Tuesday, November 3, 2009

The Pap Smear: A Symbol for Our Health Care System's Problems

Today the Wall Street Journal and other sources reported on a study from The Annals of Internal Medicine that showed that most US doctors don't know the guidelines of how often women should get a pap smear. More importantly, doctors were doing a lot of pap smears on women who didn't need them. In all the talk about health care reform, reducing costs by eliminating unnecessary testing has been mentioned multiple times. Thus, if we can figure out how to get rid of all of these unneeded pap smears, maybe we can find the cure for our health system's woes.

The results of the study are not surprising to me, as I have seen this in clinical practice. The more I thought about why this is occurring, the more I thought about the pap smear as a symbol of our health care system's problems. So why so many pap smears?

1. Pap smears have saved lives. Cervical cancer used to be a major killer of US women. Now it is rare to hear about a women who has died of cervical cancer. Not true in third world countries when screening is not possible. The fact that we have virtually gotten rid of a cancer with early detection is truly amazing. But the danger here is that it has set up the paradigm that this is true for all diseases and cancers. Recently, breast cancer and prostate cancer screening have come under fire for not really saving any lives. However, even with the data, patients and advocacy groups will not likely take a screen only if proven life saving approach. Breast self-examination has absolutely no data to support this practice, and in young women who are likely to find non-cancerous bumps, may actually be harmful. Yet, this practice is routinely recommended for many young women.

2. Women (and many men) want/expect a yearly physical, and most women believe that a pap smear is part of this. Similar to other types of cancer screenings, there is very little evidence that a routine check up is beneficial. This is not to say that you shouldn't visit your doctor regularly. However, many of the things doctors do during a physical have limited to no value. There are some things that have tremendous value, such as checking blood pressure and weight, and talking about diet, exercise, smoking cessation, etc. However, having the doctor check your whole body every year when your feeling just fine is unlikely to be helpful. Yet, the American public expect a full exam every year. After all, their health care premiums are quite high, so they might as well get checked out. This extends to the pap smear. It saves lives (as above), is part of my regular check up, and I am paying a lot of money for this; so therefore I expect my yearly pap.

3. Physicians have little disincentive to refuse to do a pap smear. The pap smear only takes a few minutes. Trying to take the time to explain #1 and #2 above makes little sense for the primary care physician who is not paid by time spent counselling a patient, but by how many patients she can see. In other words, talking a patient out of an unneeded test actually costs the primary care doc money, because that time could be used for seeing another patient. More importantly, if the physician refuses the pap smear, and the patient goes elsewhere to get the pap smear and is found to have cervical cancer; the physician could get sued placing her entire career in jeopardy!

If pap smears save lives, patients expect/demand them, talking a patient out of an unnecessary pap smear only costs me money and not doing the pap could get me sued, why wouldn't I do a pap smear on every women that wanted one?

4. The pap smear rep reminded me to get the test. The drug companies are not really the problem any more. Every day you read about a drug company laying off employees. This is because most drugs are or will soon go generic and there is little in the pipeline. This is not the case for devices and testing. Big labs have reps that come to physician's offices to discuss the latest fancy new test. Like the drug reps, they bring lunch too. The difference: medical devices and testing though FDA approved are not nearly has heavily regulated as the drug companies when it comes to selling to physicians. Drug reps by law are restricted to saying only what is in their label to physicians. It works a little bit differently for the lab and device reps. As newer tests and devices become available, watch for more of a focus on selling these products. Don't be surprised to see direct to consumer advertisements asking patients to ask their doctors about such and such a test.

5. The experts don't agree. It is very hard to keep up with evidence based guidelines in primary care. It's even harder when there are multiple guidelines, and harder still when they don't agree. For prostate cancer, the American Cancer Society and the American Urological Society say that doctors should test for prostate cancer. The US Preventative Health Task Force guidelines say that we shouldn't. Initially, some of the groups recommended more frequent pap smears, but recently decreased the interval due to evidence that less frequent screening was better. However, with all multiple guidelines that often differ, it is not surprising that so few primary care physicians actually knew what all the experts actually did agree upon. Another issue is that reasons behind differing guidelines have to do primary with politics and money. The Urologists want primary care docs to test for prostate cancer because they make money when the test comes back positive. The government doesn't want you to test for prostate cancer, because testing leads to more testing and treatment which costs them (you the taxpayer) more money.

6. Doctor's don't follow guidelines anyway. Even if there was one clear and definitive guideline for docs to follow, they probably wouldn't. There are likely multiple reasons. Our current Continuing Medical Education system (CME) that is supposed to keep docs up to date is horrible and funded by commercial interest. The stimulus package already gave some money for comparative effectiveness research and there will likely be more money for this in any health care reform bill that passes. However, if docs don't know the results of what is best or what actually works, then the data is not all that useful. It is unlikely that a drug company is going to fund a CME program that shows their drug is not useful. So who is going to fund the dissemination of comparative effectiveness findings? There is also no real incentive to follow guidelines. Again, docs get paid for how many patients they see, not by how beneficial their advice was to patients or whether they gave guideline appropriate care.

Since pap smears don't cost a substantial amount of money, it is unlikely that getting rid of all these unnecessary pap smears is going to put a dent in health care spending. However, the underlying reasons behind the many unneeded pap smears is a symbol of what what's right and wrong about our health care system. We should give this study's findings, and more importantly the reasons behind these findings, a critical look.


Anonymous said...

