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The American Cancer Society

Is a Pap test necessary every year?

March 14, 2012

By Debbie Saslow, PhD


When it comes to screening for cancer, a common belief held by doctors as well as patients is "more is better." It seems only logical that more frequent screening with the newest technologies translates to more cancers detected at the earliest possible time and, ultimately, more lives saved.


Cervical cancer is an example of why this is not necessarily so. Dating back to the late 1940s, the Pap test has been detecting not only early cervical cancers, but changes in the cervix ("pre-cancers") that when treated or removed lead to actual prevention of cancer in addition to early detection. For decades, the majority of women in this country have scheduled their doctor appointments around their "annual Pap."  As a result of widespread Pap testing, mortality rates dropped by 70% and the Pap test became the biggest success story for cancer screening in history.


In the late 1980s, it was discovered that cervical cancer is caused by HPV, the human papilloma virus. Studies of the natural history of HPV and cervical cancer showed that it takes, on average, 10-20 years from the time a woman is first infected with HPV until the time a cervical cancer might appear.


In 1987, the American Cancer Society, and several other national organizations, recommended that most women could safely be screened for cervical cancer with the Pap test every 3 years rather than every year. Twenty-five years later, studies show that the majority of health care providers still recommend annual screenings and that the majority of women expect annual screenings.


Ten years ago, the American Cancer Society and others recommended that a new screening test, one that detects the HPV virus, could be used along with the Pap test to screen women aged 30 years and older for cervical cancer.


New cervical cancer screening guidelines


Now the American Cancer Society, working with 25 other organizations, recommends that women ages 30-65 should be screened with both the HPV test and the Pap test, called "co-testing," as the preferred strategy. (Screening with the Pap test alone every 3 years is still acceptable.)


The risk of getting cancer for a woman who is screened every 3 years with the Pap test is extremely low, and similar to the risk of cancer when screened every 5 years with both the HPV test and the Pap test. In fact, in the United States, most women who get cervical cancer have not been screened in at least 5 years. About half of them have never been screened in their lifetime. 


You can see the full revised guideline here.


Guidelines often ignored


Many studies have shown that a large number of doctors screen women for cervical cancer more frequently than recommended.  One recent study, for example, found that most health care providers (65%-85%, depending on the situation) not only recommend yearly Pap tests but, when screening with both the HPV test and the Pap, still recommend repeating at least 1 of the tests every year. In one situation in the study, only 14% of doctors would recommend the next test in 3 years, as guidelines recommended.


Why is this? Why have doctors been so slow to incorporate evidence-based guidelines into their practices?  One reason is that many doctors think that patients want and/or expect annual screening. They may want to avoid having a discussion with patients about why this is not needed. Some may fear litigation if a cancer is missed, while others may simply be unaware of the guidelines. Lastly, there may be financial incentives to test more frequently. 


Little benefit, more harm with too-frequent screening


Coming back to where we started, there is a common belief that more screening is better. In fact, annual Pap tests offer very little if any benefit compared to screening every 3 years.


But there are harms to screening more frequently. False positives are very common with cervical cancer screening, and more frequent screening leads to more frequent need for follow up tests that can be invasive and have unwanted side effects, including problems related to future pregnancies and delivery, as well as increased anxiety and time away from work or home.


With the new guidelines, the American Cancer Society recommends against annual screening.


Here are a few points to remember:

  • Screening with the Pap test alone every 3 years is extremely safe and will decrease the number of false positive results without leading to an increase in cancer or cancer deaths
  • For women ages 30 years and older, testing with both the HPV test and the Pap test further decreases the risk of cancer and advanced pre-cancers. When both tests are normal, no cervical cancer screening test should be done again for 5 years.
  • Women younger than age 21 do not need to be screened for cervical cancer.
  • Women over the age of 65 who have been regularly screened, and women who have had a hysterectomy (with removal of the cervix) for reasons not related to cervical cancer or pre-cancer, should no longer be screened.
  • Women should talk to their doctors about what screening test to use and how often, and should question their doctors if they think they are being screened too often.
  • Women can and should still see their doctors more often than every 3 or 5 years - just not for a Pap test. Doctor visits should be scheduled for general wellness, with Pap tests and HPV tests given according to guideline.


