Part 6 is full. Please continue here.
I'll repost the last 2 comments for continuity.
Friday, September 2, 2011
Women's Privacy Concerns Part 7
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- Companion Blog on Modesty & Privacy
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Links for the Women's Thread
- My article on informed consent for Pap smears
- Violet to Blue: A new blog which has most of these thread references and more
- Current USPSTF guidelines for cervical cancer screening (10/11)
- Raffle: Outcomes of screening to prevent cancer
- Sense about screening
- Dangers inherent in all cancer screening
- Pros & cons of screening
- American guidelines for cervical screening compared
- ACOG new Pap guidelines
- Guidelines for HPV testing
- Ethics of UK cervical screening. Registration required
- USPSTF guidelines for cervical screening with rationale
- Cervical screening during pregnancy
- Case Against Routine Annual Pelvic Exams
- The CDC explains HPV infections
- Paps for virgins
- Cervical vaccines for girls, the other side of the story
- Dr DeMay: Should we abandon Paps?
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50 comments:
Here's an article from KevinMD about over screening for breast cancer. Interestingly it was written by an Ob-Gyn, Margaret Polaneczky, who was previously criticized in these threads for shutting down comments on her blog outlining the case against routine cervical cancer screening. Maybe she's learned a thing or two.
Elizabeth (Aust) said...
Dr Sherman, I don't think it was our comments that got to her, we could be shut down and silenced with Dr Polaneczky having the last word.
It was your input that may have surprised her and made her look at her actions and words. When another doctor challenges you, IMO, it has a greater impact. "AM I being unprofessional?"...
I firmly believe change is now happening in the UK and the States because doctors are speaking out in greater numbers - it's then safer to challenge unethical and unfair conduct, correct misstatements and fill in omissions - and that has a huge impact. Pro-screeners can no longer feel safe to do as they've done for decades - they're being watched and challenged...and that's why not much is happening in Australia...virtually no critical discussion where women can see it and no high profile advocates for informed consent for women. I'm sure doctors are fearful to stick their heads above the parapet. Papscreen and the Cancer Council feel so "safe" they use "angles" that were knocked down by UK advocates over a decade ago - like comparing our rates of cervical cancer with Africa and putting the difference down to our screening program. Dr Raffle took on that statement years ago - totally discredited the speaker.
We have Dr Gerard Wain, who'll occasionally state that we're wasting our time screening women under 25 and 2 yearly testing is too often, but Papscreen always have the final word. I wouldn't call Dr Wain an advocate for informed consent for women - I haven't seen any articles in the paper written by him - no public challenges. He also pretty much stands alone.
We do have academics who publish in medical journals, but few women see them...so it's a safe way of challenging an unethical system.
Still it gives us hope...the NCI have made some very frank comments about the NHS and their breast screening brochures. I can only hope they take a second look at ours, they're worse than the UK version and no one here seems to care or certainly isn't prepared to take on the screening industry.
The NCI criticized our brochures a few years back, shortly before they released their own informative summary, "The risks and benefits of mammograms" which most women have not, and will not see, if Breast Screen has anything to do with it...they're under pressure to hit the 70% target for women 50 to 69.
September 2, 2011 9:55 PM
Reposted from Part 6
Here's a snippet from a country we never talk about, but it's kind of illustrative.
In Jamaica last year, 567 men were screened for prostate cancer whereas nearly 11000 women were screened for cervical and breast cancer.
The article states that men avoid screening, but doesn't say why. Interestingly, the discussant is a female urologist.
It's probably another example of women being over screened while screening for men is not on anyone's agenda.
At home self administered tests to detect cervical cancer seem to be widely available in the UK.
Does anyone know their status in the U.S.? Haven't heard anything about them here.
Never heard of them being available in the US. I have seen on tv and read that doctors need to do paps so they can "hit the right spot." I don't see at home tests coming to the US anytime soon. Personally, I have never tested; the risks versus benefits seems like too much of a price to pay.
Regarding the article about Jamaica. This sentence stands out:"men often shied away from screening while women were more sensitised in dealing with health issues. "Methods used to capture women do not work for men," she argued." I wonder if they mean holding the pill hostage.
I don't think it's just an issue in Jamaica. I know here in Australia men don't want to have a prostate exam either.
Nic
RE: self-administered HPV tests in the UK.
I think in the UK, whilst a national HPV vaccination programme has been instigated, the link between HPV and cervical cancer still isn't very widely understood by Joe/Joan Public. Certainly I've heard very little about these home tests - either via the media or via general chat with other women (although I stress I'm hardly omniscient, and as this a recently released article this could change if it gains enough media attention). Also as most people's healthcare is via the NHS rather than via private treatment, a HPV test (home or otherwise) will probably only come to national attention when it becomes included as part of the national cervical screening programme.