The problem with doing too many smears and doing inappropriate smears is you expose your healthy patients to risk.
The smear produces lots of false positives and 95% of women having yearly smears will end up having a colposcopy and usually some form of biospy. These procedures are unpleasant, painful, embarrassing and stressful...some women are left with problems as a result.
I blame doctors for the fear that women carry around about this uncommon cancer. I've read the excessive colposcopy business in the States is worth a billion dollars. Excess is big business.
Perspective has been lost and balance...screening is motivated, not by women's healthcare, but financial gain and covering your back.
Women have been deliberately misled as to the risk of this cancer and so many women are fearful out of all proportion to the risk. They also have never been told the test only helps a tiny number and produces lots of false positives. Women have screening "done to them"...they are not active participants in their healthcare.
I found it interesting to read that mouth cancer occurred as frequently as cervical cancer...start screening and all of a sudden women are terrified of cervical cancer. Yet is anyone afraid of mouth cancer? You have the same risk of getting mouth cancer.
I don't accept that screening has resulted in all of the decline in the death rate...one in three US women has had a hysterectomy (horrifying!) No doubt the end result of having unnecessary and potentially harmful routine gyn exams.
Also, better treatment means fewer women die from this cancer.
Condoms provide better protection these days. (since the AIDS scare)
The disease was in decline before screening started...
I think there are many things that have contributed to the decrease.
I was shocked at the excess in the States and very pleased I didn't have to negotiate your healthcare system. I think it would detract from your life. Your focus also shifts to illness and testing instead of life and health.

Anonymous said...

I agree totally with you, Liz. I'm flabbergasted at the purposeful invasion of womens rights in America over un-needed pap smears and pelvic exams.

I'm hearing story after story of pregnant women being refused care by a OB/GYN because they say no to an 'obligatory' pap smear. What on Earth does a pap smear have to do with you being pregnant? Where is all this crap coming from?

And annual pelvic exams? Are they kidding? What a load of crap. No one needs annual pelvics!

I'm Australian. I refuse pap smears and always will, and I view gynaecologists with extreme suspicion, they are cold and dismissive of how you feel about being 'treated'. My body my rights.

Sydney Girl :-)

Sue said...

Actually pap smears during pregnancy and within 6 months of childbirth are a BAD idea.
Your smear is likely to be abnormal due to hormonal changes or trauma. (the latter after childbirth)
I know a few women who had stressful pregnancies after being forced to have pap smears and eventually had negative biopsies. All that worry for nothing.
The biopsies were left until after delivery so as not to compromise the pregnancy BUT these doctors know what they are doing...
There are many articles in medical journals that say smears during and just after childbirth have a high risk of being false positives.
Also, the number of pre-term deliveries is on the rise and one of the reasons are all the unnecessary biopsies for false positives. When about 99% of biopsies are unnecessary that leaves a lot of damaged women.
Obstetricians have been concerned for years about all this cervical damage. Scar tissue can cause infertility as well as prem babies and in extreme cases the woman can't maintain the pregnancy without having her cervix stitched closed...just awful.
What are we doing to women? All for a very uncommon cancer.
It makes no sense to me, this testing should be confined to high risk women and women who are risk averse and leave the rest of us alone!
I don't test, but I'm very low risk. I'd never chance treatment for a false positive.
I suspect if they were cutting off pieces of manhood this testing would have been ditched years ago or at the very least they'd be some respect for informed consent.
Paternalistic attitudes and profits keep this screening alive and well.
It's an unwise thing to just go along with doctors and all this screening, it really can harm you.
Re: Pregnancy
See - http://www.cancerhelp

Prem babies - Why should preterm births be rising? Shennan and Bewley 332 (7547):924 - British Medical Journal

Anonymous said...

The worry caused by pap smears, you only have to google the subject and you'll find pages of references from frightened and worried women and then the sites with all the young women having "treatments" and biopsies...and in the States that's almost everyone who has smears.
When I think how few women actually get this cancer with no smears at all, I really wonder why we're bothering...all the heartache, stress and pain is much more likely to harm us and all of this certainly detracts from a happy life.
The controlling nature of this test also bothers me. It almost controls and judges female sexuality. Men don't face this judgement.
Women who get abnormal smears feel dirty or guilty, when in fact, the test is often wrong.
I've never had them, never will, I'm enjoying my life. When someone gets a rare cancer, that's sad, but this amount of surveillance, embarrassment, pain and stress is far too much for a rare or uncommon cancer.
It astounds me so many women behave like sheep and have their whole lives dominated by this ugliness.
Instead of 1% of women worrying about this cancer, about 99% of women are worried about this cancer.
I think when a test is invasive and inaccurate, it should be ruled out for cancer screening whether the cancer is common or not.

Anonymous said...

So glad women all over the net are waking up! I feel freer. I'm gen x and hope to see an end to these bdsm rituals in my lifetime. For those high risk women who like to be careful, fight for the blood test which is actually accurate.

Anonymous said...

Many women are coerced into having these tests. The reality is we have a right to REFUSE ANY TEST! Doctors should not be telling women they "have to" or "should" have pap smears; it is suppose to be 100% optional, yet we are made to feel there is no option.

Anonymous said...


I have refused pap smears for over ten years now. But every consultation I went to I was reminded that a pap-smear was due.Lucky for me this year I found a doctor that doesn't push the subject. Seeming, I a blood test can tell me I have cancer. And all these technological equipment can surely say where it is located without going to such invasive techniques. Besides if you had a pap smear early in the year doesn't mean cancer cannot develop over the year. It is just ludicrous that people think it will save their life.If anything people have more chance of dying from skin cancer than cervical cancer but you don't see doctors pushing for that test to be done.