Many US women who have had a hysterectomy are unnecessarily screened for cervical cancer

June 22, 2004

Many women in the United States who have had a hysterectomy are undergoing Papanicolaou (PAP) smear screening even though they are not at risk of cervical cancer, according to a report in the June 23/30 issue of The Journal of the American Medical Association (JAMA).

Pap smear screening for cervical cancer was introduced in the 1940s and has become a widely accepted cancer screening test that has substantially decreased the number of cases and deaths since its introduction, according to background information in the article. In 1996, "based on accumulated evidence from observational studies, the U.S. Preventive Services Task Force recommended that routine Pap smear screening is unnecessary for women who have undergone a complete hysterectomy for benign (non-cancerous) disease." The authors add that most women who have undergone hysterectomy are not at risk of cervical cancer because they no longer have a cervix.

Brenda E. Sirovich, M.D., M.S., and H. Gilbert Welch, M.D., M.P.H., from the VA Outcomes Group, White River Junction, Vt. and Dartmouth Medical School in Hanover, N.H., analyzed data from the Behavioral Risk Factor Surveillance System (1992 - 2002), an annual, population-based telephone survey of U.S. adults conducted by the Centers for Disease Control and Prevention. The authors evaluated the information from 187,670 women who reported having a hysterectomy and answered questions about the timing of their last Pap smear.

"Twenty-two million U.S. women 18 years and older have undergone hysterectomies, representing 21 percent of the population," the authors found. "The proportion of these women who reported a current Pap smear [within the last 3 years] did not change during the 10-year study period. In 1992 (before the U.S. Preventive Services Task Force recommendations), 68.5 percent of women who had undergone hysterectomy reported having had a Pap smear in the past 3 years; in 2002 (6 years after the recommendation), 69.1 percent had had a Pap smear during the same period."

After accounting for Pap smears that may have preceded a recent hysterectomy and hysterectomies that spared the cervix or were performed for cervical neoplasia (tumors), we estimate that approximately 10 million women, or almost half of all women who have undergone hysterectomy, are being screened unnecessarily, the authors report. Although estimates based on patient self-report may over-estimate actual screening rates, these results suggest that millions of women are being screened unnecessarily, and the amount of screening has not declined following the task force recommendation, the authors note.

The authors write there may be several factors contributing to the continued screenings. "It is possible that women who have had a total hysterectomy are not aware that they are no longer at risk for cervical cancer. Or they may simply be so enthusiastic about cancer screening that they continue to have Pap smears regardless of the usefulness of the test. It is also possible that physicians are largely responsible for continuing cervical cancer screening after hysterectomy." The authors also suggest Pap smear performance measures may also be responsible. Although such measures may not be aimed at women who have undergone a hysterectomy, "The net effect may be that all women are encouraged to receive Pap smears in order to meet specified benchmarks for cervical cancer screening." In conclusion the authors write: "The U.S. Preventive Services Task Force recommendations either have not been heard or have been ignored." (JAMA. 2004; 291:2990-2993. Available post-embargo at JAMA.com)
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Editor's Note: Dr. Sirovich is supported by a Veterans Affairs Career Development Award. This study was supported by a Research Enhancement Award from the U.S. Department of Veterans Affairs to investigate the harms of excessive medical care.

The JAMA Network Journals

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