Low-grade lesions of cervical cells, which can be treated before progressing to cancer. Image: National Cancer Institute
Welcome to the latest installment of “Over 90 Percent of What Planned Parenthood Does,” a series on Planned Parenthood Advocates of Arizona’s blog that highlights Planned Parenthood’s diverse array of services — the ones Jon Kyl doesn’t know about.
Pap tests are not beloved — there, I said it. Many people who receive them hope for the day that medical science devises an equally effective but noninvasive test, whatever that might entail, as they may find them to be anything from slightly awkward to incredibly traumatizing. However, the evidence overwhelmingly shows that access to Pap testing (also called Pap smears) has transformed cervical cancer from a top killer into something that can be caught early and treated before it can do much damage. As a tool to reduce cancer deaths, Pap tests have been a resounding success.
In countries with widespread access to Pap tests, cervical cancer rates have plummeted.
A Pap test involves an instrument called a speculum being placed into the vagina to hold it open while a health care provider uses a small spatula or a tiny brush to collect cells from the cervix, which is at the opening of the uterus. These cells are analyzed in a laboratory, where a technician can determine if they are precancerous. (Cervical cancer is caused by a sexually transmitted virus called human papillomavirus, or HPV.) When caught in its precancerous stages, cervical cancer can be treated with procedures such as colposcopy and cryotherapy.
Pap testing guidelines have recently changed. It is currently recommended that:
- people with cervixes start getting routine Pap tests at age 21
- Pap tests should be done every three years or every five years if a Pap test and an HPV test are performed at the same time
- Pap tests should continue until about age 65 — or later, if there is a recent history of abnormal Pap tests
The Pap test is named for its inventor, George Papanicolaou, who immigrated to New York in 1913. Trained as a physician in Europe but without a penny to his name when he stepped off the boat, he spent the first few months of his new life in the New World as a carpet salesman before landing a job at Cornell University. His task: to study the menstrual cycle of the guinea pig, which neither bleeds nor sheds tissue during menses. He developed a technique to collect cervical cells from the rodents using a nasal speculum and a Q-tip, after which he spread the cells onto a slide in a preparation called a “smear.” He could then examine the guinea pigs’ cervical cells under a microscope, and soon determined that the cells cycled through different shapes and sizes in lockstep with the menstrual cycle itself — allowing him to track the rodents’ menstrual cycles despite the lack of telltale bleeding.
He found that human cervical cells went through such cycling as well — apparently he subjected his wife, Maria, to daily cervical-cell collections so that he could better understand the relationship of cervical-cell morphology to the stages of the human menstrual cycle. After spending many years staring at normal cervical cells, Papanicolaou realized that his seemingly useless procedure might be used to identify cervical cells that were not normal — cells that had developed abnormalities indicative of disease. So he started collecting cervical cells from people with all sorts of pathological conditions, looking for patterns amid the endless sea of cells.
Magnified cervical cells are projected behind George Papanicolaou, the developer of the Pap test. Image: Johns Hopkins University
Eventually he found a correlation nestled within the chaos: Under the microscope, cancerous cervical cells had huge nuclei while the rest of the cells’ innards wasted away, contained within uneven membranes. He revealed his diagnostic technique in 1928, but it was brushed aside as a primitive procedure that paled in comparison to biopsy, the preferred method of cancer diagnosis. The world of medicine heaved a bored sigh, and nothing came of Dr. Papanicolaou’s test.
During the next couple of decades, he refined his technique. At the time, other researchers were noting that cancer entailed a progressive series of steps as cells slowly transitioned from normal to cancerous. As oncologist and writer Siddhartha Mukherjee explains in The Emperor of All Maladies:
Cervical cancer typically arises in an outer layer of the cervix, then grows in a flaky, superficial whirl before burrowing inward into the surrounding tissues.
