“Choosing Wisely” Means Fewer Pap Tests or None At All

A public campaign called “Choosing Wisely” is helping to raise awareness about the potential harms of unnecessary medical tests and treatments.  The campaign, launched by the American Board of Internal Medicine Foundation and nine American physician organizations, promotes discussion between doctors and patients about unnecessary treatments and testing.  Fifteen commonly used tests and treatments have been singled out for discussion due to their questionable efficacy and potential to cause harm.  Four of the fifteen brought into the spotlight for scrutiny are related to pap tests and pelvic exams and include the following:

  • Don’t perform Pap tests on women younger than 21 or those who have had a hysterectomy for reasons other than cancer. In Canada, it is now recommended that Pap tests begin at age 25 and follow at three-year intervals
  • Don’t screen women older than 65 for cervical cancer if they have had adequate prior screening. *Cervical cancer is rare in this age group, so the test offers little benefit.
  • Don’t screen women younger than 30 for cervical cancer with HPV testing alone or in combination with cytology. HPV testing is now being done instead of Pap tests in some cases because it is more precise, but it is still not useful in younger women.
  • Don’t require a pelvic exam or other physical exam before prescribing oral contraceptives. There is no reason to do a pelvic or breast exam before prescribing the Pill.

Some people have been concerned about the persistent and prolific propaganda that promotes screening and ignores the potential for harm, but thankfully that is changing as research scientists, campaigns and mainstream media have been helping to raise public awareness.  Andre Picard, an award winning health journalist, states “Over-treatment is a serious problem in the U.S. and in Canada too: Performing unnecessary tests, prescribing drugs inappropriately are not benign activities. They have the potential to cause harm, and they waste in addition to wasting money.” http://www.theglobeandmail.com/life/health-and-fitness/health/unneeded-treatments-can-hurt-budgets-and-patients-too/article14567958/

And of course the ‘choosing’ involved in ‘choosing wisely’ should ultimately belong to the patient.

*Cervical cancer is rare in all age groups: http://www.statcan.gc.ca/pub/82-003-x/2012001/article/11616/tbl/tbla-eng.htm
Over-treatment in America: http://www.youtube.com/watch?v=uJ6NufAb2qc
Benefits and harms of cancer screening: http://www.youtube.com/watch?v=861GCKemvtQ
Financial incentives contributing to overtreatment and overdiagnosis: http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1001500
Women “duped” over benefits of breast cancer screening: http://www.dailymail.co.uk/health/article-2182932/Women-duped-benefits-breast-cancer-screening.html
What is what you survived wasn’t cancer? http://www.bloomberg.com/news/2013-08-18/what-if-what-you-survived-wasn-t-cancer-.html

About forwomenseyesonly

Hi. My name is Sue and I am interested in promoting holistic and respectful health care.
Gallery | This entry was posted in cervical cancer, health, informed consent, pap test, pap test coercion, pelvic exam and tagged , , . Bookmark the permalink.

31 Responses to “Choosing Wisely” Means Fewer Pap Tests or None At All

  1. OverItAll says:

    Another beautiful post!! I’ll be sure to use these links in my letter to my dr when I get home. Out of town (and state!) For 2 weeks. Keep the fabulously informative posts coming! :)

  2. Moo says:

    So how long before it trickles down into practice, particularly my doctor’s practice?

    I am wondering if any cervical screening should be done between age 30 and 65? I would maybe take a test for curiosity but I still want to preserve fertility so I don’t. Any abnormal pap is going to require further investigation and even treatments which destroy fertility. I would think that women should avoid Pap tests until they do not want any more children at least or they have symptoms that need investigation.

    • Alex says:

      Well, it’s very unsafe & inaccurate for women under 35 (not 18, or 21, or 25). It’s, in itself, unreliable & dangerous (partially because of inaccuracy) & there are alternatives if a woman was curious about something she has less than 1% chance of getting. This would be a problematic methodology, even if it WAS a means to an end & it abuse if imposed on someone.