Such is my English penny's worth anyway, and nice to see this thread still going!
rgds
V
My reading suggests that many women could forget pap testing if they were properly informed about the HPV test. One of our senior gynaecologists (Assoc Prof Margaret Davy) produced a pull-out guide for doctors that was included in "Australian Doctor" in 2006 - it clearly stated that not one country in the world had shown a benefit pap testing women under 30 - it also suggested that women could have the HPV test at age 30 and if negative for high risk HPV and in a monogamous relationship, could forget pap testing. These women are only tested endlessly "in case" their risk profile changes. Women are not given this information - they are just tested, which of course, carries risk.
I know the Australian Govt wouldn't want women asking for the more expensive HPV test or more women making informed decisions not to have pap tests when they've invested millions in a screening program for this rare cancer. Of course, most of these women are either no or low risk for cervical cancer and are unknowingly accepting risk with testing. It shows the lack of regard for our health and rights....the individual is sacrificed to feed, protect and justify the the program. Individual women don't matter...they're happy to worry and harm huge numbers to possibly help a very small number.
When you consider only 5% of women are HPV positive at age 40, that's a lot of no/low risk women being exposed to risk with this testing.
If the program concentrated on those women "at risk" (with their informed consent) and advised other women to assess their risk profile every 5 years or even have the HPV blood test every 5 years, they'd avoid worrying and harming vast numbers with this program and are far more likely to help the few that might go on to develop a problem. It seems no one cares about harming and worrying lots of women - as long as they can keep women ignorant and compliant, they'll stay with the program.
It makes me think it's politics and profits that keep the program unchanged - because a lot of money could be saved with reduced testing and far fewer women having excess biopsies and over-treatment - not to mention fewer women left with cervical danage that can mean premature babies, more c-sections, infertility etc
"ADVICE ASKED FOR MINORS WANTING TO REFUSE PAP SMEARS/ BREAST EXAMS AND CERVICAL CANCER VACCINE!!
A 17 year old girl whom's father had scheduled a *complete* medical exam with his male doctor last year because he's worried she might contract cancer since her mother died of cancer a couple years ago, asks advice on how to avoid going through this traumatising 'exam' again.
How the exam went down was very upsetting for her and done against her wishes since she told the doctor to not touch her *there* over and over again but he would not listen and told her it wasn't up to her as she was a minor and her father ordered a complete exam.
Her father even ordered a mammogram, but the doctor didn't gave her one as he said she was too young for that but instead would give her a very thorough breast exam.
Now one year later she got a reminder to go back which she definitely not wants to and asked her father if the dr is going to do all that stuff again. Her father replied to not be so silly and she needs to go every year to that doctor untill she's 21. He also wants her to get the cervical vaccine this year.
Her questions:
"Can they make me get the shot?
Can they make me go to a doctor that hurts me and has a creepy helper?
How can I get out of this? I'm sick to my stomach and can't sleep.
Do I have to do whatever they say?
Please write soon I don't have much time."
I told her this is medical rape but as to what the law really says, I'm not sure. I did find this article http://www.enotes.com/everyday-law-encyclopedia/treatment-minors which suggests that since she is a minor already having reached her teenage years she would be the one having the final say in her medical care.
But we also know that in some states they even want to vaccine girls without parental consent, I think this is a delicate issue. What would you advice her to do?
I said give your father first all the info about the real facts so he might change his mind, if not lie about it, say you went without really going, but then there's the issue with those nasty reminders....or keep saying No and threathen to get a lawyer?
What can she do at her age? She lives in Pennsylvania btw"
Dr Sherman, I was concerned to read this post over at Blogcritics.
Surely a teenager has the right to refuse routine medical care?
IMO, these exams are unhelpful and harmful, yet some American parents believe it's essential to get their daughters "used" to these exams - so they continue to have them into the future, accepting they're essential for good health. Some of your doctors are still pushing that line as well.
I suggested she refuse to undress - any doctor forcibly removing clothing in a routine consult setting would surely be on very shaky ground. Also, perhaps she could contact Dr Carolyn Westhoff who recently published an article questioning the value of these exams - she might be prepared to speak to the father and/or the doctor.
I think Hex had an issue like this with his niece - nurses used force to try and remove her clothing and from memory, they were found to have assaulted the patient.
Elizabeth, I'm not a lawyer and can't give valid legal advice. But she can refuse any part of the exam no matter what her father wants. The doctor's responsibility is to the patient, not to the father; the doctor can't force the exam which would constitute an assault. He shouldn't do exams which aren't indicated no matter what the father wants.
Now I don't know in this case what is indicated. Surely routine annual pelvic exams are not indicated, though ACOG would not agree with that. But I don't know what the mother died of and there may be other special circumstances. The daughter needs to make her position clear with her father who after all she is still dependent on.