Instead of focusing on full-fledged cancer cells, Dr. Papanicolaou wondered if he could identify the stages in the slow progression of cells from normal to malignant. This way, his test could be used to detect precancerous cellular abnormalities — when the condition could be treated — rather than as a shoddy diagnostic technique for cancer that had already developed — when the condition might be incurable.
In 1952, the Pap test got a new lease on life when the National Cancer Institute ran an enormous clinical trial to determine its efficacy in cancer prevention. In total, 150,000 cervix-wielding Tennesseans were regularly tested and tracked over time. More than 500 of them were found to be asymptomatic owners of precancerous cervical cells — and were treated surgically before the cells could continue their slow journey toward malignancy.
As they say, the rest is history. In countries with widespread access to health care, cervical cancer rates have nosedived thanks to Pap testing. In the United States, half of cervical-cancer deaths occur among people who have never had a Pap test; in some undeveloped countries, cervical cancer remains a major cause of death.
Planned Parenthood health centers offer Pap tests as part of our commitment to preventive health care. Other ways to reduce risk for cervical cancer include vaccination with Gardasil, which protects against the two strains of HPV responsible for 70 percent of cervical cancers. Planned Parenthood clinicians can also talk to you about safer-sex techniques that can further protect you from the virus that causes cervical cancer.
In countries like the States, Germany and Australia the pap test has been horribly and recklessly overused causing widespread distress and damage to huge numbers of women – women are tested far too often and far too early. I look to the Netherlands and Finland and the Nordic Cochrane Institute for evidence based advice and programs. The Finns have the lowest rates of this rare cancer in the world and send FAR fewer women for unnecessary biopsies and potentially harmful over-treatment…their program has been in place since the 1960s so none of this is new. CC was always rare and in natural decline before testing started – after you take out false negatives and consider natural decline fewer than 0.45% of women could be helped by pap testing. Lifetime risk of cc is 0.65%, lifetime risk of referral for colposcopy/biopsy in Australia is a whopping 77%, even higher in the States, thanks to serious over-screening. [Citation Needed – Ed.]
The Dutch have the same program as the Finns, but will move with the evidence yet again, do what’s best for women and will shortly introduce a new program, 5 hrHPV primary triage tests offered at ages 30,35,40,50 and 60 and ONLY the roughly 5% who are HPV positive and at risk will be offered a 5 yearly pap test. The vast majority of women are HPV negative and not at risk, they can only be worried and harmed by pap tests – they will be offered the HPV primary testing program and a reliable self-test device is already in use, the [Brand Name Removed by Editor — possible advertising]. (also being used in Italy, Singapore and elsewhere) Those HPV negative and confidently monogamous or no longer sexually active can forget all further testing. This will save scarce health resources and more lives and spare HUGE numbers of not-at-risk women from a lifetime of unnecessary pap testing and over-treatment. (which means fewer women with cervical damage and premature babies, infertility, c-sections, miscarriages etc)
The pap test IMO has been used to generate huge profits for the medical profession. Women should demand smarter testing – testing that actually adds to their healthcare, not risks their health.
As a low risk woman my risk of cc is near zero, I declined pap testing 35 years ago, the risks were too high for me. I did not get the information I needed to make an informed decision from a doctor or the Govt, I had to do my own research, that should not be necessary – we’re all entitled to the facts and to decide for ourselves which screening tests we’re prepared to accept. (if any) – we have a right to protect our healthy symptom-free bodies from risk and harm.
The use of coercion in the States and Canada to force women into screening (and over-screening and completely unnecessary and harmful routine pelvic and breast exams) to get the Pill is highly unethical. It is astonishing that women could be treated in that way.
HPV Today, Edition 24, sets out the new Dutch program.
Elizabeth, I see that you’ve posted this comment, or comments very similar to it, in many blogs across the Internet. It also seems that you have posted it without reading our post, or else you are simply ignoring a lot of the information we included in this post. Normally I don’t approve comments like this, as I see them as bordering on spam. Comments here should be made in good faith, and yours seems more like a generic anti-Pap test comment that doesn’t seek to engage the content of the post you are responding to.