      Another point to consider is that this is what is considered quality personnel & medical information. Lying is a very possible thing, as is incompetence. Pervyness isn’t limited to males, either (aggressive lesbians do exists, so do bisexuals). There’s also the potential for whatever background problems (mommy issues, the patient’s prettier than them or way out of their league, problems with someone’s face/race/age- maybe the patient’s young enough to have kids but the other women involved aren’t so they’re spiteful or careless about the subject).

    • ADM (Canada) says:

      I would think that it’s going to take a long time before things change at the clinical level and some Dr’s may never change. They do not have the time to keep up with changes in clinical recommendations or they continue with what they learned and ignore recommended changes. After all this is lost income from procedure billing and incentive payouts.

    • Elizabeth (Aust) says:

      It’s not as complicated as they make out, you simply offer HPV primary testing or HPV self testing to those aged 30 or older, and only offer a five yearly pap test to the roughly 5% who’ll be HPV+
      The new Dutch program takes most women out of pap testing and offers screening only to those with a small chance of benefiting….they don’t overdo it either, those HPV+ will only be offered a Pap test every 5 years until they clear the virus. Other countries are referring HPV+ women straight to colposcopy…that’s unnecessary. Or doing HPV AND pap tests on all women, this creates the most over-investigation.
      It’s only complex because we have so many wanting a share of the enormous profits that flow from this testing. It’s always expressed as “concern” about us when it’s nothing more than protecting self-interest.

  3. I started getting pelvic exams at age 14 because my father was so paranoid that I was having (or was going to have) sex and either 1) get pregnant or 2) get an STD. I never questioned it, but now that I look back, I wish they hadn’t started so early.

    • Alex says:

      That’s horrible! I’d think that he’d be disinclined to push something of that nature on his daughter. I mean, if someone was to decide to aggressively “play doctor” with you, wouldn’t that be a concern? Probably would be if someone were to do that to him!

  4. I thought you all would be interested in reading this article, “The Thousand-Dollar Pap Smear” (http://www.nejm.org/doi/full/10.1056/NEJMp1307295?query=TOC&&&&amp ;)

  5. Karen says:

    “Cervical-cancer screening is one of the 20th century’s true public health successes.” Sorry, I just stopped reading at that point. I saw an other patronising NHS poster today, I am so sick and tired of hearing about this nonsense test straight from the 1930s.

  6. Elizabeth (Aust) says:

    My post has been accepted…amazing that a doctor could say in a medical journal that cc was the leading cause of death for American women before pap testing, that’s myth, not fact. It doesn’t take much research to find that cc was always rare in the developed world and in natural decline. If I said that thyroid cancer was a major killer, I’d be challenged, yet no one challenges the factually incorrect statements made about cc.
    It’s important to post…for too long this nonsense has been left unchallenged in women’s cancer screening/healthcare and that’s why myth and propaganda are now facts.

    • Alex says:

      What do you say when someone DOES challenge what you say about it not being common? I guess that would be in the References & Education section, but is there something that seems to work with that? I guess some people are just strident supporters of women getting backed into things like this & just don’t want to admit it- but is there an answer you find tends to work?

    • Elizabeth I always enjoy reading your comments, but they are even more satisfying when I know they will be read by “them”. I’m pleasantly surprised it was published – the times really are changing and that is encouraging. I’ve posted part of your comment here together with the link to the article’s comments for easy access:

      “Profits come before the evidence and women’s health

      Myth has become fact with cervical cancer (cc), it was never a major killer of women in the developed world, it was a fairly rare cancer. (and it was in natural decline before screening even started) There are also, no randomized controlled trials for pap testing. The lifetime risk of cc is 0.65% while referral rates for colposcopy/biopsy are MUCH higher. (77% here, similar in the States) Over-screening leads to lots of false positives and potentially harmful over-treatment for no additional benefit to women. If you look at The Netherlands and Finland, you see the stark difference. Since the 1960s the Finns have had a 7 pap test program, 5 yearly from 30 to 60 and they have the lowest rates of cc in the world and refer FAR fewer women for “treatments”/excess biopsies . . . Excess is profitable, but bad medicine.” Elizabeth
      Link to comment: http://www.nejm.org/doi/full/10.1056/NEJMp1307295?query=TOC&&&&amp#t=comments

