Mammographies and PAP Smears: BodBeat Episode 10

Recently, .. two noted medical groups released their new guidelines for women … basically recommending we cut services for woman to have yearly mammograms and PAP smears. The American College of Obstetricians and Gynecologists ( ACOG ) now recommends that women not get their first pap smear until age 21 and that women 30 and older be tested every three years rather than annually. This comes on the heels of a new guidelines by the U.S. Preventive Services Task Force ( USPSTF ) … this a government sponsored group mind now … that now says mammography screening should start at 50 rather than 40 and that women over 50 need only be screened every two years. There are no such things as coincidences, - 192,370 new cases of invasive breast cancer - 40,170 deaths from breast cancer Breast cancer is the most common cancer among women in the United States, other than skin cancer. It is the second leading cause of cancer death in women, after lung cancer. The chance of a woman having invasive breast cancer some time during her life is a little less than 1 in 8. The chance of dying from breast cancer is about 1 in 35. Breast cancer death rates have been going down. This is probably the result of finding the cancer earlier and better treatment. Right now there are more than 2½ million breast cancer survivors in the United States. The change comes amid a separate debate over when regular mammograms to detect breast cancer should begin, in the 40s or the 50s. The timing of the Pap guidelines is coincidence, said ACOG, which began reviewing its recommendations in late 2007 and published the update Friday in the journal Obstetrics & Gynecology. The resulting evidence of such research reports (those supported by EPCs) "are used by Federal and State agencies, private sector professional societies, health delivery systems, providers, payers, and others committed to evidence-based healthcare." So, if someone tells you that the "new guidelines" aren't going to affect your choices, they're misinformed. Many doctors will take the recommendations too much to heart and do less listening than they should to women who find suspicious lumps in their breasts. And many women will die.
Let's back up, shall we? And get it right - both what we know and what we don't. Let's remember that research is a process and it takes a considerable amount of time to draw conclusions with confidence. While the two sets of recommendations are unrelated, they come at a time of intense debate over health-care reform. Mammograms in particular have drawn broad attention in Congress, reflecting a more than decade-long debate in the cancer community about how best to perform mammograms. Republicans sought to connect the mammogram recommendations to the health-care overhaul, contending that such findings are the way that medical rationing starts. Under the pending legislation, "nothing would prohibit the federal government from deciding if tests, treatments and procedures are too expensive, and therefore, unnecessary," Sens. Jon Kyl of Arizona, the Republican Whip, and Tom Coburn of Oklahoma, a physician, said in a joint statement. But the PAP guidelines promise to be far less controversial as doctors for years have been told to perform fewer PAP's among many women over 30, to cut back on unneeded care for the least at risk - and there's growing understanding that over-treating younger women is an issue, too. "The tradition of doing a PAP test every year has not been supported by recent scientific evidence," said Dr. Alan Waxman of the University of New Mexico, who headed ACOG's review. The guidelines also say: - Routine PAP's should start at age 21. Previously, ACOG had urged a first PAP either within three years of first sexual intercourse or at age 21. - Women 30 and older should wait three years between PAP's once they've had three consecutive clear tests. Other national guidelines have long recommended the three-year interval; ACOG had previously backed a two- to three-year wait. - Higher-risk women, such as those with HIV, other immune-weakening conditions or previous cervical abnormalities, need more frequent screening. PAP's can spot pre-cancerous changes in the cervix in time to prevent invasive cancer, and widespread use has halved cervical cancer rates in the U.S. in recent decades. About 11,270 new cases will be diagnosed this year, and about 4,070 women will die from it, according to American Cancer Society estimates. Half of women diagnosed with cervical cancer have never had a PAP, and another 10 percent haven't had one in five years. Cervical cancer is caused by certain strains of the extremely common sexually transmitted virus called HPV, for human papillomavirus. There is a new HPV vaccine that should cut cervical cancer in the future; ACOG's guidelines say for now vaccinated women should follow the same PAP guidelines as the unvaccinated. But the updated guidelines reflect better understanding of HPV. Infection is high among sexually active teens and young adults. Women's bodies very often fight off an HPV infection on their own without lasting harm, although it can take a year or two. The younger the woman, the more likely that HPV is going to be transient. Moreover, ACOG cited studies showing no increased risk of cancer developing in women in their 20s if they extended PAP screening from every year to every two years. As for adolescents, ACOG said cervical cancer in teens is rare - one or two cases per million 15- to 19-year-olds - while HPV-caused cervical abnormalities usually go away on their own. Treating them unnecessarily increases the girls' risk of premature labor years later, and preterm birth is a growing national problem. We want to hear what you think. We look forward to your comments on bodbeat.com. Dr. Loretta

Comments (3)

1. 

