| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH |
|
|
|
|||||||
|
|||||||||
TRACK to:
|
|
Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Self testing for pap smears
Doing the right thing.
Towards more rational use of Pap screening
Practice level experience
Assessing Patients’ Priorities for the Annual Exam
|
|
|||
|
G. Downer, Gainesville, FL USA Housewife
Send response to journal:
|
All of this is very interesting in that your study fails to ask women if they would rather not have their pap smears done by a physician or practitioner. What has become of the use of the woman taking her own specimen for pap smears. IT is my personal feeling that if I were allowed to do this I would feel 100 per cent more comfortable than having to go about it the way I do now. There is absolutely NO need in having a pap smear every year. The test that should be performed is the HPV test with a negative result and any underlying factors not changing over a woman's life meaning that she should NEVER have to have another pap smear or HPV test again. A woman that has no problems need never have to see a gynecologist or family physician for any type of female exam. There is no need. Doctors in general think that if they proscribe any type of medications such as Prempro that for a woman to get a refill for another year she must come in and get completely undressed and go through this nonsense again. Why don't the doctors do what the American Cancer Society, The OB-GYN Association, and other organizations are suggesting. Three normal pap smears and no visits. Why are the doctors forcing women to go through this embarrassing exam when they really do not need it nor is it appropriate with the above criteria present? Competing interests: None declared |
|||
|
|
|||
|
Joseph Thomas, Chicago physician
Send response to journal:
|
If it is true that having an annual pap smear correlates with annual doctors' visits and therefore not having an annual pap will lead to not having an annual pelvic exam where "screening for ovarian cancer " is done by the exam among other positive non measured benefits and that you increase your risk of having invasive cervical cancer even if only slightly, why start this cascade of negative effects. Let the patient's personal doctor advise her, not the media. Does the media ever identify the high risk group who needs paps every 6 months? Is it still true that 50% of the patients with invasive cervical ca never had a pap. What % of your study did not know the significance of age at first intercourse or number of lifetime sexual partners or that HPV is the number #1 STD and is associated with progression from dysplasia to invasive cancer at a faster rate. The vast majority of physicians will not know if their patients are in a low or high risk group for cervical cancer unless they ask or use a questionnaire to assess their risk level. I don't see in your study any discussion of the risk level of the patients you surveyed. If Cook County, according to the CDC, is endemic for STD's, telling this population facts about low risk is misleading at best. The reverse is actually better ... tell the population you may be at high risk and need pap smears every 6 months unless your doctor informs you that you are low risk and explains the options. It is a fact that the medical directors of large managed care plans do not want to spend the money to improve the screening rates because the payoff would come years later at a time greater than the average enrollment period, and they said they have to focus on shorter term objectives that show results or payoff during their expected time in office. Perhaps this reminds you of dozens of companies that have and will sacrifice the sharholders' value and the company to enrich themselves, much like politicians in an election year. Don't fall victim to the deprofessionalization that is occuring. Doing that right thing sometimes boils down to "first do no harm" ... so consider the far reaching consequences of telling the general public half truths. Ask the question, "Why does the percent of patients with invasive cervical cancer vary with different ethnic groups, and the percent who never had a pap smear remain so high?" Competing interests: None declared |
|||
|
|
|||
|
David Atkins, Rockville, MD Agency for Healthcare Research and Quality
Send response to journal:
|
The articles on Pap screening in this issue, and the comments of readers, provide interesting insights into the challenges of providing care that is both evidence-based and patient-centered. Several themes seem to emerge from the observations about patients attitudes towards screening and experiences with abnormal results. The willingness of women to accept less frequent screening is likely to depend on how the information is presented by clinicians. Given the desire of many women to be proactive about their health, and the importance they place on continuity in their relationship with their physician, clinicians may need to reassure women that forgoing the annual Pap doesn't mean less attention to the everything else patients value in the regular interaction with their doctor. Bland reassurance that annual tests "aren't necessary" may not be sufficient for women who assume the change stems from efforts to cut costs or a failure to take their concerns seriously. There is a growing recognition by expert bodies such as the U.S. Preventive Services Task Force and the American Cancer Society that annual screening in low risk women not only wastes time and resources but actually probably does more harm than good. Yet if we are to correct the widespread belief that "more is better" when it comes to prevention, we will have to allow women to feel that their concerns are respected and that they can still be in charge of their health. Competing interests: None declared |