Elizabeth,
I certainly do feel sorry for this poor girl. It sounds as if her father has let his emotions over her mother's passing cloud his judgement when it comes to health care and medical tests. She may still be a minor, but gosh darn it, she has every right to say what is or isn't done to her body and by whom it is done. For her father and the doctor to put her through that sort of trauma is beyond reprehensible!
It makes me even more grateful for my late mother who was present with me as a teenager when my pediatrician, a female Dr. with an interest in adolescent gynecology, tried to get me to submit to gynecological exams. I remember several occasions of going to the Dr.'s office for a sore throat or upper respiratory bug and being instructed by the nurse to change into the paper clothing before the Dr. came in. I did not do so and my dear mother refused the exam for me as well. She knew it was not necessary, it would be traumatizing to me and had nothing to do with the reason for my visit (sore throat, etc.) It is sad that some medical professionals seem to care more about our female bits than the rest of our bodies, even when there is a non-gynecological reason for the visit to the Dr.'s office. I certainly hope this young lady can get her situation straightened out and not have to endure any more unpleasantness.
--Susanne
I agree, Susanne...I hope it works out for her and she's not subjected to more trauma. I fear this is quite a common thing in the States.
I found this on various ACOG sites:
I hesitate to mention ACOG for obvious reasons, I'm not their biggest fan to put it mildly, but listen to this:
"For women younger than 21 years who have never been sexually active, no routine pelvic examination, cervical cytology, or testing for sexually transmitted disease (STD) is needed. If the women have ever been sexually active, however, ACOG recommends cervical cytology be performed 3 years after the onset of sexual activity, and annually thereafter. Routine pelvic examination should be performed only when indicated by the patient's medical history."
and on another of their sites:
"The revised schedule covers the long-standing staples of the well-woman exam. No matter a woman's age, there are standard components of the annual ob-gyn exam, including assessing current health status, nutrition, physical activity, sexual practices, and tobacco, alcohol, and drug use. Across age groups, the standard physical exam also includes height, weight, body mass index (BMI), and blood pressure. Annual breast and abdominal exams begin at age 19, and routine annual pelvic exams begin at age 21."
How does the doctor explain the exam he performed last year including a pelvic and breast exam in light of these recommendations?
I've suggested she show the guidelines to her father and if she ends up at the surgery - take them with her and say she's not consenting to anything outside the guidelines.
If the father does not accept the guidelines, perhaps she could also speak to a school counsellor. Her health and mental/emotional well-being is clearly being threatened...
Dr Sherman, I found a paper by the Health Council of the Netherlands, "Population screening for cervical cancer" 24/5/2011
They recommend a move to hrHPV testing as the primary test to identify hrHPV-positive women. These women are then put into the cytology stream (using the same sample) and if no abnormalities are found, are offered a pap test in 6 months time. If abnormalities are found, these women are referred for follow-up colposcopy/biopsy etc
HPV testing will be offered 5 times in total at age 30, 35, 40, 50 & 60. Women who don't respond to an invitation and reminder will be sent a HPV self-test kit.
The HPV test they plan to use is the invasive test, they don't mention the HPV blood test.
A Finnish study used the hrHPV test to triage women - into HPV positive and HPV negative. 5363 women were in the HPV positive group (including some symptomatic women) while 35,000 women were in the conventional screening group. The HPV test was used to identify those women "at risk". They believe more women will be helped with this testing and fewer women will be referred and over-treated.
I was disappointed to see the Finnish study examined in a couple of Australian articles and the pathologists and protectors of the current program naturlly had lots of "concerns" - IMO, about their profits and self-interest. They argue that HPV testing may be more helpful in Finland because they only test women 7 times in total, whereas we have a better screening program. (You must be joking!)
That statement ignores the huge elephant in the room - the massive over-detection and over-treatment caused by our program.
They're also concerned that women found to be HPV-positive will be worried unnecessarily, as most will not develop cervical cancer.
Of course, these women are at least "at risk" - our current program worries and harms huge numbers of healthy HPV-negative women...surely these women have some rights as well and deserve some consideration.
Over and over the arguments are about cost and the wisdom of disturbing a highly successful program - it's like the masses just don't matter...few know about the over-treatment, so they can get away with it.
The pap test is roughly $20 while the HPV test is $70-$100 - when you consider that far fewer women will be referred with HPV testing (and left with health issues after over-treatment) and fewer tests will be required, I doubt the HPV test would be more expensive in the long run. Also, some women might prefer the option and pay for the test or cover the difference in cost between the two tests - some women currently pay for a liquid based pap test.
