Wednesday, January 9, 2013

Pap smears, guidelines and churning

A friend called me the other day to say that his wife had just received a rather concerning message after a visit to her gynecologist. They had been away over the holidays and returned to find this registered letter.

Dear Patient,

We have previously contacted you or attempted to contact you regarding follow-up of your abnormal test results. As we have not heard from you, we are writing to urge you to seek medical attention if you have not already done so.

It is very important that you contact us at your earliest convenience. If you have any questions or would like an appointment, please call between the hours of 8:00 AM through 5:00 PM.

Very truly yours,

They were not too upset because many years ago she had a false positive Pap smear (a test done to detect cancer of the cervix) and received a similar letter. On that occasion, the repeat test was normal.

They made the appointment. During a three-minute visit with the gynecologist, they were informed that the Pap smear was normal.

My friend asked the doctor why the letter was worded in such an ominous way. He was told that was their standard letter and that the doctor “would look into it.”

My friend wondered why the normal result couldn't have been been simply told to them by phone. I replied that the purpose of the registered letter was to generate an office visit.

During the phone call, my friend told me that his wife was having Pap smears every 6 months. He asked if that was routine. I said I had never heard of anyone doing it that often, especially with no history of abnormal Pap smears in the past.

Did I mention that his wife was 71 years old?

All guidelines say that women over 65 without risk factors don’t need a Pap smear at all, so every 6 months seems a bit excessive.

Regarding the office visit and the too frequent Pap smears, the stockbrokers have a word for this sort of thing. It’s called “churning.” To boost his income from commissions, a broker will churn by unnecessarily buying and selling a lot of stocks for his clients.

It’s not unique to this gynecologist. According to an article about a CDC report, 60% of women who have undergone a total hysterectomy, a procedure which involves removal of the cervix, continue to have Pap smears done. In case you aren’t familiar with this topic, cervical cancer is not going to occur when the cervix is in a jar in the pathology department.

And even more amazing is that the article says in 2010, “About two-thirds of women 65 and older who hadn't had a hysterectomy reported having a recent Pap test. That's down from nearly three-quarters in 2000, but it's not a huge improvement.”

“It’s not a huge improvement”? That’s quite an understatement.

It's Medicare, so we're all paying for it.

Things like this make me really worry about the future healthcare of my children and grandchildren.


Josh said...

Physicians, as a profession, haven't demonstrated any inclination to police themselves, so we will be policed by the government. Everyone will complain, but we have done it to ourselves (however as a young physician I cannot help but feel much of the blame belongs to the generation preceding me). Its all very sad.

Skeptical Scalpel said...

You are right. We did it to ourselves and it was my generation, facilitated by the government, who did it.

Anonymous said...

Pap smears are not innocuous, I ended up with years of chronic abdo pain after a smear test - as a result of endometriosis. After this experience I was still called for a test even after having a hysterectomy, until I complained. My experience was in the NHS. I am not suggesting people shouldn't have smear tests and long term problems as a result of having one must be rare (I don't know the figures.) This testing clearly has a role, but excessive testing is wrong. Lets hope the cervical cancer vaccination reduces the need for this test in the future.

Anonymous said...

(kms_md on twitter)

There are pretty clear national recommendations/guidelines for the frequency of pap smears with/without HPV screening. There does exist a cadre of women for whom a pap smear is indicated on a less frequent basis than yearly. However, we as gynecologists need to separate "pap smear" from "annual exam". I usually explain to my patients that I will collect the pap smear during an annual exam based on her risk factors and history. A pap smear does not need to be done at every pelvic exam - and past a certain age is not necessary at all. However, for women with significant dysplastic lesion, they may still benefit from a pap smear following hysterectomy as they are at risk for a neoplastic lesion at the vaginal cuff.

Medicare will cover a routine pap smear every 2 years unless the patient is "high risk" ie having certain risk factors CMS has determined necessitate more frequent screening.

Skeptical Scalpel said...

Anonymous commenters, thanks for chipping in. Nice to hear that unnecessary smears after hysterectomy are done in the UK too.

I appreciate a gynecologist backing me up on this issue.