To see an American Cancer Society Behind the Science video detailing the new guidelines, click here.


Saslow is director of breast and gynecologic cancer for the American Cancer Society. 

Comments

3/15/2012 2:18:34 PM #

C. Peel

What this story does not address is the high percentage of false negative Pap tests.  Three years is a long wait for a woman whose Pap results are false negative.  Unless the statistics have recently changed, one-third of all women who contract cervical cancer will die of the disease.  That percentage has remained constant for a long, long time.  How can we say now that less is better when nothing has changed?    

C. Peel

3/15/2012 9:25:58 PM #

MadMom

This is BS!!!  So very disappointed with the ACS and others...so if they really made this recommendations before why all of a sudden are they kicking in now???  Can you say OBAMACARE??  Soon, we will have very little preventative options available to us...they will wait until we all get cancer, pump us full of high price pharmaceuticals and wait for us to die.  I truly hope both Obamacare and these new guidelines are revoked quickly.  If not, heaven help us all.  Oh, and the ACS can forget about receiving any further donation money from me!

MadMom

4/2/2012 2:46:06 PM #

admin

Regarding C. Peel's comment above, Dr. Saslow has this to say, and thank you for your comment and for reading Expert Voices!  

"It is true that there is a significant percentage of false negative Pap tests.  Most of these are false negative for precancers rather than cancer.  Of the 12,000 or so women in the US who get cervical cancer every year, 50% or about 6,000 have never been screened in their lifetime. Another 10% or 1200 had their last screening test over 5 years ago. That still leaves a little over a third of the women, between 4000 and 5000 women, who do get cervical cancer even though they were screened.  We don't have the numbers beyond this, but many of these women were screened less than 5 years ago but more than the recommended 3 years.  Some are HIV positive or have other problems with their immune systems, such as organ transplant recipients on immunosuppression drugs,  and should follow different, more frequent screening guidelines.  Some got screened, got an abnormal or positive result, and did not get the appropriate follow up care (reasons include that the women did not go back for further tests, or did not have access to care).  In about a third of the cases, for about 1500 women a year, the Pap result was truly a false negative.  This statistic was taken into account in the story as well as in the development of the new screening recommendations. Because cervical cancer is such a slow developing cancer, taking on average 15-25 years, unlike many other types of cancer, a woman who has a false negative Pap test, which usually  means a precancer was missed, will most likely have her precancer detected 3 years later at her next Pap--still in time to be removed or successfully treated before it progresses to cancer.

But unfortunately, some cancers are difficult to detect.  The Pap test finds the most common type of cervical cancer, the squamous type. It does a poor job of detecting the second most common type, called adenocarcinoma (these make up many of the cancers that occur in women who have been screened).  Getting the Pap test every year instead of every 3 years will not find more of these cancers. The good news is that new recommendation for HPV testing plus the Pap test will find adenocarcinomas.  A second problem is that some cancers, the squamous type, are difficult to detect as well.  These cancers that are missed by a Pap test are likely to be missed by the next Pap test, whether that occurs in one year or 3 years.  These reasons explain why the rate of cervical cancers and cervical cancer deaths in the US, where most women get screened every year, is no different than in countries such as the Netherlands, where women are screened every 5 years.  

The bottom line is this: less screening will not lead to more cancer, but it will lead to less harms (biopsies, bleeding, premature births, etc.). What WILL lead to less cancers and less cancer deaths is getting the women who have never been screened, or have rarely been screened, to get their Pap (and HPV) test."

admin

4/11/2012 10:27:33 PM #

terri

I am so very disturbed by this as I had annual paps performed from age 18 and was diagnosed with stage IB2 cervical cancer at age 24.This was clearly due to a false negative reading as cervical cancer does not progress that quickly.   I underwent a radical hysterectomy and am lucky to have my life, health, and a child via adoption today.    I understand evidenced based medicine and am an oncology nurse and cancer survivor of 16 years now, but don't condone the reccomendations.

terri

4/17/2012 4:53:12 PM #

Jacquelyn Bakewell

I would just like to coment that since age 16 I have been getting regular pap tests once a year. 33 years later I was diagnosed with endocarsonoma of the uteres. 4/19/2012 will be my first yr annerversary ! I have a strong family history of estrogrn/progestren cancers and not one of the OB/GYN cared. PLEASE PLEASE get it out there and push these Dr. for better care. The Dr. performing the surgery didn't even know it until three days later when the pathologhy report came back . WHAT a shock,so I'm askig for help to protect the other young women who could have this silent cancer in them and not know it like me. OH I went through the paps, ultrasounds and regular Dr> visits but how could they miss this? Well being young, fit , active, in good health and slimmer they told me I didn't "fit the bill" someones got to help us !!!!!!!!!!!!!!!!!!!