Some countries consider the majority of women who are HPV negative, while other countries have used these programs to take advantage, maximize profits or further political and other interests. Women have paid a high price with the violation of their rights and bodies and harm to their health and emotional well-being.
http://www.australiandoctor.com.au/news/dc/0c0656dc.asp
http://www.abc.net.au/science/articles/2010/04/28/2884457.htm
http://www.gezondheidsraad.nl/en/publications/population-screening-cervical-cancer
Thanks for all those links Elizabeth. Though I'm not an expert by any means, I have no doubt that HPV is grossly underused here and in most countries. I don't know the reason for it, but clearly its greater use would cut down on over testing and unneeded procedures.
Dr Sherman,
Just read that a draft recommendation by the United States Preventive Services Task Force, due for official release next week, will NOT recommend PSA testing in symptom-free men. They say overall it does not save lives and often leads to painful, unnecessary treatments and biopsies that can leave men impotent and incontinent.
http://www.nytimes.com/2011/10/07/health/07prostate.html
Thanks Elizabeth. I'm sure the USPSTF's guidelines are factually correct. On the whole lives are not saved by routine PSA testing. But in an interview one of the members of the committee admitted that of course the test itself is just a blood test (unlike the more invasive Pap smears) and harmless in itself. It is usually done with routine annual blood work and doesn't even require an extra procedure. If you know what it means you can use it to help assess your risk and subsequent follow up routine.
I for one will definitely continue my routine testing because of an at risk family history despite being asymptomatic.
For cervical cancer screenings, which the government panel says can usually stop at 65, over 80% of Medicare claims -- more than 13 million -- were for women who were 65 or older.
This report based on a government study on the over screening of Medicare age population in the US. Lesser results were found for many other cancers including breast cancer.
Yesterday the Annals of Internal Medicine released an article by the USPSTF which has gotten wide publicity. The gist of it is that HPV is no better than liquid based Pap smears for screening for cervical cancer.
That may be, but primary screening was not the major use of the HPV test to my non expert understanding. I believe the major use for an HPV test is that a negative test strongly implies that the woman is at very low risk of cancer for at least 3 years.
Call me a cynic, but if they moved to high risk HPV testing as a primary test, the number of women having pap tests would dive dramatically...it would also send over-treatment rates way down.
Only 5% of women are HPV positive at age 40.
You'd only be pap testing those women "at risk" - positive to hr HPV and the others (most women) could have infrequent hrHPV testing or if monogamous or no longer sexually active, forget about testing. (and maybe revisit the subject if their risk profile changes) The Health Council of the Netherlands have recommended a move from their 7 pap test program, 5 yearly from age 30 to high risk HPV testing as the primary test - 5 tests would be offered at 30, 35, 40, 50 and 60. Pap tests ONLY for those who test positive for hrHPV, those "at risk"...
The industry that has been built around the unreliable pap test and the mythical "every woman is at risk from cc" would fall like a house of cards. Would that be welcomed by those who make huge profits from these tests/exams and over-treatment? I doubt it...
I wonder why the Netherlands seem to get these things through fairly quickly, while other countries are still using outdated/excessive and harmful pap testing programs. It seems the powers that profit or derive a political benefit from these programs don't have the same influence in the Netherlands.
Trust the Dutch to put common sense first and they'll save a fortune as well. Not to mention it's a MUCH better result for all women - hrHPV positive and negative...and hopefully, they get results, without the awful burden and cost paid by women not even at risk from this rare cancer.
Here are the latest guidelines from the USPSTF for cervical cancer screening wherein they state that once every three years is sufficient, especially once you have had several negative Paps.
As before you can anticipate many organizations and physicians will still push annual exams so come prepared. I will add this to the links.
We have a new article on our companion blog concerning modesty from a woman's perspective. It can be found here.
Dr Sherman,
Prof Baum and others have finally forced some action in the UK...a full review will be conducted into the risks and benefits of breast screening. The action was finally prompted by an open letter sent to Mike Richards, National clinical director for cancer and end of life care in the Department of Health by Dr Susan Bewley.
Wonderful news for English women - nothing in the "News" here. Hopefully, it will find its way down here and someone will feel motivated to make some noise.
http://www.guardian.co.uk/society/2011/oct/26/breast-cancer-screening-review-launched
http://www.bmj.com/content/343/bmj.d6894
http://www.bmj.com/content/343/bmj.d6843
Dr. Brawley of the ACS has written an opinion piece on the downsides of prostate screening for CNN. Now if only he would do the same regarding pap tests, which are for a cancer much rarer than prostate cancer.
http://www.cnn.com/2011/11/01/opinion/brawley-prostate-cancer-screening/index.html
If only...but this rare cancer is continuing to decline, so the credit goes to screening. I think it "might" be PART of the reason, but the over-detection and over-treatment of healthy women that occurs to try and prevent a rare cancer makes this testing unacceptable IMO, for mass screening, and definitely not without informed consent.
