The pap smear has been one of the greatest public health wins of the past century. Deaths from cervical cancer in the U.S. have dropped from 37.5 per 100,000 women to 7.5 per 100,000 women as a result of the simple screening test.
But with our increasing understanding of the role of human papillomavirus (HPV) in the development of cervical cancer, the pap test may end up being pushed aside by HPV screening.
Today, 2 Docs Talk about Pap smears, HPV screening, the current recommendations for cervical cancer screening, and the research that may push us to shifting away from the pap smear to the HPV test.
[00:00:00] This podcast is brought to you by Dr.Amy Rogers and Dr. Kendall Britt.
[00:00:11] Welcome back, Kendall.
[00:00:12] Likewise. How was your trip to Europe?
[00:00:14] It was fantastic. Fantastic. We saw all the good things.
[00:00:18] How was traveling with your kids – two high school children?
[00:00:22] It was really fun – really really fun.
[00:00:24] You weren’t slowing them down, you weren’t cramping their style?
[00:00:27] I think I was dragging them along. How about you. You were in China.
[00:00:33] We went to China. It was the trip of a lifetime. I highly recommend traveling to China. Eye opening experience amazing things to see and do.
[00:00:42] Yeah. What was your favorite thing.
[00:00:43] I can’t really say because there were so many in fact we had so many overwhelming I mean so many amazing experiences it was kind of overwhelming but I will say that the Great Wall was everything advertised and more.
[00:00:56] Wow. Awesome.
[00:00:58] Sounds good.
[00:00:59] Impressive and I traveled with my two Middle-Aged. No. I traveled with my two middle school children.
[00:01:05] OK. And how was that.
[00:01:06] I was definitely dragging them along.
[00:01:11] That’s awesome. Well it’s good to be back here talking about all things health care I guess.
[00:01:17] Yes and we have a new and exciting pod several new and exciting podcasts.
[00:01:21] Yeah, quite a few lined up. Yeah yeah.
[00:01:23] So a lot happened while we were gone and we’re not going to address all of it and that frankly we don’t really understand all that.
[00:01:31] Yeah and and honestly if we addressed it it would be different by the time we did address it.
[00:01:35] Very true. We can’t keep up with the fast pace of the world of health care these days.
[00:01:41] So anyways but today we have a podcast about something that is kind of changing as we speak, too, a little more slowly than maybe health your policy or actually health care policy may be very slow to change who knows. But anyways…cervical cancer screening.
[00:02:00] So yes it’s actually changed quite a bit since you and I were in med school.
[00:02:04] A lot. Yeah yeah a lot. So let’s get into it.
[00:02:07] And for the better I might add.
[00:02:09] I think so.
[00:02:09] As someone who personally as well as professionally is interested in cervical cancer.
[00:02:17] OK. So screening for cervical cancer with the pap smear has been one of the biggest public health wins in the last 100 years.
[00:02:25] That’s true. Yeah. Yeah in the early 1900s, in fact cervical cancer was the number one cause of cancer death in women in the U.S.. Did you know that? I did not know that until recently.
[00:02:36] No I knew that yeah. Yeah.
[00:02:38] I mean that’s hard to believe it’s hard for me to get my mind on that.
[00:02:41] And still in a lot of parts of the world where they have difficulty screening and it’s a very important cause of death.
[00:02:47] But in the I mean but in the U.S. women don’t die from cervical cancer.
[00:02:51] Not anymore. Yeah. Very rare. Yeah. So anyway after George Nicholas Papanicolau.
[00:02:57] And Aural Babes.
[00:02:59] How do you say that guys name are all babies babies. Of Romania.
[00:03:07] Papanicolau and Babes – however you say his name. They both developed a method of detecting abnormal cervical cells under the microscope.
[00:03:15] Yeah. And in the 1940s the Pap smear that’s Papanicolau to us for short or pap tests as it became known in honor of that great guy became very widely used and the incidence of cervical cancer in the US has plummeted.
[00:03:34] Yes. Yeah. In the 1930s the incidence was thirty seven point five cases per 100000 women.