The original post talked about the recent changes in U.S. Pap testing guidelines. We also have a post scheduled for next week, which talks more about these new guidelines and addresses many of the claims you made. Furthermore, tomorrow’s scheduled post is about Planned Parenthood’s HOPE program — in which patients are able to obtain birth control prescriptions without submitting to pelvic exams. While it is commonplace to tie pelvic exams to birth control prescriptions in the United States, there is no legal requirement for health care providers to do so, which is why we’d like for more people to be aware of programs like HOPE. I agree with you that patients should be able to make their own decisions based on the most reliable evidence. That is why the U.S. Preventive Services Task Force recently revised Pap testing guidelines (so that they start later and are less frequent), and it’s why Planned Parenthood does not practice this coercion of which you speak.
I disagree with what seems like a dismissal of the severity of cervical cancer. You stated that “CC was always rare and in natural decline before testing started,” which is just flat-out false. There are populations where it is definitely not rare — in countries without access to Pap testing it remains a top killer — and despite an individual’s chance of developing cervical cancer, the test’s role in public health has been incredibly beneficial. I also seriously question your 77% stat — it would be nice if you provided sources for all of your claims, but that one especially raises my suspicions.
We would appreciate less formulaic responses, which actually engage the posts as the unique pieces of writing they are. Please keep that in mind for any future responses.
I’m more than happy to include references, I wasn’t sure whether links were permitted, I try to post real information whenever I can, there is so little real information available for women. No one has ever referred to my posts as spam…although I know many don’t like women reading real information.
I find it unacceptable that women have never been provided with balanced information on this subject.
I’d like to think HOPE provided women with the Pill with no unnecessay exams or tests, but I’ve heard from many Americans that women are pressured to test by PP and some branches even refuse to provide the Pill if the woman continues to decline testing. I assumed your policy must have varied from branch to branch…or it was only possible to delay the exam.
Perhaps, women having issues should contact your head office. It still seems to be a common problem accessing the Pill without unrelated exams and cancer screening.
The lifetime risk of referral is 77% here in Australia due to serious over-screening, the US rate would be as high if not higher, I know one older article by Dr Richard DeMay “Should we abandon pap smear testing” online, put it as high as 95%…which would be likely with annual testing starting very early…hopefully, that figure has fallen with the recent changes in the States, although sadly, many women tell me their doctors are still “requiring” more frequent screening.
Cc was always rare in Australia, the UK and in many other developed countries and it was in natural decline….those factors would still be having an impact, more women have had hysterectomies, better condoms and hygiene, fewer women smoking, less STD (Dr Gilbert Welch mentions better hygiene and less STD in his book, “Over-diagnosed”)…yes, fairly small numbers of women are helped by pap testing, but as Finland has shown there is no need to over-screen and over-treat huge numbers to achieve that end…and now it’s possible with HPV primary testing to identify the roughly 5% at risk. Why would any HPV negative women (most women) wish to endure a lifetime of unnecessary pap testing and the risk of over-treatment?
If women received balanced information and that IMO has never happened, there would be no need to post, but I feel morally obliged to warn women and to let them know about smarter testing. Hopefully, one day the system will treat women fairly and respectfully, I live in hope. Women cannot protect themselves from over-screening and over-treatment and make an informed decision unless they have access to real information and I think smarter testing is only likely to happen if more women demand access to it. It can’t be demanded if women don’t know about it.
I think many women would prefer to self test for HPV or have access to HPV primary testing – women should be provided with options…if you know you’re HPV positive and are 30 or older, you know you might benefit from pap testing, if you’re negative, you know you can’t benefit…I believe women are entitled to this information and should have access to smarter testing and it is more likely to save lives by identifying those at risk.