There are much better ways to help this relatively small number of women. It's unfair to only consider their health and harm and worry the more than 99% who can never benefit from screening.
When only 5% of women are HPV positive at age 40, it's insane to pap test everyone every 2-3 years until they're 60 or 70.
It convinces me the countries that have not made changes to better protect the healthy population of women are motivated by the income that flows from over-screening and over-treatment and of course, political factors, it's viewed as better to over-everything, rather than cut back - even if the former harms the masses. I remember reading that 1 billion dollars is made every year in the States from excess cervical biopsies. It's hard to fight a system that generates that sort of money.
Common sense seems to prevail with prostate screening, but is missing in breast and cervical screening. I think the coercive and dishonest "climate" that has always controlled our programs means there is no room or tolerance for facts or informed consent.
We're still largely viewed as fools if we refuse screening - outcasts and idiots. Nice to know more women are joining me though...
The war that's raging in the UK over breast screening received one small paragraph on page 6 or 7 of the paper here...final word went to a pro-screening academic/doctor.
Nothing further has been said...without advocates anything critical dies a natural death very quickly. The screening authorities are firmly in control here and everyone is silent.
Interesting article in Australia re the over diagnosis and subsequent treatment for breast cancer.
http://www.theage.com.au/national/breast-cancer-overdiagnosed-20111103-1mxyj.html
Chris
Yes, Chris...it was a delight to see some amazing coverage on over-diagnosis in breast screening.
The Minister of Health has made no comment though, so I fear it will be left to disappear...
Breast Screen are meanwhile pushing this Swedish study and suggesting this should make us feel more comfortable with the breast screening program.
Clearly they intend to ignore the criticism and carry on with their efforts to achieve their political goal - 70% of women screened in the target age range, 50 to 69.
The breast cancer lobby is so powerful and political, one brave Assoc Prof is probably no match and I note no one else has come forward to support her. Prof Olver from the Cancer Council surprised me, he agrees women should receive more risk information.
We'll see, but hopefully the article will spur more women to do their reading and ask more questions. Breast Screen and Papscreen are political organizations and we should keep that in mind when we consider their advice.
I must note that in the Journal of American College of Cardiology, Vol. 58, No. 19, 2011 they reported a very significant association between being HPV positive and the presence of atherosclerotic heart disease. In my mind it is another good reason for being tested for HPV. If positive, you should be followed more closely not only for cervical cancer, but for heart disease as well.
"I must note that in the Journal of American College of Cardiology, Vol. 58, No. 19, 2011 they reported a very significant association between being HPV positive and the presence of atherosclerotic heart disease."
That's a very interesting association, Dr Sherman. Is the article linkable/accessible to the layperson at all? If not I may add it to my site as a relevant note at least.
Sorry Violet, the article is not freely available on the web, but can be accessed at almost any medical library.
Here's another article from the NEJM which summarizes the present views of American medicine about cervical screening recommendations. It is worth a read.
Well, our program will remain unchanged for some time to come - the review is only just starting and the report isn't due until mid 2014 and then women must wait for the government to make changes, if that ever happens. In the meanwhile women are being urged to stick with 2 yearly testing from teens - over-screening and that means more over-treatment. Of course, these things are not mentioned to women so many will take their doctor's advice and over-screen to their detriment.
There is no gray area here, the delay is inexcusable and I believe is a deliberate strategy to allow the completion of unauthorized research on young women. The point has been made that this research is only possible because we still screen young women.
I cannot believe we have fallen to this level...
I hope more women and doctors walk away from this harmful program.
They have the audacity to say there will be no delay in the preparation of this review - we're about a decade or more behind the evidence and knowingly harming women. I cannot believe our doctors and others who could stop this are all silent and allowing this to go on and on...
It shows what can happen when we put our trust in the medical profession. I know many doctors are uncomfortable with the program and all of the referrals, but 60% of women are still being over-screened...at this point when the evidence is crystal clear, I would have thought it was more dangerous to recommend this program - surely it amounts to professional misconduct to knowingly expose your patient to risk for no benefit or no additional benefit and to collect an undisclosed payment for doing so? To make matters worse Papscreen has started a new campaign to get more women in for over-screening including young women...it's just sickening.
http://www.medicalobserver.com.au/news/no-delay-on-cervical-screening-review
The ping-ponging recommendations on mammograms continue. Here's the latest from CNN. Of course, those touting the start-at-40 guidelines and rejecting the USPSTF ones are the radiologists who likely have a vested interest in this case. It's frustrating to read this.
http://thechart.blogs.cnn.com/2011/11/29/radiologists-say-mammograms-should-start-at-40-not-50/?hpt=hp_bn10
A letter appeared in the "Lancet" recently in response to the mounting criticism of breast screening - light on facts as usual, but they state they have no conflict of interest. What? Most of them work for screening authorities or cancer charities. I think that's a conflict of interest.