[00:03:39] That’s US right.
[00:03:40] In the U.S.. Yeah yeah. And now by 2008 after decades of use and improvement on the pap smear the number of cases were 7.5 per 100000.
[00:03:50] That’s huge. Thirty seven point five to seven point five. Yeah that’s a big success. But is the Pap smear about to go the way of 8 track tape.
[00:03:59] Or the cassette or even the CD. Actually.
[00:04:01] I still have all of those. What about answering machines and payphones.
[00:04:07] Typewriters. What about folding paper maps.
[00:04:10] Oh my gosh remember those huge great big books of maps that you would take. Rand McNally When you’re traveling across multiple state. Yes. Yeah. Those were the days. Road trips back in the 80s so all those technologies seemed like they would last forever but for most purposes obsolete today. And maybe the past year will be too before too long.
[00:04:44] So Hello and welcome to 2 Docs Talk. The podcast about health care the science of medicine and everything in between.
[00:04:51] OK. So it sounds insane to suggest that the pap smear is about become obsolete it has prevented so much disease over the years.
[00:04:59] Yes highly successful. But not only that it’s improved so much that the recommendations to have it annually or the recommendation to have it annually was scrapped. Not that long ago because it was better than ever finding abnormalities and testing too often could be associated with unnecessary harm false positive things that would resolve on their own.
[00:05:18] Yeah exactly. But before we go on let’s talk about what exactly is a pap smear.
[00:05:22] OK this is for the men in our audience right now. So very simply the doctor scrapes some cells from the surface of the cervix and they are examined in a microscope.
[00:05:32] Yeah. And there are certain characteristics of the cells when they’re looked at under the microscope. That suggests they have a higher risk for turning into cancer. So if these are present. The doctor will then recommend maybe follow up screening in a shorter amount of time than normal or some procedures to locate and remove further risky cells.
[00:05:50] OK so what are. Let’s start with the current recommendations.
[00:05:54] Right now. This is what is recommended. The USPSTF – United States Preventive Services Task Force recommends that women age 21 to 65 receive a pap test once every three years. OR they can extend the time between testing by having a pap test combined with cytology for human papillomavirus or HPV and then they only have to do it every five years.
[00:06:17] Right. And this is something that’s changed since we were in med school they don’t recommend screening for people under 21.
[00:06:23] That’s right.
[00:06:24] Nor do they recommend it for women over 65 who are not at high risk for cervical cancer and have had adequate prior screening.
[00:06:32] They recommend against screening for women who don’t have a cervix. Again I remember doing a pap smears on the vaginal cuff in women that had had a hysterectomy when I was in residency.
[00:06:45] The only exception to that is that the reason is that they had the hysterectomy because they had surfaced cervical cancer. So yeah. But otherwise no.
[00:06:54] And the American College of gynaecologists their guidelines are essentially the same.
[00:06:57] Yes. So OK. So this is pretty cool for a woman turning 21 today. They can only require nine or 10 pap smears in their entire life if they combine it with HPV screening.
[00:07:07] That’s very different from the “every year forever.” That used to be the case. No big improvement in my opinion. And most women’s. What woman would argue with that.
[00:07:16] Exactly. So apparently actually a lot of women who are you know probably our age and older who are used to “you do it every year” can’t wrap the brain around. I need to wait three years. What are you talking about. So that’s something. Yeah. So I know that there have been doctors who have had patients argue with them about it and they’ve had to do some convincing. Yes it’s interesting. OK.
[00:07:39] So those changes to the United States Preventative Services Task Force recommendations. Can I just say USPSTF.
[00:07:46] I think we should say that.
[00:07:47] OK. So those changes to the USPSTF recommendations were made in 2012. Yes but research from 2014 Two years later suggests we may be seeing another change in those recommendations before too long. Yeah it all comes down to that HPV screening. Right. So HPV human papilloma virus is a sexually transmitted virus that is known to cause two major problems. Genital warts and cervical cancer.
[00:08:16] Right now this is the reason the development of the immunisation for HPV has been such a big deal.
