Pap smear has become an annual screening rite among American women

Since it was first introduced six decades ago, the Papanicolaou (Pap) smear – widely credited with substantial reductions in the incidence and mortality from cervical cancer – has become an annual screening rite among American women. Recently, however, long-accepted Papanicolaou smear screening standards have been re-examined.

Current recommendations from the American College of Obstetricians and Gynecologists, the American Cancer Society and the US Preventive Services Task Force stipulate that screening intervals can be extended to every 2 to 3 years in women over age 30 with more than 3 prior normal test results and that most elderly women can cease screening. But are woman willing to forego their annual test?

In a study published in the current issue of The American Journal of Medicine researchers at the VA Outcomes Group (White River Junction, Vermont), Dartmouth Medical School, and the Norris Cotton Cancer Center examined the beliefs and attitudes of 360 women aged 40 or older about reducing Pap testing frequency and eventually stopping the test completely. When questioned about their preferences for screening, 75% preferred screening at least annually (12% chose screening every 6 months). More than two thirds said that they would try to continue being screened annually even if their doctors recommended less frequent screening and advised them of comparable benefits, and only 35% thought that there might come a time when they would stop getting Papanicolaou tests. The most powerful drivers of attitudes toward screening intensity were a habit of annual screening, a woman's perceived risk of cervical cancer, and her belief that cost was the basis of current screening frequency recommendations.

Writing in the article, Brenda E. Sirovich, MD, MS, states, "One of the most powerful determinants of higher perceived risk of cervical cancer was having had an abnormal test result…. A self-fulfilling cycle ensues: more annual screening leads to more abnormal results, and more abnormal results lead to more women with increased risk perception who engage in more annual screening (and plan never to stop). Reducing high-intensity screening is therefore particularly difficult. It involves interrupting this positive feedback cycle in addition to breaking the ingrained habit of annual screening."

The authors point out that even with successful educational efforts, it may be difficult to gain acceptance for less intense screening. Even among women who believed that screening recommendations are based solely on scientific evidence, just over half would agree to give up their annual screening habit, and even fewer think they would eventually stop screening.

In an editorial in the same issue, George Sawaya, MD, University of California, San Francisco, emphasizes, "Sirovich and colleagues have garnered the all-important perspective of individual US women. The response is clear: women do not want less-than-annual screening, regardless of guidelines and, curiously, regardless of whether or not they have a cervix."