I think the NCI are preparing their response. These groups must hate that - not having the last misleading or arrogant word and shutting down the discussion.
I've loving all of this and I should add, have waited a long time to see the facts/evidence being released, and for some discussion about informed consent and the unethical tactics used by the screening authorities.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2811%2961766-2/fulltext
The hrHPV self-sample test is being used in the Netherlands. (it's being looked at by the UK, Italy and Germany as well, so I understand)
If you test negative and are no longer sexually active or monogamous, you can forget all testing, you're not at risk from this rare cancer (unless you take a new and infected partner)
If you're positive you know you might be "at risk" from this rare cancer and if you're negative and sexually active with more than one partner or want the reassurance of continued testing, you can simply self-test for hrHPV at infrequent intervals throughout your life. (The Dutch program is 5 times in total - at 30, 35, 40, 50 and 60)
Our doctors tend to block everything to force women into the over-screening program, they're paid to reach pap testing targets. Some of our doctors even mislead women by saying HPV testing won't help them. Of course, HPV primary testing is not being offered here, just serious over-screening with the unreliable pap test.
So the Dutch have lots of options that minimize testing and over-treatment. Here in Australia women are offered an over-screening program - 2 yearly from teens to age 70 - how harmful and archaic! Plus the fairly high risk of a false positive and unnecessary biopsy or over-treatment.
Here is an article on the self-sample test being used by the Dutch, the Delphi Screener.
http://www.sciencedaily.com/releases/2011/10/111020163909.htm
Delphi hrHPV Self-Screener:
http://www.delphi-bioscience.com/Paginas/default.aspx
Here's the abstract of another just published article concerning over screening in the elderly for cancer including breast, cervical and prostate.
The message is always the same. Although guidelines for all these screening tests have been modernized and improved, many providers don't follow them. Eventually they will I'm sure, but until then it behooves every patient to be familiar with them so that you can judge screening recommendations from your doctor independently.
Hope everyone had an enjoyable and relaxing break, and Happy New Year!
I've been doing a little research into the plight of poor German women, some of the most over-screened in the world and it appears they'll continue to be into the future. Very few seem to be aware they're risking their health with this excess. Not only are they pap tested annually from teens, they also have annual bimanual pelvic and breast exams and are offered an annual TV ultrasound - talk about being obsessed with one area! They must have huge over-treatment rates and I wonder how many lose healthy ovaries.
It is a huge concern when women are offered things that are not backed by evidence, are harmful, but because they're promoted by doctors as sound preventative healthcare many women follow the advice. That seems like knowingly harming your patients to me. Surely doctors have a higher responsibility and if there is no benefit, but evidence of harm, they're obliged to advise women? But then we're still pap testing young women when there is no evidence of benefit, but lots of evidence of harm - so our doctors are no better.
I've also been looking for research into rates of over-treatment and even though it's an epidemic, very little money and time has gone into this research - it's like everyone is turning a blind eye. I have one case for Australia that's quite old now that gives 77% the lifetime risk of referral here...my GP said the changed guidelines for referring patients isn't really working as most women panic when they get an "abnormal" result and want to be referred...after decades of scare-mongering and misinformation that's hardly surprising, so I suspect our referral rates are still very high and include lots of women under 30. Almost all of this damage is avoidable now, but we choose not to make changes. So much for following guidelines...might as well go straight to day procedure.
I can't imagine how anyone could justify doing routine annual transvaginal ultrasounds.
That makes Pap smear abuse almost appear trivial in comparison.
They've proposed doing routine TVU and CA-125 blood testing to screen for ovarian cancer, but thank goodness it's been knocked on the head - studies showed it wasn't helping at all, but women were having surgery after false positives.
Doing an annual TVU and promoting it as healthcare is very concerning. The insidious thing is many women embrace these things - if it's being offered or recommended, it must be beneficial and they pressure other women to have these exams - they're being "proactive with their health". It's hardly surprising these things can become part of our healthcare when they're not evidence based. It says to me we should be very careful introducing anything without randomized controlled trials.
My GP worked in a city practice for a few years and saw a few German tourists. She was amazed these young women were anxious because their uterus and ovaries had not been checked for a year - she told them the routine TVU and pelvic exam were not recommended here and annual pap testing was also unnecessary. They left unconvinced - they've obviously been told these things are vitally important, when nothing could be further from the truth. My GP felt they'd be going straight to the gynaecologist as soon as they got home. She also noted most of these women had already had multiple procedures even though they were in their early 20's - cervical biopsies, LEEP and other assorted investigations. This further convinced these women that they were at risk, when they'd previously had "abnormal" results. No one had obviously told them false positives are very common when you do these exams and tests and the risks with pap testing are even higher for young women.
