American women having unnecessary PAP smears

jama-archives.orgJun 22 2004

Many American women who have had a hysterectomy are still having routine PAP smear tests even though they are not at risk of cervical cancer, according to a new report published in the Journal of the American Medical Association (JAMA).

Introduced in the 1940's PAP smear screening is now a widely accepted cancer screening test that has substantially decreased the number of cases and deaths since its introduction. In 1996, "based on accumulated evidence from observational studies, the U.S. Preventive Services Task Force recommended that routine Pap smear screening is unnecessary for women who have undergone a complete hysterectomy for benign (non-cancerous) disease." The authors add that most women who have undergone hysterectomy are not at risk of cervical cancer becausedue to the absense of a cervix.

Researchers from the VA Outcomes Group, White River Junction, Vt. and Dartmouth Medical School in Hanover, N.H., analyzed data from the Behavioral Risk Factor Surveillance System (1992 - 2002), an annual, population-based telephone survey of U.S. adults conducted by the Centers for Disease Control and Prevention. Information from 187,670 women was studied.

"Twenty-two million U.S. women 18 years and older have undergone hysterectomies, representing 21 percent of the population," the authors found. "The proportion of these women who reported a current Pap smear did not change during the 10-year study period. In 1992, 68.5 percent of women who had undergone hysterectomy reported having had a Pap smear in the past 3 years; in 2002 (6 years after the recommendation), 69.1 percent had had a Pap smear during the same period."

After accounting for Pap smears that may have preceded a recent hysterectomy and hysterectomies that spared the cervix or were performed for cervical neoplasia (tumors), we estimate that approximately 10 million women, or almost half of all women who have undergone hysterectomy, are being screened unnecessarily, the authors report. Although estimates based on patient self-report may over-estimate actual screening rates, these results suggest that millions of women are being screened unnecessarily, and the amount of screening has not declined following the task force recommendation, the authors note.

The authors also noted that there are several factors contributing to the continued screenings. "It is possible that women who have had a total hysterectomy are not aware that they are no longer at risk for cervical cancer. Or they may simply be so enthusiastic about cancer screening that they continue to have Pap smears regardless of the usefulness of the test. It is also possible that physicians are largely responsible for continuing cervical cancer screening after hysterectomy."

The researchers also suggest Pap smear performance measures may also be responsible. Although such measures may not be aimed at women who have undergone a hysterectomy, "The net effect may be that all women are encouraged to receive Pap smears in order to meet specified benchmarks for cervical cancer screening." In conclusion the authors write: "The U.S. Preventive Services Task Force recommendations either have not been heard or have been ignored."