|||
|
|
|||
|
Wilson D. Pace, Denver, USA Family Physician, University faculty
Send response to journal:
|
I read Drs. Smith, French and Barry's article with interest as my practice has been promoting simple "risk based" Pap smear frequencies for approximately a decade. A quick review of our tracking system for patients I care for indicate that approximately half are on prolonged (either 2 or 3 year) follow up intervals. I routinely counsel against Pap smears for women who no longer have a cervix. The response I typically get when discussing this issue with women is one of relief not to have this test on a yearly basis, not concern and reluctance to follow a different recommendation. While some women reject the concept of extending the interval for testing, in my experience it seems to be far lower than would be expected from the focus groups Smith et. al. conducted. I have been in my current practice for over 20 years with a relatively stable patient population, which may account for some of the variation. But, I would have expected this type of scenario from the rural participants. I didn't see any mention of how many of the participants, if any, were currently utilizing a less than yearly screening program. It is unclear if this was an exclusion criteria, but if it was then this could affect the views of the remaining participants. Competing interests: None declared |
|||
|
|
|||
|
Diane M. Harper, Lebanon, USA Associate Professor, Dartmouth Medical School, Heidi I. Becker, Meghan R. Longacre
Send response to journal:
|
To Editor: The data presented by Sawaya et al (1) convincingly show the beneficial outcome of an increased cervical cancer screening interval. Smith (2) indicates that women will not accept an increased screening interval. We recently assessed by focus groups and self-report surveys New England women’s priorities for the annual examination. Three age groups (<=24, 25-39 and >=40 years) of women (n=121) receiving health care at three specialty clinics (ob/gyn, general internal medicine and college health center) reported and ranked 22 elicited reasons for their annual examination. The reasons were classified as ‘test-seeking’ reasons and as ‘provider-patient relationship’ reasons. Having a Pap smear was the eighth most common reason for attending the annual examination (n=85, 70.2%), after five ‘relationship’ reasons: comfort with the provider (n=102, 84.3%), continuity of a single provider (n=95, 78.5%), clear communication skills of the provider, that included educating and listening to the woman (n=92, 76.0%, n=91, 75.2%, n=89 73.6%, respectively); and two test reasons: mammogram and blood test orderings and results tracking (n=88, 72.7%). The importance of an annual Pap test did not vary by age, education level, and number of health care visits made in the last year. Women were highly likely to choose patient-provider reasons as more important components of the annual exam than test taking reasons (X2=31.43, p<.001). Implementation of the new cervical cancer screening guidelines in a cost effective manner (3, 4) requires acceptance of the triennial screening interval in cytologically normal women. Our results support the view that, in addition to receiving a variety of medical tests and the actual exam, women view their yearly visit as a means to promote a comfortable and consistent relationship with their health care provider. These important patient perspectives should be valuable to the ongoing dialogue about the necessity of the annual Pap test (5, 6). Interval screening may be limited not by the frequency of the woman’s visit to her provider, but by the physician’s ability to change his/her screening behaviors. 1. Sawaya GF, McConnell KJ, Kulasingam LS, Lawson HW, Kerlikowski K, Melnikow J, Lee NC, Gildengorin G, Myers ER, Washington AE. Risk of cervical cancer associated with extending the interval between cervical cancer screenings. N Engl J Med 2003;349:1501-9. 2. Smith M, et al. Periodic Abstinence From Pap (PAP) Smear Study: Women’s Perceptions of Pap Smear Screening. Ann Fam Med 2003; 1: 203-208. 3. Wright TC Jr, Cox JT, Massad LS, Carlson J, Twiggs LB, Wilkinson EJ; for the 2001 American Society for Colposcopy and Cervical Pathology Consensus Conference. 2001 Consensus Guidelines for the management of women with cervical intraepithelial neoplasia. Am J Obstet Gynecol. 2003 Jul;189(1):295-304. 4. Saslow D, Runowicz CD, Solomon D, Moscicki AB, Smith RA, Eyre HJ, Cohen C; American Cancer Society. American Cancer Society guideline for the early detection of cervical neoplasia and cancer. CA Cancer J Clin. 2002 Nov-Dec;52(6):342-62. 5. Laine C. The annual physical examination: Needless ritual or necessary routine? Ann Intern Med 2002;136(9):701-703. 6. Oboler SK, Prochazka AV, Gonzales R, Xu S, Anderson RJ. Public expectations and attitudes for annual physical examinations and testing. Ann Intern Med 2002;136:652-659. Funding provided by the Robert Wood Johnson Foundation, Susan G. Komen Foundation (DMH), and The Hitchcock Foundation, Dartmouth-Hitchcock Medical Center (HIB and MRL). Competing interests: None declared |
|||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH |
TRACK: