Clinical Question: How often do women who are not at risk of developing cervical cancer have Papanicolaou (Pap) smear screening?

Setting: Population-based

Study Design: Cross-sectional

Synopsis: Since 1996, the U.S. Preventive Services Task Force (USPSTF) has stated that routine Pap tests are unnecessary for women who have had hysterectomy with removal of the cervix for benign disease; without a cervix, they are no longer at risk of developing cervical cancer. Many physicians still perform Pap tests on these women, purportedly to screen for vaginal cancer. However, because the risk of vaginal cancer is so low, women with an intact cervix who currently are screened for cervical cancer are not screened routinely for vaginal cancer. To determine the frequency of inappropriate screening, the authors used data from a survey conducted by the Centers for Disease Control and Prevention from 1992 to 2002 that reported the proportion of women with a hysterectomy who had a subsequent Pap smear within three years.

During this 10-year period, 22 million U.S. women 18 years and older had a hysterectomy, representing 21 percent of the population. The proportion of these women who reported a subsequent Pap smear within the three years before (68.5 percent) and the three years after (69.1 percent) the release of the USPSTF recommendations in 1996 did not change. The authors estimate that one half of these women had hysterectomies that spared the cervix or were performed for cervical neoplasia, resulting in almost 10 million women being screened unnecessarily.

Bottom Line: Many American women who have had a hysterectomy with removal of the cervix for benign disease continue to receive routine Pap smear screening, despite a lack of supporting evidence and a clear recommendation from the USPSTF against routine screening. Conversely, the vast majority of American women who die of cervical cancer were underscreened or never screened for cervical disease, most likely as a result of real or perceived cost barriers. The money saved by not inappropriately performing Pap tests on low-risk women would cover the cost of screening for the 17 million women in the United States who currently are underscreened for cervical cancer (Saraiya M, et al. Observations from the CDC. An assessment of Pap smears and hysterectomies among women in the United States. J Womens Health Gend Based Med 2002;11:103–9). (Level of Evidence: 2b)