    • Anonymous says:

      Reading that article I am even more convinced that Dr’s and other medical personnel don’t learn the truth about the prevalence of (or lack of) CC. They are taught that CC was a common cancer and killer of women and that the pap saves women’s lives and without it women would be dropping dead of CC. I believe they also don’t know about the inaccuracy of the pap and the number of women with abnormal cells are false positives. As you said myth has become fact with CC and I think the myths are being taught as fact in medical school. CC is not even a major killer in third world countries. Famine, war, disease, and death in childbirth are greater concerns.

    • ADM says:

      The anonymous post above is by me.

    • Lady Tips says:

      Anonymous, I’ve interned/shadowed with several doctors. They’re well aware of the false positives/unnecessary treatments, but when it comes to women’s health, they just don’t care.

  7. Lynne says:

    The World Almanac is another source of facts. Every year every statistic possible is recorded, not only in the medical field but weather, military facts, economics, politics etc.

    I asked once on a story what years those were exactly and I never get an answer.

  8. Moo says:

    I am wondering if it is possible to get an anonymous Pap test in Ontario. I know that people can get anonymous HIV tests where they receive a code and can get their results. The clinic does not “share” the results with their doctor unless they give permission.

    I think however that a Pap test cannot be done without a health card number, name, and contact info and I know that all Pap test results are put into a central registry whether you consent to or not, any any doctor you use can access it. You can opt out of receiving reminder and result letters from the government though. You doctor can still check the computer registry and harass women about getting paps.

    I might try to find out. I am wondering if I can go to clinic to get a pap and say I do not have a health card, no ID, no phone number etc and I will come back after a few weeks and ask for the results. I would not even give them my real name.

    Why would anonymous testing be allowed for HIV but not for paps?

    • Alex says:

      I’ve got to ask & I know it’s been said before once or twice on here: Why bother with all this? There’s the concept that one is going to die at some point, but also that there’s such rarity of these things & since they use whatever “results” as a jumping-off point for additional actions. It’s definitely been brought up that liver & thyroid cancer is more common and no one goes & randomly gets tested for that. Just food for thought.

  9. Mary says:

    I’ve been reading on the mamamia blog on whether women prefer male or female doctors to do pap tests. Well get this: someone from pap screen posts this:

    “Amy Collie
    • a year ago △ ▽
    − We understand some women prefer to see a female GP when it comes to having a Pap test. On our website, women can actually search for their nearest female Pap test provider (in Victoria) simply by submitting their postcode – http://www.papscreen.org.au/wh…. You can also search for other special requirements like disability access and a practitioner who speaks a language other than English.
    Also, you don’t always have to go to your GP to get a Pap test. Right now there are close to 500 Pap test nurses in Victoria alone, the vast majority of whom are female.
    So come on ladies, no more excuses!”

    Can you fucking believe this? I’d like her to come here and tell us “no more excuses”.

    • Alex says:

      “No more excuses?” Sounds like a rejection of refusal- someone trying to counter her initiative. If a man said “No more excuses, let’s go upstairs & do some role-playing” that would be an issue. I get very aggravated at how something antagonistic is seen as innocent when a woman does it. Women seem to see other women as support, at least when things get serious (particularly when it’s a sexually threatening environment). The fact that a woman would use that trust against someone is absolutely appalling.

  10. Moo says:

    Trivagene now has a urine test for HPV. It costs $150 US though.

    • OverItAll says:

      That’s still cheaper than a pap, even a cervical hpv test. My copay alone is $60 plus the $350 cerv hpv test, according to the bill I saw for my mom.