[00:08:22] Yeah. And if anybody out there remembers We did a podcast on it and we’ll link it in the notes if you want to learn more about it.
[00:08:29] So instead of finding certain abnormalities in a pap smear HPV screening looks for evidence of active HPV in the cervical cells instead. So if active HPV is found on patients are then taken to have a colposcopy.
[00:08:42] Probably we should say what a colposcopy is.
[00:08:45] During a colposcopy the physician examines the cervix through a special microscope they often use a vinegar solution applied to the cervix to help visualize any abnormal tissue.
[00:08:55] And they can identify tissue that is precancerous or even cancerous. Yeah. So the 2014 research showed a couple of things.
[00:09:03] Right. The Journal of the National Cancer Institute published a study that showed and this is a quote Women with a negative HPV test had half the risk of developing developing cancer over three years as women who had a negative Pap test and similar rates to women who are negative on both tests.
[00:09:22] So the pap smear wasn’t really adding any benefit even in the combined test.
[00:09:27] Right. That’s the take home message.
[00:09:30] Another study published in the Lancet looked at four randomized trials and found that HPV screening was superior to pap smear by about 60 to 70 percent.
[00:09:40] But… end points.
[00:09:42] Yes the end point was precursor cancer cells and noninvasive cancer. But still it’s good data to add to the pile, if not the very best possible data.
[00:09:50] Well there was a study in NEJM in the New England Journal of Medicine that showed that a single round of HPV screening in villages was low resources for testing was associate with a decrease in advanced cervical cancer and deaths from cervical cancer. Those are good points right. So that’s ultimately what we’re trying to prevent.
[00:10:06] Exactly. There are other studies. Some are better than others. But it does seem that the trend is toward HPV screening alone in women over 25.
[00:10:15] Yes. And the USPSTF did outline the reservations they had about HPV and their 2012 recommendations. And it looks as if research is making a dent in addressing those reservations.
[00:10:27] So why not just do both? I mean it’s not all that different for the patient. I mean if you have to put your feet in the stirrups and have one sample taken why wouldn’t shouldn’t they just take two samples and do two tests at once.
[00:10:39] Why Amy. I thought you were going to avoid politics in this episode. Two tests cost more money than one test.
[00:10:46] Yes that’s true.
[00:10:47] Women who don’t have health care may have trouble paying for one test much less two.
[00:10:51] And with cuts in funding for women’s health care.
[00:10:54] We could go on.
[00:10:55] But we won’t…today.
[00:10:58] OK so what’s our takeaway. Well first get your children the HPV vaccine.
[00:11:03] It is proving to be quite effective in preventing the strains of HPV that cause cervical cancer.
[00:11:07] Right. And second practice safe sex. Yes. HPV is a sexually transmitted infection. Seventy nine million Americans have an HPV infection and there are 14 million new infections each year.
[00:11:19] Right. Cervical cancer takes a long time to develop. So most people who have HPV have no idea about it to even warn their partner about it.
[00:11:27] Yes that’s exactly right. And even some women who have genital warts they don’t even know that they don’t know they have. Exactly. Yeah it’s not like chlamydia GC or something like right.
[00:11:36] And even chlamydia, a lot of them, can be hidden. So you can’t assume that. Right. You’re having safe sex you know.
[00:11:44] Yeah. It means if you’re in a monogamous monogamous relationship one of you may have HPV from past relationship, so both partners are at risk.
[00:11:52] Yes. And third get the appropriate screening.Right now, That is a pap smear every three years or a combination pap smear and HPV screen every five years.
[00:12:01] But stay tuned for potential changes in the near future. Definitely stay tuned because this is a moving target. We hope you like the show and we hope you’ll tell your friends about it. Andshare it on social media. And until next time.
[00:12:16] Hey I just noticed this. OK. You should start getting a pap smear at age 21 which is also the same age you can start drinking. So here is how you encourage you go. No no this is a bad idea. Get your pap smear and then go celebrate with a drink.
[00:12:34] Or maybe gynecologist can start serving shots in the waiting room.
[00:12:39] Superbad idea.
[00:12:42] By everybody.
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