Why Women Skip Pap Smears and Why It's Crucial Not To

By Dr. Liji Thomas, MDReviewed by Danielle Ellis, B.Sc.

Understanding Pap smears
Reasons for low uptake
The importance of regular screening
Encouraging Pap smear compliance
References
Further reading

Cervical cancer is the fourth most common female cancer, with about 6,60,000 new cases and 3,50,000 deaths in 2022. It is also among the most easily prevented and treated cancers if caught early. This article discusses the importance of cervical screening as a crucial preventative measure in women's health.

Understanding Pap smears

A cervical smear is a test that uses cells collected with a small spatula or soft brush from the uterine cervix. It may be used to test for human papilloma virus (HPV) DNA (HPV testing) or precancerous changes (the Papanicolaou, or Pap, test), singly or together (cotesting).

The Pap test looks for potentially precancerous or dysplastic changes from mild through moderate and severe grades. These correspond to cervical intraepithelial neoplasia (CIN) 1, 2 and 3. CIN3 includes carcinoma in situ (CIS) when the cervical epithelium contains non-invasive but cancerous tissue.

HPV is found in practically all cervical cancers. This common sexually transmitted infection (STI) is typically asymptomatic and self-resolving within two years. ^1,10

Cervical cancer is the most common cancer caused by HPV. Conversely, all HPV infections DO NOT lead to cervical cancer, though HPV drives up the risk sixfold.

Chronic HPV infection of the cervix may activate oncogenes within the cervical cells. These cells then begin to transform into cervical cancer cells, typically over 15-20 years or 5-10 years in case of weakened immunity. ¹

Two high-risk strains of HPV, strains 16 and 18, cause half of all cervical cancers. Immunization with current HPV vaccines before the age of 15 years can protect against these, but not other oncogenic strains. ¹

Cervical smear results determine the need for follow-up and treatment. With CIN1 and 2, approximately 80% to 90% regress, most of the rest being HPV-positive. In contrast, only 47% of CIN3 may regress, up to 40% becoming cancerous. ^{7, 8, 12}

Proper cervical screening could reduce the incidence of cervical cancer by 80%, according to the World Health Organization (WHO), which estimates that coupled with HPV vaccination of girls under 15 years, it could avert 74 million cervical cancers and 62 million deaths. ^{1, 7, 8, 12}

Reasons for low uptake

Women often refuse or ignore cervical screening because of prior bad experiences, misinformation, or lack of time off from home or the workplace. Others feel healthy or think that having had the HPV vaccine protects them from cervical cancer. ²

Some women refuse testing based on their sexual behavior, such as never having been or no longer being sexually active or being monogamous. Despite reduced HPV risk, cervical screening is still recommended. ²

What is Cervical Cancer?

Other factors include embarrassment at having a man do the test, fear of the procedure, feelings of shame, and poor body image. Fatalism, not wanting to know, and equating a cancer diagnosis with a death sentence may play a role. Conversely, women with a family history of cervical cancer and those who trust their healthcare provider are more likely to get tested. ^{2, 5}

Even today, "cervical cancer screening was concentrated among individuals from wealthier households." ⁴ Lack of access, awareness, availability, and resources continue to plague women's health programs worldwide. ^{3, 4}

The importance of regular screening

Regular screening allows early detection and prevention of 80% of cervical cancers. Delayed diagnosis makes treatment more difficult and dangerous. ¹

Following HPV vaccination before 15, cervical screening should begin with an HPV smear at 25 years, repeated every five years until 65 years. Beyond this age, continued screening depends on the last test result. ¹

Alternatively, an HPV/Pap co-test may be done every five years, beginning two years after a normal Pap test. Or a Pap test may be done every three years. Globally, the WHO advises at least two cervical smears by 35 and 45 years, respectively. ^{1, 10}

More frequent screening is indicated for women with

• prior cervical cancer or abnormal smears
• human immunodeficiency virus (HIV) infection
• weakened immunity
• intrauterine exposure to diethylstilbestrol (DES). ¹⁰