I have a link that may interest some of you. A colleague/friend has just tested for hrHPV in Amsterdam. Her Australian doctor told her HPV primary testing doesn't help women and they still need pap tests - that's misleading.
She was negative for hrHPV and is no longer sexually active and is therefore not at risk from cc, a false negative is unlikely, but women can re-test in 5,7 or 10 years time if they want further reassurance. (depending on your age)
Those positive are offered 5 yearly pap tests (no more than 7, not before age 30 or past 60 - unless there was a problem with previous pap tests or they've had cc) - most women clear the virus at some point and then will be offered infrequent hrHPV testing.
Those negative, but sexually active with more than one partner and who might contract a new hrHPV infection, will be offered the HPV program. By age 40 only 5% of women are HPV positive, so this program is likely to further reduce testing, false positives and over-treatment.
The adoption of this program in Australia would mean a vast reduction in pap testing and over-treatment, but we're light years away from this sort of program. They need another few years to decide whether it's "safe" to move to 3 yearly pap tests from age 25 to 70. Of course, we have no high profile advocates for informed consent so IMO, our program basically operates for the benefit of vested interests.
We don't need to harm vast numbers to help a few and the Dutch program is more likely to catch those 9 cases in 100,000 women - the pap test misses at least 25%-30% of squamous cell carcinoma and at least 50% of adenocarcinoma. So, our program is not about our healthcare, it harms women in vast numbers and a few women probably die as a result of false negative pap tests, when hrHPV primary testing and the option of the Delphi Screeer may have saved them.
http://www.hpvtoday.com/webEng/material/material.php
Dr Sherman, I'm curious and wondered if you'd give me your opinion: if a cancer screening program you know is harmful remains in place - do you as a doctor advise your patients to reduce or stop testing, or do you continue to recommend the program?
I know legal liability is a big factor in the States and so hiding behind a program might be the safer option for the doctor, but I wondered whether that would save a doctor from a law suit by a person harmed by the program, surely they'd join the Govt and the doctor.
(especially when women are tested with no informed consent and women are becoming more aware that our program is harmful)
I've been posting on the Mamamia site and an Australian doctor has chastised a woman for being critical of this life-saving test - after I and a few others posted, she claims all doctors can do is follow the program while the research is being done and options examined and eventually, perhaps the program will be changed and other options will become available.
I don't accept this for one moment, while some in this country might like more time to consider HPV primary triage testing and the Delphi Screener, we could minimize harm by immediately extending the testing interval and exclusing women under 25. IMO, every competent doctor in this country would know that our program is excessive and harmful, I've found numerous articles in "Australian Doctor" and the MJA.
In my opinion, if doctors had refused to continue to co-operate with the Govt, had walked away from the program, this program would have been changed long ago - OUR doctors have kept this harmful program in place. The doctor has fled now, you can fob off and discredit some women, but you can't do that to multiple articles from medical journals. I hope our posts make some doctors uncomfortable, perhaps some will then advise their patients properly and spare some of them from excessive testing and potentially damaging over-treatment - others may even be prompted to write to the AMA urging them to make an announcement on behalf of all doctors. Doing something, anything, is better than doing nothing...
http://www.mamamia.com.au/health-wellbeing/the-5-things-you-need-to-cross-off-your-health-checklist/
http://www.medicalobserver.com.au/news/no-delay-on-cervical-screening-review
"The review chair, Perth gynaecological oncologist Professor Ian Hammond, said a committee formed last week would hold its first meeting before December and report to government mid-2014.
By then almost a decade will have passed since the 2005 NHMRC recommendation that the screening interval in Australia “be reviewed as soon as possible”.
Frustration over delays was evident as details of the review were revealed at the Preventing Cervical Cancer conference in Melbourne on 11 November.
A federal health department officer was quizzed from the floor on whether the National Cervical Screening Program (NCSP), which has turned 20 years old, would remain unchanged “until 2020”."
How can they possibly say a delay of more than a decade is acceptable, especially when our program was already excessive?
Elizabeth, as a cardiologist I don't do much well patient screening. Nearly all of my patients have disease. I certainly wouldn't push a screening test I thought was harmful, but medicine is often not that clear cut. If there was a controversy about a test, I'd try to explain that and give the patient options, likely with my own personal recommendation.
Doctors in the US are somewhat in a bind. Many women have come to expect yearly exams and Paps and might leave the doctor if they stopped recommending them. Plus of course there is a financial incentive. The path of least resistance is to do the test unless the patient demurs.
