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Michael Parsons, MD FACOG

PAP Smear

The PAP smear is a screening test for cervical cancer that continues to save women's lives.  It also can detect endometrial cancer.

The recommendations have changed recently.  

I still recommend getting a PAP smear every year for the reasons detailed below.

The current official recommendations are listed below.

Younger than age 21:        No PAP smear

Age 21-39:                                       PAP smear every three years

Age 30-65:                                       PAP smear every three years or every 5 years if done with HPV test.

Age 65 and above:                         No PAP smear.

No cervix:                                         No PAP smear, unless history of cervical dysplasia or cancer.

Exceptions:                                      If an abnormal PAP smear occurs, new guidelines are in place.

My recommendations:                 Yearly PAP smear, No age cut-off. 

I saved a patient's life by ignoring these recommendations.   

She was an African American woman in her early forties presenting for a routine annual GYN exam. She gave a history of having two normal PAP smears the preceding two years. Her exam was normal.

Using expert criteria I would have been justified had I NOT performed a PAP smear. Years of experience have taught me that 'expert recommendations' are not always made for the patient's benefit. So I performed a PAP smear.

It came back abnormal (LSIL).

I performed colposcopy which showed CIN 2 of the outer cervix and CIN 1 of the inner cervix. I performed a LEEP procedure which showed invasive squamous cell carcinoma (SCC) of the cervix.

I referred her to a GYN oncologist who performed a robotic radical hysterectomy. The surgical pathology showed moderately differentiated SCC with negative margins.

She is still alive, because I deliberately chose to ignore the recommended PAP guidlines. I obtained the previous PAP smear reports and also had the labs review the PAP smears.

2005   normal 2006 slightly abnormal (ASCUS), negative high risk HPV 2008  normal, negative high risk HPV

2009   abnormal PAP obtained by me, leading to the diagnosis of cancer.

(The other PAP smears were done at other clinics.)

NOTE: This patient had two PAPs NEGATIVE for high risk HPV just prior to the diagnosis of cervical cancer! Using the screening criteria in effect at the time, the patient would not have had another PAP smear until 2011, two years after her radical hysterectomy.

Using the 2013 screening criteria, the patient would not have had another PAP smear until 2013, four years after her radical hysterectomy.

The experts state that cercial cancer is 'slow growing', but that is not always the case.  Lab tests and personnel are not infallible. The experts also state that all cervical cancer will NOT be preventable under the new guidelines.  

Experts also know that sampling, lab, technician, and physician errors can add up to a missed or late diagnosis that leads to increased patient morbidity and mortality.  Extending the PAP smear screening interval will only magnify this problem.

People also need to know that the companies who manufacture the HPV tests need to get physicians to extend the PAP smear screening interval in order to justify the additional cost of the test when added to the PAP smear.  The PAP smear is cheap can be performed by any lab while the HPV test requires the lab to buy the test kit. The HPV test kit manufacturers provide financial incentive to physicians who advocate the extended testing intervals.

I have seen other patients like the one above, which is why I still offer yearly PAP smears to my patients.

But the decision is yours.  NOTE: I have also detected vaginal dysplasia in women without a cervix using the PAP smear. April 2013 Obstetrics & Gynecology

CONCLUSION: Updated screening guidelines may prevent the expeditious diagnosis of AIS in females younger than 21 years and those aged 21–29 years, many of whom had normal Pap test results within 3 years of diagnosis. (Obstet Gynecol 2013;121:759–64)  (AIS is Adenocarcinoma in Situ)