Cervical cancer screening overused in women at low risk

Kepka D. JAMA Intern Med. 2013;doi:10.1001/jamainternmed.2013.12607.

  • December 31, 2013

Nearly 14 million women in the United States underwent unnecessary Pap tests for cervical cancer screening in 2010, according to results of a cross-sectional study.

The US Preventive Services Task Force recommends against Pap tests for women who underwent hysterectomies because the majority no longer have a cervix, the target of the cancer screening test. The USPSTF also recommends against Pap tests for women aged older than 65 who have no history of cervical cancer or pre-cancerous conditions because the risk of developing cervical cancer at such a late stage in life is low.

 

Deanna Kepka

“We knew there would be overuse of Pap tests because the few studies of cervical cancer screening showed overuse 10 years ago,” researcher Deanna Kepka, PhD, MPH, an investigator at the University of Utah’s Huntsman Cancer Institute and assistant professor in the university’s College of Nursing, said in a press release. “But we were shocked to see so little change over the past 10 years.”

Kepka and colleagues reviewed data from 9,494 women who participated in the 2010 National Health Interview Survey.

Researchers identified 2,278 women who reported having undergone hysterectomy. Of them, 34.1% (95% CI, 31.7-36.6) reported receiving a Pap test within the past year and 64.8% (95% CI, 62.2-67.3) reported receiving a Pap test after their hysterectomy.

Also, 58.4% (95% CI, 55.3-61.4) of women aged 65 years and older who had not undergone hysterectomy reported receiving a Pap test in the past 3 years.

Based on those screening rates, researchers projected 14 million women nationwide underwent unnecessary cervical cancer screening in 2010.

“We’re hoping to see better use of the tests over the next decade as changes in the health care infrastructure take place,” Kepka said. “Electronic medical records, health care provider reminder systems, decision support and new strategies to improve the quality of care may promote guideline-consistent practices among clinicians.”

Disclosure: The researchers report no relevant financial disclosures.

Perspective
Aparna Kamat, MD

Aparna Kamat

  • This study sheds light on practice patterns for cervical cancer screening and Papanicolaou testing across the country. Even though the USPSTF guidelines have been available since 2003, patients and physicians are not always aware of what the guidelines are. Patients see their physicians for a well-woman exam expecting to get a Pap smear. Consequently, educating physicians is important to prevent unnecessary Pap smears being performed on patients who do not fit the high-risk group. Awareness of the current guidelines, and continued education for both physicians and patients, is key to improving the quality of evidence-based care that we provide our patients.

    The biggest caveat of this study is the fact that all data are patient reported. Because of the nature of the study, accuracy of the numbers cannot be verified. Patients who had a pelvic exam may incorrectly assume they had a Pap smear. Nonetheless, it is obvious from the data that the overuse of Papanicolaou testing outside current guidelines is widespread among health care practitioners.

    Sometimes when we tell patients, “You don’t need a Pap smear,” they assume that they don’t need a pelvic exam and, therefore, are lost to follow-up. Although the guidelines indicate that low-risk patients do not need an annual Pap smear, these patients still need an annual pelvic examination. This is the big disconnect, and we need to do a better job conveying that message to patients. If patients feel they are still being monitored closely, these low-risk women would be feel more comfortable about not getting an annual Pap smear.

    • Aparna Kamat, MD
    • Gynecologic oncologist
      Houston Methodist Cancer Center
  • Disclosures: Kamat reports no relevant financial disclosures.