Jacquelyn Bakewell

4/21/2012 8:13:30 AM #

Mary Beth

My concern about this change is the very real possibility that after being told they don't have to have another Pap test done for 5 years,  some women will neglect to go see their gynecologist during the interim. This will mean less frequent breast exams conducted by a health professional and less frequent pelvic exams to palpate the ovaries for abnormalities.  
This potential unintended effect could have VERY detrimental outcomes for women who develop breast or ovarian cancer in the 5 year interim period and should not be overlooked or minimized.
The new guidelines are remiss as they neglect to stress the very important and continued need for annual breast and pelvic exams in the absence of Pap tests. I sincerely hope the ACS will add this to their guidelines and that health professional will take proactive steps to remind women of this.

Mary Beth

4/25/2012 1:04:31 PM #

Linda

I have had Pap smears every year for years.  thankfully my doctor did this, because at the age of 66 they detected what they thought was cervical cancer through my annual pap smear.  After my hysterectomy, they found that it was an aggressive cancer that started in the uterus.  Having the pap smear yearly detected what might have been deadly if i hadn't had my annual pap smear.  This may be a small percentage, but I was in that percentage!

Linda

4/30/2012 3:53:30 AM #

Sheryl

In 1996  I was a graduate student at Wake Forest University Medical School. I had missed having a PAP test for two years in a row. Since I would be graduating, my partner recommended that I get a Pap test before leaving. Cervical cancer  was my graduation present.

Sheryl

4/30/2012 3:57:20 AM #

Sheryl

I forgot - I would be leaving and I would no  longer have health insurance.  

Sheryl

5/2/2012 2:30:57 PM #

RS

Yearly screening is much easier for people to follow than to remember a date for pap-check every 3 or 5 years. Plus as someone earlier suggested it gives women a chance to check up on their other feminine problems, which they would otherwise ignore since they are not as feared as cervical cancer.

As Dr. Saslow mentioned earlier statistics have gone only so far as to show 4000-5000 women get cervical cancer even with screening. Is the approx. 1500 women who are truly false negative a conjecture (because then there is a possibility that the number might actually be way higher) or a research statistic?
Even if the 1500 is research based or a close enough estimate, the actual percent of difficult-to-detect squamous cancers and adenocarcinimas is probably low since the one of the reasons why the screening is done is because the easy-to-detect squamous cancers are commonest. If a yearly pap still does not detect enough of the commonest cancer type then the guarantee of a 3 yearly pap working alone to detect any sort of cancer type early doesn't increase by much with false negatives right?

If the HPV test is that more specific why not do the HPV test alone every 3 yearly for screening (not diagnosis)? If no HPV so no HPV related cervical cancer...plus you have around another average 14 years (if one HPV test is false negative) to17 years after detecting HPV before a lady develops full fledged cancer.

Also if it takes 15 - 20 years for cervical cancer to develop and the rate of cervical cancers in USA detected yearly is equal to rate of cervical cancers in Netherlands detected every 5 years then why not recommend to screen every 5 years in the USA? Is there an extra risk factor in Netherlands for cervical cancer that is not present in USA?

RS

5/21/2012 11:23:58 AM #

Ximena

If I just took my last PAP plus a Pathology Test called "Real-time PCR (Multiple Abbot Real Time PCR)" which uses the same liquid sample of the PAP and it’s good for the detection of  12 different types of high risk human papilloma virus (HPV) and individual genotyping HPV 16 and 18.

I just got the results and it shows NEGATIVE for these HPV types.

Now, I’ve had sexual relationships before with more than one person but let's say that I will no longer have them because....well, because for example, I’m entering a religious life where no men will be involved, so I want to understand what these results actually mean for me, ¿do they mean that in all of my previous sexual life, I did not get the virus so it isn’t in my system and as long as I stay without sexual relationships I will not be infected?, or, it only means it’s not showing now but it could be in my system and show later?