Most gynecologists know the facts. My wife has been used to getting annual Paps and exams every year, and was somewhat reluctant to believe me. But on her last visit to a gynecologist she mentioned my blog. Afterwards, for the first time ever, the gynecologist told her that at her age she didn't have to return unless she had a problem.
Don't know if that fully answers your questions. It will take time to change long standing habits of both doctors and patients.
Dr Sherman how does your wife feel about that? Does she feel that she's been lied to all these years?
Mary
Mary, my wife certainly doesn't feel she'd been lied to. Indeed the needed information has really only become clear in the past 5-10 years and she's been doing this for 45-50. She it's no big deal to her.
I'm in a dilemma now where I have no good family doctors in my area. The best, who perhaps saved my life due to her willingness to stick her neck out for me and prescribe strong painkillers for a 24 year old because she believed I had IC before I got diagnosed (and had a bladder scope done on her and she knew the pain, so understood why I wouldn't have one or be diagnosed until a better method was found), still believes paps are necessary every year under no condition. Recently I was told there wasn't enough cells and I had to go back (because I had valium stuffed up there the night before, because, you know, I have IC and it hurts). I thought it'd dissolve by morning but didn't.. Lead to some laughter from the two of us, but wanting me to go back for a test I don't believe in is harsh. I growled over the phone to make them wait six months when it wasn't mid-winter to get naked again. They obliged. Everything else about her practice is fantastic, but its just she's been ingrained with that mentality from the horrible doctor's she's having to work under since she's a NP. I could fight it, yes, but I don't want to "break up" with her because she's truly the best in the region when it comes to dealing with people like me who's terrified of doctors in general. I don't even know how to bring this up without insulting her. I questioned her about every 2 years since that's the new guidelines but she said no, not ever until you're 65 which I know is a load of horse crap. But she just doesn't know. And like I said she's my only resource for so much. I did get diagnosed with IC so my Uro is taking care of my pain meds, but I still need a family doctor I can trust for general illnesses and such.. plus since IC is a pelvic pain disorder a basic exam is kinda necessary on a routine schedule (not the pap though). So I'm not really sure how to handle this. She's very firm in her beliefs, but she's still a caring person. Allowing me to avoid it for 6 more months shows she remembers my loathing for the exam. And to her credit she never pressured me into starting to get it, but did need a pelvic done for the IC thing and once she say there was no infection or anything she agreed with me, and the exam wasn't bad which gave me courage to have the pap (which gave me panic attacks on a weekly basis) and find it was *that* bad, but emotionally it leaves me shaking regardless.
I don't want to fight her. The main reason here why they enforce it is because evidently the BC pill can make the cancer grow faster? Any insight on that? If I can prove that wrong then I think I can gently win the argument.
I note that it is slowly becoming recognized that we over test in all areas. All regular screening is being looked at more carefully.
This article also contains a reference to a CDC article (which I couldn't find) which questions why if women need Paps only every 2-3 years, what is the value of annual pelvic exams? Exactly.
May I draw all your attention to this: http://www.digitaljournal.com/article/319756
tl;dr pro-lifers passed a bill forcing women to have a vaginal ultrasound before obtaining an abortion. Doctor has no say in the matter.
That's the article I wrote on it. More depth can be found in Google.
Something else.. Who do we challenge about this issue of the pap smear? My GP just won't listen to a word I say and outside of the 3 hour trip to Baton Rouge there's no planned parenthood with HOPE around.
I don't want to lose my GP, but how do I politely bring this issue up without feeling entirely ignored or insulting her? Or better yet, who do I send my hate mail to?
Nekura, I like your analogy to forcing men to have a rectal exam to get a Viagra prescription. It's about as pertinent as a transvaginal ultrasound.
In terms of your own GP, give her lots of references and hope she will read them. If she's open minded it should make a difference.
Dr Sherman, regarding your wife you wrote "Afterwards, for the first time ever, the gynecologist told her that at her age she didn't have to return unless she had a problem."
It's an interesting comment by your wife's doctor as cancer is usually a disease that is more common as we age. I realize of course that we get to a point when we will die with cancer rather than from it and it is best to leave a cancer alone at a cetain age but I am guessing your wife isn't 80+ years old yet.
And also considering that I have heard stories of 90 year old women in nursing homes being forced to have pap smears, I find your wife's doctor's comments a little suspiscious. And I wonder if her doctor wouldn't have let it go so easily if you weren't a doctor.
Mary
Mary,
The evidence is clear that past age 65 or so women with negative histories, i.e. prior negative Pap smears, don't need them anymore. That may not apply to women who continue to be active with new partners.
None of that obviates the benefit of recommended Pap smears in younger women. Here's a recent study from Sweden which validates it.
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