Sunday, November 21, 2010

Informed Consent Is Missing from Cervical Cancer Screening

Really ?
This article of mine was first published in November 2009 on  See links.

The American College of Obstetrics and Gynecology (ACOG) has just revised their guidelines for Pap smears under some pressure. This resulted from an Annals of Internal Medicine article which documented that only 16.4% of gynecologists followed the College’s prior guidelines. Most did more screenings than indicated, the worst record of the specialties tested. But the ACOG still recommends that nearly all women obtain regular screening at intervals of 1-3 years.

The facts are that cervical cancer is a rare disease in the US, a point which is never made. The American Cancer Society (ACS) predicts that there will be just over 11,000 cases in 2009. There will be nearly as many cases of testicular cancer, 8,400. In comparison both breast and prostate cancer are just under 200,000. Most women have been led to believe that cervical cancer is rampant and they need yearly screening to prevent it. Testicular cancer however, is rarely mentioned. Most physicians don’t even bother to recommend that young men self-examine.

Cervical cancer was once more common in this country and that accounts for some of the disparity. Pap screening has helped reduce the incidence, but far more is now known about the disease than when the Pap smear was introduced. Cervical cancer is in essence a sexually transmitted disease (STD) caused by the human papillomavirus (HPV). Thus any woman can estimate her personal risk. It’s high if a woman has had multiple sexual partners. With prior negative Paps it’s low if she abstains or if she is in a long term mutually monogamous relationship. The newer HPV DNA test will further increase safety.

For comparison’s sake, HIV (AIDS) is an even more dangerous STD with a five times greater incidence than cervical cancer. Yet no one ever suggests that everyone be tested for HIV, and there are laws in many states restricting testing. Testing is suggested only for those at risk, but this tactic is never used for cervical cancer.
I have seen a spontaneous outpouring of sentiment from women who are angry that the facts on cervical cancer have been hidden from them. They are pushed into getting Paps, but never told the pros and cons of screening. Never mentioned are the high incidence of abnormalities that resolve spontaneously, negative biopsies and colposcopies. It’s an uncommon doctor who even advises that every 2-3 year screening is considered appropriate in low risk women. My wife has had about 45 negative annual Paps and still her doctors haven’t said she can skip any. There are many recent recommendations suggesting that men be carefully told the options concerning prostate screening. We are just beginning to see that for breast cancer screening. But for cervical cancer screening there has been near silence on the issue.

Informed consent on cervical cancer screening is completely lacking in this country. Women are told that they need Pap tests, but rarely told if they might not need them or asked if they want them. The ratio of negative biopsies and colposcopies to cases of cervical cancer is very high given the rarity of cervical cancer. If women are given brochures, they are for the sole purpose of convincing them to get regular testing.

The negative aspects of mass cervical screening are never mentioned. Women should be given the facts and allowed to decide for themselves based on their individual risk benefit ratio whether or not they need regular cervical cancer screenings. The ACS and the ACOG could do a real service by providing pamphlets to providers’ offices that fully explain both the pros and cons of testing. Then let each individual woman decide for herself.

Links and extensive discussion of this topic can be found here.


Joel Sherman MD said...

The accompanying picture is typical of the propaganda that women face when they try to get straightforward information about the need for cervical screening. Even conservative recommendations now suggest that screenings shouldn't begin till age 21 and should end for most women by age 65-70.
Hopefully this article has contributed to bringing access to unbiased information to more women.

Anonymous said...

I was re-reading Dr. DeMay's article "Should We Abandon Pap Smear Testing?" At the end he writes:

* The Pap smear is often said to have reduced the mortality of cervical cancer by 80%, because the mortality rate in the 1940s was 26,000 (note,however, that this was uterine cancer mortality, presumed to be mostly due to cervical cancer1) and is now about 5,000 annual cervical cancer deaths (from
26,000 to 5,000, about an 80% reduction). But if a correction is made to account for the doubling of the population since the 1940s, then the relative reduction is 90% (from 52,000 to 5,000, about a 90% reduction). However, in the screened population, which is the only group in which the Pap smear can have any effect, there are only 500 to 2,000 deaths due to cervical carcinoma(since 60% to 90% of patients are unscreened or underscreened3-8). Therefore,
among women who are screened regularly, the Pap smear may have reduced cervical cancer mortality by as much as 99% (from 52,000 to 500-2,000, a 96% to 99% reduction)!"

At the beginning of that statement he says that uterine and cervical cancer were basically lumped together to get the CC mortality of 26,000 a year.

But later he says since the population of women has doubled over the years and that without screening CC would kill 52,000 women a year, as opposed to 5,000.

Uterine and cervical cancer are two different things with different causes; so 26,000 women did not die of CC, that number is a combined figure.

That statement is very confusing and it seems like he's using an invalid number since the two cancer death numbers were combined. I doubt 52,000 women a year would die of CC in America. What are your thoughts on this?

Joel Sherman MD said...

I reread the article anon. I agree that it is confusing. The incidence of uterine cancer (corpus) vs cervical cancer is roughly 3.5:1. So if present figures are for cervical cancer only (and I believe that is correct) the reduction rate is much less. Still and all, I believe it is accurate that regular Pap tests can nearly eliminate the usual causes of cervical cancer. It does so though at a substantial personal cost to women which may not be warranted given the rarity of the disease.

Violet to Blue said...

Ah, simplicity is beauty! Glad to see you're still fighting the good fight, have added the link for this to the front of my blog (if that's alright?).
Violet to Blue

Joel Sherman MD said...

Glad to see you're still here Violet. I miss your posts.
Of course you can add a link.

Elizabeth said...

Hi everyone,
Pleased to see some media coverage of American doctors requiring unnecessary pelvic exams for birth control. Hopefully more women will challenge their doctors demands in the future - they'll be more aware of what is and isn't required for the Pill and they'll have something easily accessible they can show their Dr. It may even encourage more women to complain about doctors who refuse access until women submit to these exams.
I think this sort of coverage is very helpful.

Joel Sherman MD said...

Elizabeth, I agree with you. That is a very encouraging article, especially to be found in the mass media blog. I haven't gone through the comments. I hope they are supportive.

Nekura said...

Ah I'm a year late. This is the first time I've ever seen this on Google's Homepage about smears and privacy rights. Thank you for writing this. I suffered extreme anxiety and crying over the pap. I had a boyfriend I loved and didn't want to lose because I was afraid to have sex due to the risk of pregnancy (even with condoms, and everyone says just get on the pill). I suffered so much from this policy. For 4 years my life was hell and the enforcement felt like rape to me. I was sexually active at 17, had to buy pills overseas. When I told people why they, especially women, verbally attacked me to the point that I was in tears. It wasn't right, no one agreed with me but one friend who got pregnant due to this policy.

Thank you for this blog, and this post. I do have annual screening now (which is useless a s I've been with my pre-virgin highschool sweetheart for 7 years) but I put up with it because I like my doctor, but it always leaves me trembling despite the test not being painful. It's just humiliating and terrifying to me, every time.

Medical Patient Modesty said...

I recently wrote an article about pap smears, "Truth About Pap Smears" and I definitely used this article as one of the sources. I really appreciate Dr. Sherman's great article. Women should always be offered informed patient consent for pap smears. It is ridiculous about how the guidelines do not take into consideration that there are different risk groups.