   By truecolors on July 9, 2010

   Dr. Loretta has it ALL WRONG about mammograms. She quotes the yearly no. of deaths and new diagnoses of breast cancer in the US in her article and then implies, in her confusing article, that mammograms are ‘the’ way to test for breast cancer and that this will ‘save lives.’ She then makes the outrageous statement, “Many doctors will take the recommendations too much to heart and do less listening than they should to women who find suspicious lumps in their breasts. And many women will die.

   Dr. Loretta, google “dangers of mammograms” and find out the truth. No, what you read isn’t hype. Studies show that mammograms (especially yearly mammograms because years of exposure to radiation adds up) INCREASES the risk of life-threatening cancer rather than decreases it.

   Read Time Magazine’s article on mammograms. The kind of cancer mammograms ‘catch early’ is not even fatal. Ie., mammograms rarely save lives, and the radiation exposure increases women’s risk of getting the very disease that they’re trying to avoid.

   …and THAT is why the gov’t groups have decreased the number of mammograms that they recommend–because there is little evidence that mammograms save lives and there are serious risks associated with exposure to radiation.

   My own physician acknowledged yesterday that she personally thinks mammograms are dangerous, but that she has to prescribe them because the majority of physicians do (and that’s how the law works in the US. If one of her patients gets cancer and she didn’t prescribe a mammogram in advance, she could be viewed as negligent in spite of the evidence that’s accumulating showing that mammograms do more harm than good).

   So THINK TWICE about what you’ve said here, Dr. Loretta. You imply that women should be allowed to get mammograms paid for by their insurance companies every year in spite of gov’t recommendations to decrease the no. of (health-threatening) mammograms a US woman receives in her lifetime. Maybe these gov’t groups know more about the risk of mammograms than you think, Dr. Loretta.

2. 

   By Eliz52 (Aust) on April 14, 2011

   It’s unfortunate that these guidelines were changed at the same time as the reforms because women will assume it’s about cost-cutting.
   I’m Australian – pap tests are recommended 2 yearly from around 20 – our program is out-of-step with the evidence and harms large numbers of women (to some degree). The facts are: the lifetime risk of cervical cancer is 0.65% – no more than 0.45% of women are helped (and there are sadly, no random controlled trials for pap tests) BUT the test is intrinsically unreliable and produces lots of false positives – the lifetime risk of referral in Australia for colposcopy/biopsy is a high 77% – in the States, it’s 95% – to cover a 0.65% lifetime risk of cancer! That’s high over-detection and potentially harmful over-treatment. Almost all referrals are unnecessary and made worse by over-screening and inappropriate screening. I know US doctors over-screen and even include women not yet sexually active – and that greatly increases the risks. Virgins are excluded from other programs, to protect them from harm. Also, “no country in the world has reported a decline in the incidence of or the mortality from cervical cancer in women under 30, irrespective of cervical screening. Many countries do not perform cervical screening on women under 30″ (taken from, “Cervical cancer screening” in “Australian Doctor” 2006 by Assoc Prof Margaret Davy, Director, Gyn-oncology, Royal Adelaide Hospital and Dr Shorne)
   So, screening does not benefit women under 30, but leads to high over-detection and over-treatment. Dr Angela Raffle, UK screening expert tells us that 1 in 3 pap tests will be abnormal in women under 25, false positives caused by the pap picking up normal changes in the maturing cervix OR transient and harmless HPV infections. The pap test tends to miss the very rare case of cervical cancer in a young woman. (false negative cases) Dr Raffle also shows the rareness of cervical cancer, “1000 women need regular smears for 35 years to save one woman from cervical cancer”. (BMJ:2003 – Commentary at, “Why I’ll never have another pap smear” by Anna Saybourn.)
   As a low risk woman, it was an easy decision – I have always declined pap tests.

