Dr. Pat Responds:

Dear Kathy:

I am sorry for your loss and recognize that it must be hard to understand your sister’s death from cervical cancer since she thought she was following new guidelines for performance of pap smears. It took her two hours each way to visit a gynecologist and she took away the message from her primary care doctor that since she was at low risk for cervical cancer she did not need to see the gynecologist unless she developed symptoms that required evaluation from a specialist.

The prevention of cervical cancer is one of the great triumphs of cancer screening.

Since George Nicholas Papanicolaou developed the Pap smear — the screening test — in 1943, the incidence of cervical cancer in the United States has declined by 50 percent. Most women who develop the disease have not undergone recommended screening or have had false-negative Pap smears (the pap smear was actually abnormal or had an inadequate sample). In areas of the world where Pap-smear screening does not exist, cervical cancer remains a leading cause of death for women.

For decades women were advised to have a Pap test every year — generally by a gynecologist, who would also review their general health and well being. The need to go for a regular Pap smear reminded a woman that she should see her doctor annually.

Recently, however, panels of experts recommended that some women have less frequent screenings. Several factors influenced their recommendations: (1) a new understanding of the molecular origins of cervical cancer; (2) a better understanding of precancerous changes related to the disease; and (3) the fact that testing for HPV, the human papillomavirus, can now be added to the Pap smear for screening. If your sister had been tested for HPV she would have been followed more carefully with annual Pap smears.

Human papillomavirus, a very common sexually transmitted virus, is now recognized as the cause of cervical cancer. Approximately 50 percent to 70 percent of sexually active women will be infected at some point during their lifetime. It is important to realize, however, that the vast majority of women who have an HPV infection do not have problems from it. Still, the presence of HPV may signal that a woman has some elevated risk of pre-cancerous and cancerous conditions of the cervix.

The Pap smear was designed to diagnose pre-cancerous changes in the cervix so that these changes can be treated before they have a chance to become cancer. HPV testing on Pap smears has been incorporated into most physicians’ practices. This HPV test is generally done on cells that are removed at the time of the Pap smear. If a women is celibate or certain that she is in a monogamous relationship and has never had an abnormal Pap smear and is free of the HPV infection, than she may be a safe candidate to have Pap smears on a less frequent basis.

Sexually active women over the age of 50 should not  discontinue annual Pap-smear screening. These women should discuss their personal health and sexual history with their physicians to determine how these new recommendations should be incorporated into their care. Women with elevated risk factors should continue to see their gynecologists on an annual basis to reassess their risk factors for cervical cancer and further refine their screening. At this point, studies show that many physicians (private practice and academic) choose not to follow some of these new recommendations, focusing on the individual patient instead of epidemiologically derived data about groups of women. It may take many years before we know that that this type of screening is indeed safe and effective. The Pap smear has saved countless women from developing cervical cancer but the ongoing analysis of large amounts of data will allow us to use this important test in the most effective way. In the meantime, Kathy, continue to see your gynecologist for your annual well woman exam and discuss the latest recommendations for any change in screening tests each year.

Dr. Pat

On the following page, we have asked Dr. Melissa Frey, a new member of our Medical Advisory Board, to discuss cervical cancer and the new screening guidelines. Dr. Frey is a gynecologic oncologist and assistant professor of obstetrics and gynecology at Weill Cornell Medical College.