Periodic Abstinence From Pap (PAP) Smear Study: Women’s Perceptions of Pap Smear Screening

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

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

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