It has been difficult to see so many women being worried and harmed by this testing and over-treatment over the decades….and the tragedy is, most of this damage was avoidable. I should add my younger sister endured an unnecessary cone biopsy after a false positive pap test, she did not give informed consent for the test…like many women she was simply told all women should test. Only one person can say the risks are worth it, the individual woman, we understand and accept that with PSA testing, but not with women’s cancer screening, that needs to change.
http://www.nypcancerprevention.com/issue/4/pro/pro_spot/cer_can.shtml
Footnote 8 refers to the article by Kavanagh et al (77% lifetime risk of referral)
Links are permitted; more than two links will divert something to the moderation queue, but most comments here are moderated anyway (because of high volumes of spam and the risk of abusive comments from abortion opponents). I didn’t refer to your post as spam, but rather as “bordering on spam.” The reason for that was (1) you leave a lot of similarly or identically worded comments on many blogs, (2) your comment didn’t engage the original post but rather read like boilerplate, and (3) it struck me as very similar to previous spam-like comments we’ve received from agenda-driven organizations/companies posing as concerned citizens.
Many Planned Parenthood affiliates have HOPE programs. I don’t know how many do — Planned Parenthood has dozens of regional affiliates — and I don’t know whether or not your claims about some affiliates refusing birth control are true. I can tell you that many Planned Parenthood affiliates, such as those here in Arizona, do have HOPE programs, and they are options for those of us who have made informed decisions not to submit to Pap testing. Please see our post on the HOPE program.
I can’t access the full article that you cited, but the abstract makes it seem that the 77% stat was extrapolated from colposcopy rates derived from testing that is much more frequent than what happens in real life. Do you really think 3 out of 4 women who get regular Pap tests have had (or will get) colposcopies? I don’t think the 77% stat reflects what happens under real-world circumstance, even though the stat is bandied about a lot (including in this paper, which incidentally says that only 20% of American women have had at least one abnormal Pap test — which would lead me to believe that colposcopy rates are closer to 20% as well).
You bring up interesting points, though, and when our bloggers do a post on colposcopy (which is indeed on the to-do list), I’ll be sure that we find some good information on these issues. (My response here is just based on cursory research.) Also, while cervical cancer remains a top killer in many developing countries, I am curious to know how cervical cancer rates in developed countries compare between those who undergo regular Pap testing and those who refuse such testing. (My very cursory search turned up nothing, but I’m sure the data are out there somewhere.)
Self-testing should be an option, if the technology is acceptable, but part of informed consent is sharing what the data say about the accuracy of self-testing compared to the accuracy of on-site testing by a health care provider.
People can’t really know if they’re HPV negative. Also, if they are found to be HPV positive at one point, they are not necessarily going to remain HPV positive for the rest of their lives. I am confused by this aspect of your comment — without with physical exam that is a necessary component of Pap testing, you can’t test for HPV DNA in the first place, but because of false negatives you can’t know for sure that you really are HPV negative.
I recommend the book The HPV Vaccine Controversy, by the way. As I recall it address and clarifies a lot of your points.
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Hi Anna, I think what Elizabeth is trying to get across is that the Pap test is far from what it is cracked up to be, and there are already better options out there. My frustration, like Elizabeth’s, is that there are very few places that advise about the high false positive and negative rates, and also about the damage that can be done to women’s cervixes by the follow on treatment. Without all the facts and true informed consent, what woman would be willing to take a wait and see approach rather than having possibly unneeded biopsies and other treatment? Try looking at Dr. Angela Raffle’s work, or at Dr. Carolyn Westhoff, or check out Joel Sherman’s blog regarding the total lack of informed consent when it comes to women’s health. Also, why do women need to have an hrHPV test AND a pap smear? If the HPV test is negative what point is there in then having a pap smear? I do applaud PP for their HOPE program though, it is really nice to see that there are places women can go to get birth control without being forced into a pap smear that the woman has every right to decline. Thank you for providing this service, I am sure many women must appreciate it.