The benefits of cervical screening probably outweigh the possible harms, such as false-positive results (especially among young women) causing unnecessary testing, anxiety, and fertility-impacting treatment. Again, false-negative results may reduce the chances of a cure. ⁹

Encouraging Pap smear compliance

Relative to HPV testing, Pap smears are inexpensive, offer single-visit point-of-care screening, and have the ability to triage women for further care without delay, making them ideal for low-resource settings. ⁶

Healthcare providers should encourage cervical screening at every visit, leveraging patient trust. With non-aware and/or non-engaged women, physician guidance, smartphones, television, and radio are more effective than written material. ⁵

Personalized messaging can pull in more women for awareness, screening programs, and tailored follow-up, irrespective of participation. ⁵

Community-based interventions and mobile screening clinics can transcend barriers of time, convenience, and financial insecurity. Testing should be culturally attuned and sensitive. HPV self-sampling is another promising alternative that could improve screening uptake in some settings. ²

References

1. Cervical cancer. Retrieved from https://www.who.int/news-room/fact-sheets/detail/cervical-cancer#: Accessed on August 8, 2024.
2. Bennett, K. F., Waller, J., Chorley, A. J., et al. (2018). Barriers to cervical screening and interest in self-sampling among women who actively decline screening. Journal of Medical Screening. doi: https://doi.org/10.1177%2F0969141318767471.
3. Damiani, G., Federico, B., Basso, D., et al. (2012). Socioeconomic disparities in the uptake of breast and cervical cancer screening in Italy: a cross sectional study. BMC Public Health. doi: https://doi.org/10.1186/1471-2458-12-99. 
4. Chirwa, G. C. (2022). Explaining socioeconomic inequality in cervical cancer screening uptake in Malawi. BMC Public Health. doi: https://doi.org/10.1186%2Fs12889-022-13750-4.
5. Marlow, L. A. V., Ferrer, R. A., Chorley, A. J., et al. (2018). Variation in health beliefs across different types of cervical screening non-participants. Preventive Medicine. doi: https://doi.org/10.1016%2Fj.ypmed.2018.03.014.
6. Suba, E. J., (2024). Researchers should no longer delay implementation of Pap screening in low and middle income countries pending research into novel screening approaches. Infectious agents and Cancer. doi: https://doi.org/10.1186%2Fs13027-024-00576-5.
7. Srivastava, A. N., Misra, J. S., Srivastava, S., et al. (2018). Cervical cancer screening in rural India: Status & current concepts. Indian Journal of Medical Research. doi: https://doi.org/10.4103%2Fijmr.IJMR_5_17.
8. Ehref, A., Bark, V. N., Fehm, T. N., et al. (2023). Regression rate of high-grade cervical intraepithelial lesions in women younger than 25 years. Archives of Gynecology and Obstetrics. doi: https://doi.org/10.1007%2Fs00404-022-06680-4.
9. Cervical Cancer Screening (PDQ®)–Health Professional Versio (2024). Retrieved from https://www.cancer.gov/types/cervical/hp/cervical-screening-pdq. Accessed on August 13, 2024.
10. Cervical Cancer Screening (2024). Retrieved from https://www.cancer.gov/types/cervical/screening. Accessed on August 13, 2024.
11. Cervical Dysplasia (2024). Retrieved from https://my.clevelandclinic.org/health/diseases/15678-cervical-intraepithelial-neoplasia-cin. Accessed on August 13, 2024.
12. Tainio, K., Athanasiou, A., Tikkinen, K. A. O., et al. (2018). Clinical course of untreated cervical intraepithelial neoplasia grade 2 under active surveillance: systematic review and meta-analysis. The BMJ. doi: https://doi.org/10.1136/bmj.k499.

Further Reading

• All Cervical Cancer Content
• What is Cervical Cancer?
• Cervical Cancer Causes
• Cervical Cancer Diagnosis
• Cervical Cancer Treatment