Screening Exams

Should I still get a yearly mammogram and Pap smear? This question is frequently asked during the office day. In the past, it would be assumed the answer would be yes, but some new recommendations have created some confusion.

We will take the Pap smear question first. Several groups make recommendations on the best interval for Pap smear screening. The opinions from the American College of Obstetrics and Gynecology (ACOG) are probably the most influential. There is also another important group called the American Society for Colposcopy and Cervical Pathology (ASCCP).  Both organizations have looked at the best intervals for screening. The short version is that a low risk woman can get a pap smear every three years. Low Risk means that she is in a mutually monogamous relationship, has no recent history of abnormal paps and is Human Papilloma Virus (HPV) negative. The virus, HPV, is thought to be the cause of cervical cancer and may be more accurate in predicting progression to cervical abnormalities than the Pap smear itself.  I agree with a 3 year interval screening for the Pap smear in truly low risk women. What women are hearing, however, is that they only need to come into the office every 3 years. This is a serious misunderstanding. The annual gynecological exam screens for many other disorders in addition to the Pap smear for cervical cancer. The annual exam screens for breast cancer, vulvar, vaginal and ovarian cancer. I also routinely detect other cancers of the colon and thyroid. It is important to be screened annually for these disorders. You still need your annual gyn exam, you just may not need a bill from the lab for a pap smear.

The mammogram question is still unsettled. The US Preventive Services Task Force created quite a stir when they released recommendations around the time of the healthcare debate. This went to the media when normally it would not be that newsworthy. Basically, they looked at the effectiveness of annual screening starting at age 50 instead of age 40. They also looked at annual screening versus every other year screening. This is common practice in other countries. The unanswered question is whether less frequent screening will still give acceptable detection of early cancers. They based their recommendations on the past 20+ years of breast cancer detection data. The problem is that technology for detection has changed a lot in those twenty years and I believe breast cancer itself is changing. We may not be able to predict future best practice based on data from a different time. Right now the recommendation is for annual mammography in all women starting at age 40. In low risk women, every other year screening in the 40-50 year old age group is an option.

Since good health care is based on relationship, you need to see your provider at least once a year, and more often if you are following a problem. Overall, I believe you will get fewer unnecessary tests if you have a good relationship with your provider. The guidelines are just that-guidelines. The best application of guidelines occurs in the context of a good relationship with a healthcare provider. You want your care custom tailored for you.