My question goes to understanding the Virus itself, understanding if the Virus lives in your system but not shows or if it is in your system, it’ll definitely show in your laboratory results even though it’s been controlled by your immunological system and not causing cancer.

Thanks in advance for your time

Ximena

5/21/2012 12:40:16 PM #

admin

Hi, Ximena, thanks for reading Expert Voices and for writing. I would recommend that you call our National Cancer Information Center at 1-800-227-2345. They're open 24 hours a day, 7 days a week and can answer all your questions. Best wishes!

admin

6/13/2012 12:30:52 PM #

admin

RS, sorry for the delay in responding. Dr Saslow says this:

"Yes, yearly medical tests of any kind are easier for people to remember. However, too frequent screening is harmful and that harm outweighs the benefit. It is not a good idea to give unnecessary medical tests, especially when they can lead to unnecessary invasive procedures, for any reason. Instead, we can and should do a much better job of un-linking a particular annual test to a doctor visit (meaning, women should go to their doctor for a health visit and get all of the necessary tests they need at that time, rather than going to the doctor for their "annual Pap test" and getting other care while they are there). We also can and should do a better job of reminding people when they are due for tests, whether it be their annual mammogram, their cervical screening at 3 or 5 years, or a colonoscopy at 10 years.  Another way to make it easy to remember: get your Pap test at ages 21, 24 and 27. Then get your Pap plus HPV tests at 30, 35, 40, etc.

Research has shown and confirmed the estimate for false negative Pap tests.  Three year screening with Pap tests will have only a very slight impact on detecting these missed cancers.  Adding the HPV test to the Pap after age 30 will detect many of these missed cancers. When we reviewed and updated the screening guideline, we considered whether to recommend the HPV test alone for screening. The research for this is very promising, and some countries are considering a switch to HPV-alone screening. However, we concluded that more research is needed on the best strategies for what to recommend as follow-up for women who have a positive test result (for example, should women who are HPV positive then get a Pap test, or some other test?), and other implications including adherence, especially in this country where we do not have organized screening programs. The absence of organized screening in the US also explains why we recommend more frequent Pap screening than in the Netherlands."

admin

6/28/2012 11:59:10 AM #

suzi

I think this country does so much unnecessary testing.   People think that more testing is great.  We are an over tested, over medicated society.  If people would eat well, exercise, stop smoking and limit drinking we'd ALL BE BETTER OFF. By that, I mean that so much of the expense of our insurance is the added price of those who are overweight, taking drugs for everything from high blood pressure to adult onset diabetes.  We are oen of, if not THE fatest country.  So many of our medical issues come from weight, lack of exercise and poor nutrition.  Mainly junk food, processed food and overeating.  
So......we wouldn't need so many tests if we took care of our own bodies.   Yes, there are cases of cancer and horrible diseases.  Sometimes the testing doesn't even help.  
Our medical community is test happy.  They medicate without seeking other solutions.  People AND doctors are lazy.  They want the quick way out....a drug, a fad diet.  Shape up people !!!!

suzi

8/13/2012 3:06:05 PM #

Loreen

I agree with most comments, annual screenings are the best option to catch anything early. I've always wondered, I heard that the Thin Prep test would help in the accuracy, avoid some of the false readings. Is it just the cost of this test that most doctor's don't do it...it is FDA approved and my health insurance has never had a problem paying for it. I've been asking for this test, which you have to do, for about 5 years now.  

Loreen

8/21/2012 2:20:07 PM #

juanita

For what it's worth here is my mothers story. She kept having bleeding so she went to the dr. The Dr. could visibly see the cancer. She did the pap and a punch biopsy. Biopsy was positive, she had invasive cervical cancer. Here's the kicker!, the pap came back clean stating all was good!!!! The Dr. was floored and had no idea what to say. My mother passed away less than 5 years later..... NEVER trust a pap. If you are having the slightest issue, ask for a biopsy! It's your right and your life!!!!