Has anyone looked at the value of a routine yearly pelvic exam?

Anonymous said...

Routine pelvic exams are no longer recommended at all in asymptomatic women, many years ago they were tacked onto a pap test. I have never had one and would never permit that sort of harmful exam. The evidence is clear, they are of low clinical value, it is not a screening test for ovarian cancer and it carries risk, even unnecessary surgery. Dr Carolyn Westhoff, American ob-gyn, partly blames this exam for your high hysterectomy rates and for the loss of healthy ovaries.
Pap testing has been horribly overused to create IMO, a hugely profitable industry in the over-treatment of CIN. Over-screening provides no additional benefit, but sends risk way up from false positives and potentially harmful over-treatment. You have only to look at countries that offer evidence based screening to see the difference, these program seek to protect women from cervix cancer and over-treatment.
Countries like the States and Australia seriously over-screen sending risk way up for no additional benefit. Since the 1960s the Finns have had a 7
pap test program, 5 yearly from 30 to 60 and they have the lowest rates of cc in the world and refer far fewer women for potentially damaging over-
treatment. (their program produces fewer false positives) The Dutch have the same program, but will move with the evidence and scrap population pap
testing and shortly offer instead 5 hrHPV primary triage tests at ages 30,35,40,50 and 60 and only the roughly 5% of women are are HPV+ will be
offered a 5 yearly pap test. These are the only women who can benefit from pap testing.
Those HPV- will be offered the remaining HPV primary tests and there is a HPV self testing option. This takes most women out of the pap testing
program protecting them from over-treatment and is more likely to save lives by identifying the small number actually at risk, those HPV+
The lifetime risk of referral for colposcopy/biopsy here is a whopping 77% for a cancer with a 0.65% lifetime risk, shocking over-detection caused by serious over-screening. Women here are still being told to have 26 or even more pap tests, 2 yearly from 18 to 70. This is bad medical advice that simply exposes women to high risk for no additional benefit. Most of this damage is avoidable with evidence based programs.
The lack of respect for informed consent and even consent itself in women's cancer screening is disgraceful, many American women are coerced into
screening and over-screening to get the Pill. The Pill has nothing to do with cancer screening and pap testing can never be "required" for anything, it
is always elective and legally and ethically requires your informed consent. Women should demand real information, HPV primary testing, self
testing options and respect for informed consent and our right to accept or decline screening as we see fit.
Women need to be careful with breast screening as well, the Nordic Cochrane Institute concluded ten years ago that screening is of little benefit but
leads to significant over-diagnosis. A recent study by Prof Baum in the BMJ concludes the risks of breast screening exceed the benefits when you
take into account the death of women due to over-diagnosis. The NCI have produced an excellent and unbiased summary of all of the evidence on
breast screening, it's at their website. Routine breast exams are not recommended here either, there is no evidence of benefit, but they lead to excess
biopsies. IMO, powerful vested and political interests have been allowed to influence and control women's healthcare in some countries.
HPV Today, Edition 24, sets out the new Dutch program.
I made informed decisions not to participate in cancer screening...and currently I'm researching the risks and benefits of bowel screening. If I'm not
satisfied with the evidence, I will be declining that as well. Informed decisions are the best decisions. Elizabeth (Aust)

Skeptical Scalpel said...

Thanks for the detailed comments. Good points.

Anonymous said...

I had a hysterectomy for benign reasons about 10 years ago. At each subsequent pelvic exam I have had to explicitly remind the provider that a Pap was not indicated. Had I not spoken up who knows how many inappropriate Paps I would have had.

Skeptical Scalpel said...

Unfortunately, many patients do not know better and do not question their doctors.

Unknown said...

I really appreciate your last comment, Mr. Skeptical Scalpel. However, this comment seems to indicate a reversal of opinion. You see, above, your comment leads me to believe that you are understanding, if not supportive of patients (or relative's) asking questions of their MDs. Yet in a Reader's Digest slideshow, you are quoted with the following: “When one extremely hostile relative bombarded me every time I walked in, I developed a tendency not to go in the room. If you have three pages full of questions, show them to the nurse. Say ‘How many of these should I wait to ask the doctor about? How many can you help me with?’”
—General surgeon who blogs under the name Skeptical Scalpel”

Read more:

While I do understand that a patient's relative can appear as hostile to a MD, I fail to see how someone with many relevant questions could ever be understood to be hostile. If someone has taken the time to think of and even write down many questions, actually pertaining to the illness and care of said illness, why would they be hostile?

