controlling costs, according to Florida Hospital gynecologic oncologist Dr. Robert Holloway. Pap smears are relatively cheap, he said, but the costs add up when they're recommended for more than 100 million women.

"Everyone's looking at where we're wasting dollars," Holloway said. "As long as we're saving dollars and not costing lives or complications or side effects, I don't think there's anyone in the public domain who's against that."

It's probably not necessary for a 40-year-old woman in a monogamous relationship to be screened every year, Holloway said. But a sexually active woman in her 20s, or a 60-year-old widow who is dating new people, should be screened more frequently.

The newest guidelines state that instead of having annual Pap smears, women older than 30 can use a negative HPV test along with a normal Pap smear to extend the time between screenings to three years. Doctors don't recommend that women in their 20s get HPV tests because in about 90 percent of 20-something women who test positive for HPV, the virus leaves the body within two years.

The push toward fewer screenings for both breast cancer and cervical cancer comes from weighing costs and benefits, Holloway said. Although Pap smears are cheaper than mammograms, women are 10 times less likely to die from cervical cancer than from breast cancer. A Pap test costs between $15 and $30, according to Saraiya, while an HPV test is about $50 or $60.

As long as doctors continue to recommend annual Pap smears for healthy women, costs are likely to increase "with little improvement in reducing cervical cancer incidence and increasing survival," the authors of the new study wrote.

But Holloway cautions against one-size-fits-all guidelines because a patient's medical and sexual history are important factors: "Sometimes we have to make individual decisions."

When should women be screened?

•According to the U.S. Preventative Services Task Force, women should start getting Pap tests no later than age 21 and be retested every two years between ages 20 and 29.

•Women over 30 can extend the time between screenings to three years if they have either three normal Pap tests in a row or one normal Pap test combined with a normal HPV test.

•Women age 65 and older who have had three consecutive normal Pap tests — and no abnormal ones in the last 10 years — can decide to stop getting Pap tests.

SOURCE: Sentinel research

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