   I’d urge every woman to look at her risk profile for this rare cancer (always rare and in decline before screening started) and look at the ACTUAL benefits and risks of testing. You won’t get that information from your Dr or the Govt, you’ll find it in medical journals.
   Dr Joel Sherman’s medical privacy forum has a section – “womens’ privacy concerns” which contains many references in the side bar, including Dr Raffle’s research and his article, “Informed consent is missing from cervical screening”. The Violet to Blue site also has a huge list of informative articles. Make a list of questions for your Dr and go elsewhere if you don’t get decent answers. Also, ask your Dr if he/she has a vested interest in screening? Our doctors are paid undisclosed financial incentives when they reach targets for pap tests – IMO, this is unethical as it places our doctors in a conflict of interest situation. (NZ doctors also get kickbacks and UK doctors did as well, until recently…now the UK payments do not depend on numbers screening, which caused some very unethical conduct – bullying, coercion, intimidation, harassment etc – all for an elective screening test!)

   If women want to have pap tests, consider a program that offers more protection from false positives. Finland (the same program is used in the Netherlands) has the lowest rates of cc in the world and JUST as importantly refers the fewest women for colposcopy/biopsies (fewer false positives) – they offer 5 yearly testing from age 30. Even so, 35% to 55% will still be referred at some stage to cover a very small risk, but that’s the best you’ll do with this test. Cervical damage from unnecessary biopsies and procedures can lead to cervical stenosis (endometriosis, infections and may need surgery), infertility, cervical incompetence – miscarriages, high risk pregnancy and cerclage, more c-sections and premature babies plus psych issues.
   Mammograms – once again, American women are over-screened and few of you would understand the risks and actual benefits. (most women don’t)
   I recently made an informed decision not to have mammograms – a more difficult decision, as breast cancer is fairly common, but be careful of statistics, they mislead – the lifetime risk of breast cancer varies with your age – the 1 in 8 would apply in advanced old age and is often used to scare women. The risk is MUCH lower in younger age groups. You’ll find the staggered risk of breast cancer for various age groups if you google the subject. The Nordic Cochrane Institute were so concerned at the misinformation being given to women that they produced, “The risks and benefits of mammograms” which is at their website. Our program offers screening 2 yearly for women aged 50 and over…
   Dr Alexandra Barrett has also produced a decision-making aid for women aged 40-50 who might be considering a mammogram. (on line)
   After decades of research there is still enormous controversy about breast screening – decide for yourself. Dr Gilbert Welch has also included breast screening in his new book, “Over-diagnosed”…very helpful.
   Sadly, screening is often pushed at women as if it were compulsory – in fact, men AND women have a choice and legally and ethically should be providing informed consent for all cancer screening. I was appalled to hear that American and Canadian women are routinely denied birth control UNTIL they agree to cancer screening. That is a shocking abuse of your rights and body – the only things clinically required for the Pill is your medical history and a blood pressure test. The other exams that are also aggressively promoted in the States – routine bimanual pelvic, recto-vaginal, rectal and breast exams – NONE are recommended here at any age and that also applies in many other countries – they are of poor clinical value in symptom-free women and expose you to risk (biopsies, surgery, procedures etc) – these exams may partly explain your high hysterectomy rates, excessive cervical and breast biopsies and surgeries to remove healthy ovaries after a false positive routine pelvic exam.
   Fortunately, more of your doctors are speaking out – Dr Carolyn Westhoff confirms the routine pelvic exam is not helpful without symptoms – see: “Questioning the value of the routine pelvic exam” – also, “Women after birth control get unneeded pelvic exams” WSJ.
   Dr Robert Hatcher from the “Managing contraception” site has also had some stern words for doctors who “hold” scripts. (Search his name plus routine pelvic exams and BC)

   Having read many of your health forums, I see over and over women dreading this annual ordeal to get the Pill and all the horrifying over-treatment of young women after false positive pap tests – the damage caused to healthy women is tragic and unnecessary.
   Many of your women receive no/little medical care – women basically locked out if they refuse these exams or elective cancer screening – these women end up getting pills over the internet or while overseas or they use less reliable methods – that shouldn’t be happening….
   The consequences of tying up the Pill are severe – unplanned pregnancies, miscarriages, ectopic pregnancies and abortions etc
   Women are entitled to have a respectful, equal and honest two-way relationship with a trusted health care provider.
   I hope more women will take the time to do their own research and make informed decisions about their healthcare.