juanita

7/1/2013 9:45:03 PM #

Dr. Antoinette Levasseur

There is a reason that only 14 percent of ob/gyn's follow the current guidlines for less paps, and that reason is that they ignore very important probability statistics, and their patients are person needing individual care, and are not considered a "statistic" .  In other words, any practicing physician knows screening test such as pap smears and mammograms are not even designed to catch 100 percent of the disease.  They are designed to catch about 95%, and when repeated three times then would catch percent.  Thus until that test is done 3 times, it is not even considered completed.  And practicing physicians see false negative pap's often, and they KNOW not to trust a single pap smear.  And the test for high risk HPV is so unreliable, it often is positive in January and negative in March, and not even reliable in the same laboratory.
If a screening test (which all are designed to screen large groups of patients in a cost effective manner), was designed to be 100%, there would be too many false positives and thus too many referred for diagnostic tests such as colposcopy and biopsy.  Thus all are designed to be 95% sensitive, and thus by the laws of probability statistics need to be repeated three times to have the desired near 100% sensitivity.
Given these basic laws of mathematics, KEEP GETTING YOUR ANNUAL PAP SMEAR AND TRUST YOUR DOCTOR who is looking out ffor you.  Believe me there is NO FINANCIAL GAIN as suggested by Dr. Saslow , who apparently is not a practicing physician.  That suggestion is an insult to any patient or doctor.

Dr. Antoinette Levasseur

9/23/2013 2:49:30 PM #

Linda Woode

9/23/2013 -   I was denied a Well Woman pap test 6 times in 2012, by my health insurance provider Kelsey Care Advantage because I was over the age of 65. I had brought lab reports in with past bleeding problems.  I joined Medicare, two weeks later a pap test then a biopsy diagnosed cancer.  Surgery path report said papillary serous carcinoma 85%, had not breached other organs at that time.   If I had waited, because I felt fine, I would not be writing this comment.   EVERY WOMAN NEEDS AN ANNUAL PAP TEST.better to have to have a second look than be told if you are over 65 you don't need one.  

Linda Woode

9/23/2013 6:16:47 PM #

Linda Woode

9/23/2013
I can't say enough about getting an annual pap test done.  Six doctors of my former health insurance company refused, saying I didn't need it.  The 7th doctor now in Medicare did a pap, which showed abnormal cells FIGO 2 and a biopsy with cancer.  The surgical pathology report showed papillary serous carcinoma, a very aggressive sneaky cancer.  Thank GOD for pap tests.  

Dr. Diaz of Johns Hopkins and Dr. Ernest Hawk of M.D. Anderson have found that 50% ovarian and 100% endometrial  cancer were found by pap tests as of the study of January 2013.  

Linda Woode

Linda Woode

9/23/2013 6:21:35 PM #

Linda Woode

9/23/2013  

Have to add this study regarding the importance of pap tests is reported in Sept 2013 Readers Digest.

Pick up a copy

Linda Woode

Linda Woode

9/27/2013 11:19:18 AM #

E Roth

I have had quite a few false positives during the last 15 years.  In 2000, I had a cone biopsy for CIN II which turned out to be metaplasia.  I have had positive paps almost every year since then.  I have been checked for the HPV virus (both high and low ) a few times and do not have the HPV virus (at least not the ones that cause cancer).  My last pap was supposedly CIN III ( the lab did not do an HPV test as they said that HPV tests were not done if the pap was CIN III)  My ob called and said I needed an immediate hysterectomy as the lab at our hospital had  gotten a consult with the Mayo Clinic which concurred that the pap was CIN III.   Since I already had plans for a trip and this had happened before (CIN with nothing there), I had a colposcopy and my uterus and ovaries checked through an ultrasound about 2 months later.  Nothing was seen during the colposcopy (I have had quite a few of these and nothing is ever seen) and the biopsies came back metaplasia. The ultrasound was also negative.  I am afraid to have another pap as I do not want them to, probably, misread it again and go through the pain of another colposcopy.  Since I am past menopause, the OB had to "pop" open my cervix to get a good look and I bled for several days.I asked for, and received the diagnosis from the lab.  After the procedure, I asked for the doctors records of the procedure which stated the reason for the colposcopy was CIN I and not III.   I do not want a hysterectomy which, I believe, is not necessary due to the findings of every single biopsy that I have had in the past 15 years.

E Roth

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