I have never commented on an internet article before and the reader's digest slideshow with "your" contribution finally pushed me over the edge. So far, over the edge, I looked for and read some of your blog. I am now convinced that reader's digest took your quote out of context or something. Something, because you appear to be a fully functional human on this blog. Regardless, I still take offense.

When my husband had emergency appendectomy surgery, I had an experience with a MD that had that attitude. I tried asking the nurses and anyone else I could find. I waited during the day; I wrote my phone number on the room's white board, asking someone to call me. I spent several nights in the hospital room waiting to talk with this MD. The MD visited my husband at 3 in the morning, every day, and at no other time, or so the other staff claimed.

I wanted to know what was going on, I expected a daily update. In addition, I had many questions, stemming from my lack of medical education. Why could I not receive such updates from my husband? Because the nurses allowed him to ask for and receive a dose of Dilaudid, every 6 hours. After the second dose, he was counting the minutes down until he could ask for the next dose. After 2 days, he starting suspecting his nurses were not giving him the full dose. After 11 days at 4x a day, I was happy to see he didn't seem completely brain dead (11 days for the second hospital admittance for the infection from the ruptured appendix).

Unknown said...

I wanted to meet with the doctor because I knew of my husband's problem with addictive substances. I knew he would ask for everything the nurses would allow. I wanted to save him the time and trouble of an opioid addiction.

Once I heard him moving about the room at 3 am, being ever so quiet, trying not to wake the patient he was trying to review. I was able to wake up enough to ask a few questions. He did not understand that my husband had been intoxicated every moment since his admittance and had no recollection of any staff interactions. Once he finished berating me for acting like a nanny to my adult husband, he then said that I could sign a HIPA form and get answers from the nurses. He did not have time for questions. This is the condensed version.

The full-length version ends with a meeting of the "head" nurse. Where I had to ask her if the code being announced and her pager meant someone was dying. When she said yes, I asked to end our meeting. She was going to finish the meeting first! My husband and I ran far far away from that hospital.

Obviously, the MD did not want to see me. He probably thought I was "hostile" because the nurses had warned him of the list of questions and the request for updates. What can a person do to avoid being seen as hostile by the hospital staff? I am a scientist, I am consumed with curiosity all of the time and more so when my husband is sick in the hospital. I want to know everything little thing I can, mostly to help him get better, partially to understand causes.

I wish I were an over-reacting nanny-wife. However, this is not the only time I have received or witnessed this attitude from healthcare professionals.
And then.....
Then I find your comment above. Is there an area between not knowing enough to question the doctor and knowing enough to question the doctor? You may not be completely representative of the entirety of professional healthcare providers, but I read enough of your blog to know that you could represent the people trying to deny me information about my health status just because.

What can I do to work with people like that? Anything? Pet their egos and make them feel like good dogs instead of threatening their validity as a human because I want to know why?


Comment visible after approval? I guess I will find out what kind of person you are. Cheers.

Skeptical Scalpel said...

Leslie, thanks for the comments.

You said, "I fail to see how someone with many relevant questions could ever be understood to be hostile." The key word is "relevant." Rarely would 3 pages of questions all be relevant. Also, many times the questions had been asked and answered before. If you read my Reader's Digest comment carefully, note that I said "one extremely hostile relative bombarded me every time I walked in." The relative was already hostile. The questions were simply one manifestation of the hostility. Sometimes people take is out on the doctor when a family member is sick. Those folks become irrational.

I have no problem keeping patients and families informed. My practice was always to be proactive. I would call the family member to update them rather than wait for them to call me.

I don't think many doctors want to deny patients and families information about their illnesses. I always felt that a better informed patient and family were easier to take care of.

By the way, it's nice to see that the Reader's Digest piece led to a least one new reader of my blog.

Nice said...

Great articles!

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