      My mom is having a double mastectomy and ovaries removed due to brca genes. Well, she’s had a few ruptured ovarian cysts in the last 6 months. She talked a few months ago about having her implants “updated”. Guess whose insurance will give her “free corrective surgery” if she undergoes the mast “for brca”. Also, her dumbass obgyn told her she had a 99% breast and ovarian cancers risk due to brca. She won’t listen to me. I do think her diet is causing her cysts (nothing but a gallon of black tea with 2.5 cups of sugar and out-of-the-box “food”, 12+ cups of coffee a day and smokes 2+ packs a day). I give up on her.

      Get smart with your health. Research everything. Make YOUR OWN decision. For fuck’s sake, never believe a word a “doctor” says.

    • Alex says:

      So this company is offering a discount if someone gets a double mastectomy?!

      I remember hearing something along those lines a while back with that whole Angelina Jolie thing- doesn’t that gene only activate if someone leads a cancerous lifestyle? I don’t understand how someone’s got that high a risk from these genes that doesn’t have it yet, either. She’s obviously in the 40-50 years old bracket, at least (since you’re old enough to have your own kid)- so how is it hat this hasn’t happened?

      She’d probably have a splitting headache if she went cold-turkey on all that, but she might very well get a reduction in problems if she tones it down a bit. That “food” as you call it, might very well be most of the cause- since there’s a lot of extra estrogen & things that mimick estrogen in them (at least, in America). If I remember right, that causes cysts & other problems (endometriosis, being one of them). Interesting how that’s not “moved on” like lead & asbestos was.

    • ladyprotips says:

      Actually, OverItAll, BRCA can very much increase risk for breast and ovarian cancer. The types of mutations are germline and somatic. These are the differences in hereditary and sporadic cancers. OB/GYNs are notorious for doing whatever they can to make money, but in this case, your mother’s OB/GYN is not being a “dumbass,” but is actually trying to help her. You also have a 50% chance of having BRCA, so for you and any siblings you may have, getting tested honestly probably wouldn’t hurt. And they aren’t offering plastic surgery as an incentive to get her to have the mast, it’s reassurance that if she gets the mast they’ll also provide corrective surgery, as a mastectomy is an incredibly disfiguring procedure.

      Yes, diet has a lot to do with ovarian cysts. I personally cut out gluten and it has helped mine a lot. However, I’m still looking at potential surgery for endometriosis.

  11. Moo says:

    The HPV digene (self test is not available) with the pap is $90 in Ontario. The public insurance pays for the pap but not the HPV. So the HPV test is optional but will not be taken without a pap. The HPV test is recommended and used in “triage” to “treat” women over 35. So really, you would have to be stupid to pay for it since the recommended course with any abnormal pap, even ASCUS with HPV positive is colposcopy for all women over 35. Without the HPV test, with the ASCUS the course would be repeat pap in 6 months. A positive HPV test would mean a push for LEEP or cone not any recommendations to wait and change diet. They will not just let anyone off with abnormal pap because then colposcopy is flagged in the system of cytobase and the hassles start.

    This is the huge reason why I will not get a pap just for piece of mind. Being that pap are so inaccurate anyway, why bother? I would rather just get a urine HPV test which is supposed to in approval process. Likely it will not be just come in for a urine test. They are never going to get rid of paps.

    What really bothers me is that any Atypical glandular cell result is going to be endocervical curettage or cone biopsy. Most of them , greater than 80 percent are due to benign stuff yet that result would have them demanding entrometrial sampling and a whole mess. The transformation zone in older women moves up the cervical canal so it “cannot be visualized” so well during colposcopies. That makes them want to do the worst kinds of biopsies ECC and cones on women, even hysterectomies. Cannot agree because because if I feel fine why mess with it?

    • Alex says:

      So they won’t do a urine test in Canada without an internal one attached to it?

      I’ve got to ask: Is Canada a real dictatorial place, overall? I had the impression that it was like America, if America wasn’t always giving orders.

