Friday, 14 September 2018 16:42

Are pap smears going away?

Written by Dr. Daliah Wachs
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For some yes, as new cancer screening guidelines suggest swapping the embarrassing procedure with HPV only tests. These HPV only tests can even be done in the privacy of one’s home.

The US Preventive Services Task Force (USPSTF) suggest women between the ages of 30-65 may be screened for cervical cancer by testing for the HPV virus, high risk strains, every 5 years without undergoing a concurrent Pap smear. This is opposed to the “co-testing” recommended up until now. Women can, however, if desired, choose to have Pap smears every 3 years. These guidelines do not pertain to those who have cervical cancer or symptoms that could suggest a malignant process such as pain, bleeding and weight loss.

However one concern many physicians have is the lack of other testing being done during a “Pap Smear” visit.  Pelvic exams evaluating for gynecological pathology, breast exams, counseling and preventative health recommendations are often done during a woman’s physical and extending the testing intervals to twice a decade could put one at risk of another illness being missed.

Moreover, would an at home HPV test be sufficient enough to screen for cancer?  Smoking may also predispose one for cervical cancer so testing for the HPV virus alone may not be enough.

What is the cervix and what is cervical cancer?

 

The uterus looks similar to a light bulb.  The larger top portion being where the fetus develops, and the bottom, narrower area, the cervix.  The cervix thins and dilates during childbirth, as you’ve heard in the movies “she’s only 7 cm!” and then after childbirth becomes narrow again.  It affects nearly 12,000 and kills 4,000 women each year.  It can affect women of any age but is more common between 20 and 50.

 

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HTTP://WWW.WEBMD.COM/WOMEN

 

What causes cervical cancer?

 

The most common cause is HPV (Human Papillomavirus), especially HPV-16 and HPV-18.  This is acquired through unprotected sex, so condom use is encouraged. Thus it's one of the most preventable causes of cancer.  Additionally, there are 3 vaccines for HPV currently approved by the FDA, Gardasil, Gardasil 9, and Cervarix.

What are the symptoms of cervical cancer?

 

Early cervical cancer may not be symptomatic but as it develops it may cause an odor, pain with urination, pelvic pain and bleeding. This bleeding may occur after sex, a pelvic exam, or intermittent bleeding not associated with a menstrual cycle.

Is cervical cancer treatable?

 

Yes.  Early detection is key and can be done by a Pap Smear, explained below.  Multiple treatments are available including surgery, chemotherapy,  radiation therapy, and targeted therapy such as Bevacizumab (Avastin®) which prevents new blood vessel growth that can feed a tumor.

Who should get screened for Cervical Cancer?

 

The USPSTF (United States Preventive Services Task Force) recommended the following:

Women aged 21 to 65 years

The USPSTF recommends for cervical cancer every 3 years with cervical cytology alone in women aged 21 to 29 years. For women aged 30 to 65 years, the USPSTF recommends screening every 3 years with cervical cytology alone, every 5 years with high-risk human papillomavirus (hrHPV) testing alone, or every 5 years with hrHPV testing in combination with cytology (cotesting).

 

See the Clinical Considerations section for the relative benefits and harms of alternative screening strategies for women 21 years or older.

A

Women older than 65 years

The USPSTF recommends against screening for cervical cancer in women older than 65 years who have had adequate prior screening and are not otherwise at high risk for cervical cancer.

 

See the Clinical Considerations section for discussion of adequate prior screening and risk factors that support screening after age 65 years.

D

Women younger than 21 years

The USPSTF recommends against screening for cervical cancer in women younger than 21 years.

D

Women who have had a hysterectomy

The USPSTF recommends against screening for cervical cancer in women who have had a hysterectomy with removal of the cervix and do not have a history of a high-grade precancerous lesion (ie, cervical intraepithelial neoplasia [CIN] grade 2 or 3) or cervical cancer.

The first 3 recommendations apply to individuals who have a cervix, regardless of their sexual history or HPV vaccination status. These recommendations do not apply to individuals who have been diagnosed with a high-grade precancerous cervical lesion or cervical cancer. These recommendations also do not apply to individuals with in utero exposure to diethylstilbestrol or those who have a compromised immune system (eg, women living with HIV).

 

What is a Pap Smear?

 

It is the cytology (cell analysis) of the cervix. Years ago, a cytobrush would collect the cells and the medical provider would “smear” it onto a slide, place fixative, and then send it to the laboratory for the pathologist to analyze it. Now ThinPrep® Pap tests are used more commonly as the cells from the brush are placed into a container with fixative, and this vial is sent to the pathologist to spin down and analyze.

 

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TEK IMAGE/SPL / GETTY IMAGES

 

In order to obtain the cells from the cervix, the medical provider needs to use a speculum to open the vaginal canal and allow access to the uterus.  A woman may be in the lithotomy position…lying on one’s back on the exam table with her feet in stirrups and knees bent. During the speculum exam, the medical provider may take cultures to test for common vaginal infections such as yeast, bacteria vaginosis, or sexually transmitted illnesses such as gonorrhea and chlamydia.  After the speculum exam, the provider may perform a pelvic exam with her gloved hand to examine the uterus and ovaries, evaluating for tenderness, shape, size and masses.

How is an HPV test done?

 

An HPV test can be done with the cells obtained during the Pap Smear.  At home tests require the patient to swab their vagina (female) or urethra (male) or rectum and then mail the swab to the lab.  The laboratory evaluates the cells to see if the HPV virus that causes cervical cancer is present.

In summary the thousands of deaths that occur each year to cervical cancer can be prevented with simple testing, such as the Pap Smear.  Discuss with your medical provider when cervical cancer screening is best for you.

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Daliah Wachs is a guest contributor to GCN news, her views and opinions, medical or otherwise, if expressed, are her own. Doctor Wachs is an MD,  FAAFP and a Board Certified Family Physician.  The Dr. Daliah Show , is nationally syndicated M-F from 11:00 am - 2:00 pm and Saturday from Noon-1:00 pm (all central times) at GCN.

 

 

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