New Cervical Cancer Test Guidelines

Are women under attack? That seems to be the question hanging in the air after the American College of Obstetricians and Gynecologists issued new guidelines for Pap smear testing right on the heels of the new mammography guidelines issued earlier this week. One has to question the wisdom of the College’s decision to release the report given the public reaction to the mammography recommendation but the chairwoman of the panel, Dr Cheryl Iglesia, insists the timing is purely, and unfortunately, coincidental. Dr Iglesia said the recommendation had been in the works for several years and was not influenced by the new health reform debate. We have every reason to accept this explanation because it will be very easy to confirm, or challenge, from a history of emails, early drafts, etc. The new recommendation will probably carry considerably more weight than the mammography changes because of the specific expertise of the College versus the broad medical expertise of the mammography task force. But the changes will likely need to be confirmed by other groups of cancer experts before they are generally accepted or insurance companies deny coverage. 

The argument, like the one for mammograms, centers around statistics and one of those numbers is cost. Unlike mammograms, cervical cancer tests are invasive. That clearly raises the level of risk and leads to overtreatment. History showed that because cervical cancers grow slowly stretching out the tests from annual to every two years would have little impact on early detection and treatment. Further, early treatment may have later implications for early births and C-sections that add dangers of their own. OK, that makes sense. I am puzzled, however, by raising the age to 21 regardless of sexual activity. The previous guideline, at 21 or three years after the start of sexual activity whichever comes first, seems logical. Perhaps the decision is linked to the availability of the HPV vaccine and the ability of the body to naturally fight off the HPV virus that is the cause of cervical cancer (so that detection and treatment in teens may be unnecessary – just give the body time to do the job itself). Or we could do the earlier tests but reconsider how to treat though non-treatment will clearly cause enormous stress issues. Tough one. But look at the statistics given in the New York Times this morning: 

 There are 11,270 new cases of cervical cancer and 4,070 deaths per year in the United States. One to 2 cases occur per 1,000,000 girls ages 15 to 19 — a low incidence that convinces many doctors that it is safe to wait until 21 to screen. 

Let’s assume a pap test costs $100 including doctor fees and lab fees and let’s also assume there are roughly 10 million girls age 15-19 in the US (both best guesses on my part but they should be reasonably close). So we spend about $1 billion per year to give these girls cervical cancer tests in order to detect cancers in 10-20 of them. I’m not clear from the NY Times quote if that 1or 2 per million is the cancer detection rate from the tests or the death rate from cervical cancer in that age group. But even if it’s the death rate, should we be spending $1 billion per year to save those 10-20 lives? A brutal ethical question for sure but these are the tough questions we need to ask and are afraid to ask – or answer. 

Perhaps the best question I’ve heard raised is whether the new guidelines for mammograms and Pap tests will have implications for women making regular visits to their doctors. If women go for annual exams largely for one or both of these tests, and the new recommendation extends them to two years, will women stop seeing their doctors annually? What are the risks associated with that decision? Very good questions.