  12. I’ve been doing some more research and it is oh, so clear this testing has little to do with saving lives. We continue to resist self-testing of any sort even though they know this would be a welcome option for many women. Some high risk women who might like to test find the pap test unacceptable. Yet the system is content to deny this option to force women into population pap testing or to hell with them.
    Also, there are so many studies going back many years that show the futility of testing young women, of testing women too often or for too long, yet nothing changes. It says to me better options for women are irrelevant, what makes the most profit?
    The profession has plummeted to the level of mass abuse of women to feed these programs, it says to me this group of people don’t give a damn about our heath, legal rights, quality of life and welfare.
    The attitudes are so different in the Nethetlands, largely it’s about saving money or not wasting money and they recognize these progams will be abused by vested and other interests if you give them the chance. So they offer evidence based testing with a self test option, more likely to prevent this rare cancer AND they minimize the risk to the vast majority of women who cannot benefit from pap testing, many of whom will be removed from the program.
    Whereas here, in the States, UK, Germany and elsewhere, we end up with women developing cc who might have been helped with better testing options and huge numbers damaged by over-treatment…and all women being unnecessarily burdened with lifelong testing. (or close to it)
    It’s a great business model, but lousy medicine.

  13. Anonymous says:

    Thank you… I stumbled across this site… I thought I was the only woman who feels shame in subjecting herself to pelvic exams… Why is this the only part of my body that the medical community cares about? The worst part is the pressure! “I’m a smart educated modern woman… shouldn’t I care about my health?” (That is my internal voice speaking). I have had 4 colposcopy exams as follow-ups from abnormal pap smear results… all of which have come back as normal (and therefore unnecessary!!!). My GP treated me like I was an irresponsible risk taker – when I ask if all this fuss and waist down nudity and examination is really needed. As a side bar – on one occasion, I allowed a student to be present for my colposcopy – the doctor poked and prodded my cervix (ouch) which was displayed on a big screen (very strange to see and feel at the same time). He proceeded to label different areas – and to show her how mucus came out of various regions when poked. At the end he patted me on the leg in an intimate and comforting way (like: ‘there there’) – which made me feel odd. All very strange and painful – and educational? (sarcasm included). Now when they ask if a student can watch I say no.

  14. Elizabeth (Aust) says:

    Anon, I hate to read this sort of post, so many women have endured so much, when almost all of these exams are unnecessary. Many women endure pap testing, colposcopy and biopsies without even being tested for HPV, if you’re HPV- (or under 30) then this is all unnecessary and not recommended under an evidence based program. (Note: all cancer screening is elective and legally and ethically requires our informed consent)
    The medical obsession with our breasts and reproductive organs will only stop when more women get to the evidence and say NO.
    For almost all women this testing carries risk for no benefit, also, routine pelvic/rectal/recto-vaginal, visual inspections and breast exams are not backed by evidence but carry risk to your life and health.
    I’d urge you to read, get informed, and you may feel that an educated and intelligent woman who cares about her health would tell the medical profession in no uncertain terms there will be no more medical excess and no cancer screening unless it’s your idea.

    If you’re worried about rare cervical cancer, consider testing for HPV, if you’re over 30 that is, no testing at all is recommended under that age, pap or HPV testing. The HPV test can be carried out in your own bathroom, Delphi Bioscience can mail the test to Australia, the UK and elsewhere, you could see if they cover your area yet. Tampap is available in the UK.

    If you’re HPV- forget about pap tests and you might choose to re-test in 5 or 10 years time (depending on your age) but if you’re HPV- and no longer sexually active or confidently monogamous you might choose to stop all further testing.

    I’m almost 56 and have never had a pap test, routine pelvic exam or breast exam or visual inspection of the genitals or any of the other harmful nonsense sold by the medical profession in many countries.
    I’m also, an educated woman and have always said NO to pap tests etc. and now mammograms have been added to the list, I call it being responsible for my health. Hopefully, more women will start to see that being responsible for your health means making informed decisions and that might well be a NO.
    It makes me sick to think the profession uses that expression to justify their exploitation and abuse of women.
    I hope this ugly part of your life becomes a thing of the past.
    Welcome to the forum!

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