Older women still getting Pap smears despite guidelines

NEW YORK (Reuter Health) - Women who’ve had a hysterectomy, and most women over 65, don’t need regular swabs for signs of cervical cancer - but lots of them are getting the test anyway, say U.S. researchers.

Experts recommend that young women start having internal pelvic exams, including a Papanicolaou test, or “Pap smear,” to check for abnormal cells on the cervix, performed by a gynecologist at age 21. The United States Preventive Services Task Force (USPSTF) recommends that women ages 21 to 65 without a history of cervical problems have a Pap smear every three years.

Women over 65 who have had recent regular Paps with normal results, and those who have had total hysterectomies and no longer have a cervix no longer need to have the screening test, according to the government-backed panel.

“There is very little benefit to continue screening women over 65 who are low risk and have no history of abnormal Pap tests, cancer, or precancerous lesions,” Deanna Kepka said. “The procedure is not dangerous but is an unnecessary use of resources.”

Kepka studies public health at the Huntsman Cancer Institute and the College of Nursing at the University of Utah in Salt Lake City.

But according to U.S. national survey data from 2010 analyzed by Kepka’s team, a third of women who had had a hysterectomy also reported having had a Pap smear in the past year.

Two thirds had had a Pap smear since their hysterectomy.

Among the women over 65, half reported a Pap smear in the past three years, according to the results published in JAMA Internal Medicine.

In 2012, the USPSTF, American College of Obstetricians and Gynecologists and the American Cancer Society all agreed that women age 65 and older do not need these tests.

“That was the first time every national guideline matched,” Debbie Saslow said.

Saslow is director of breast and gynecologic cancer for the American Cancer Society.

“Not only do they not recommend the tests, they specifically recommend against them,” she said.

Unnecessary Pap tests can turn up abnormal cells and lead to costly and stressful follow-up tests, she said.

“It costs money to perform unnecessary Pap tests - period,” Kepka said. It may not always cost women money, especially since the Affordable Care Act eliminated co-pays for those kinds of preventive screening tests, but it does cost the U.S. healthcare system money.

Doctors might do the tests anyway because women expect them, or doctors think they expect them, Saslow said.

“A lot of gynecologists think the only reason a woman comes in is for the annual Pap tests,” she said, but women might actually be more inclined to come in for annual checkups if they knew they would not have to disrobe and have an internal exam.

“It is entirely reasonable for a woman to request no more Pap tests if she believes she is in a low-risk category and does not want the exam,” Dr. George F. Sawaya said.

He’s a professor of Obstetrics, Gynecology and Reproductive Sciences and Epidemiology and Biostatistics at the University of California, San Francisco.

“All women over age 65 should ask their clinician if they could end screening,” he said.

In their report, the researchers note that relying on survey answers means it’s possible some women don’t accurately recall what tests they had and when. The study team also lacked data on the specific types of hysterectomies women had.

It is also possible that fewer women have unnecessary tests now compared to 2010 when this study was done, Saslow told Reuters Health, but future studies will need to assess that.

According to the New Mexico state cervical cancer screening registry, for example, only about 8 percent of ineligible women have these tests.

“We don’t know what the true number is, but whatever it is too high,” Saslow said.

“We need to find ways to educate providers and women about this,” she said. “If you don’t have a cervix, don’t get screened for cervical cancer.”

SOURCE: JAMA Internal Medicine, online November 25, 2013.