The Pap test is not a perfect test by any means, but despite the flaws you just can’t argue that it hasn’t been responsible for a nosedive in cervical cancer rates. Its importance to public health has not been overstated, in my opinion. You are right that it would be best to explain the benefits and drawbacks of the test in order to practice true informed consent. The concepts of sensitivity and specificity can be very tricky to explain, and it doesn’t help that our educational system doesn’t put a lot of emphasis on health literacy. Combine that with an overburdened health care system, and there is a lot of frustration all around. (I’m not making excuses, rather I am stating my opinion on the current state of affairs. I would love a health care system in which physicians had more time to talk to their patients, get to know them as individuals, and go over all of their options; and I would love an education system that instilled more scientific and health literacy in its students.)
You seem to be contradicting yourself when you question the need for an HPV test and a Pap test. Co-testing gives better results and allows patients to have less frequent Pap tests — aren’t you in favor of that? If you are going to complain about the Pap test’s sensitivity, it seems that you would welcome the additional information offered by an HPV DNA test, making for a more robust data set. For those of us over 30 years of age, the HPV/Pap co-test has a lower false-positive rate (see No. 5) — how does that not address your previous criticisms?
You also speak of HPV and Pap tests as if they are separate procedures. In actuality, the cells that are collected during the physical exam of the Pap test are used in the HPV test — they are taken from the cervix during the exam and then tested for HPV DNA in a lab. You can’t have an HPV DNA test without collecting cells from the cervix! I think you might be misunderstanding what an HPV test and a Pap test are — from the patient’s perspective, they are no different. Cells are collected from the cervix and then examined under a microscope (the Pap test component) and analyzed for viral DNA in a lab (the HPV test component).
Please stay tuned for our post about the updated Pap testing guidelines, which is scheduled for next Tuesday. It addresses many of your points.
This link I provided discusses the HPV testing with or without pap testing.
It seems that initial HPV testing only will be the way of the future. The pap test would only be needed if the woman is HPV postive and it would rule out sending a women for treatment if she has an abnormal pap but a negative HPV test. That would indicate that her abnormal result was caused by something other than HPV.
“The evidence that we should begin planning for a switch to HPV-only testing from aged 30 is now becoming overwhelming. Some think we need to ‘dual test’ – i.e. run both cytology and HPV testing in parallel on all samples. I disagree. As this study shows, the risk of developing significant disease in the next 10 years in women who have an abnormal cytology result in the absence of HPV infection is so low as to be negligible.”
http://scienceblog.cancerresearchuk.org/2012/07/31/expert-opinion-now-we-need-to-plan-for-first-line-hpv-testing/
Some of the other commenters here seem to be objecting to the physical exam itself, claiming that it’s too invasive, too frequent, too inaccurate, etc. When they speak of “Pap testing,” I assume that they are mostly referring to the physical exam, and not to the practice of examining cervical cells under a microscope. So, the link you provide does indeed discuss HPV testing without Pap testing, but it doesn’t discuss HPV testing without a physical examination:
If you want to be tested for HPV, cells must be collected from the cervix, whether they are going to be looked at under a microscope (cytology, i.e. Pap test) or examined for the presence of viral DNA (HPV test). Either way, a pelvic exam is performed and cervical cells are collected. To the person undergoing the procedure, it makes no difference.
So far, the evidence doesn’t seem to support HPV testing without cytology for younger people, in whom HPV infections are incredibly common — a great proportion of sexually active young people will turn up HPV-positive, but might not have any cellular abnormalities. Only cytology — not DNA testing — can show if cells are abnormal.
However, I’m very pleased that the medical establishment is examining the evidence and moving toward higher-quality and less-frequent testing.
The article also says that, in the UK, 8 out of 10 12- to 13-year-old girls have completed the HPV vaccine series since 2008. I’m thrilled to see that the vaccination rates are so high across the pond! That’s wonderful.
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what lab does planned parenthood send their pap tests to?