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Am Fam Physician. 2000;62(10):2232-2235

to the editor: In their review article, “Cervical Cancer,”1 the authors accurately present the evidence that “cervical cancer is a sexually transmitted disease,” based on the known causal association between human papillomavirus (HPV) infection and cervical neoplasia. Yet, in their discussion of cytologic screening of patients for cervical cancer, the authors fall back on the often cited recommendation that “all women receive screening Pap [Papanicolaou] smears at the onset of sexual activity or [my emphasis] at 18 years of age,” adding that “routine screening with Pap smears will lower the rate of cervical cancer.”1

In my own practice, I routinely inform women that the purpose of the Pap smear is to screen for sexually transmitted disease and allow them to take part in the decision-making process. I am mystified by the reluctance of many physicians who provide health care to women to let their patients in on this “trade secret,” that is, virginal women and women at no risk of exposure to a sexually transmitted disease—in the past or present—do not need to be screened for cervical cancer! The insertion of a vaginal speculum into the vagina of a virginal woman (or, for that matter, many postmenopausal women with atrophic vulvovaginitis) is certainly not a benign procedure. Yet, we insist (based on recommendations such as those stated in the article) on obtaining Pap smears from women who are virtually at no risk for a sexually transmitted disease.

At a minimum, I propose that we follow the guidelines established by the U.S. Preventive Services Task Force that “Testing [for cervical cancer] should begin at the age when the woman first engages in sexual intercourse.”2 Furthermore, in an age when adolescents and young persons increasingly choose to remain chaste until marriage, would it not be reasonable to screen for cervical cancer in much the same way that we screen for other sexually transmitted diseases—offer the test only to those patients “at risk” for the disease being screened? Perhaps further review articles on the topic of cervical cancer will not promulgate the widespread assumption that all women, at the age of 18, commence sexual activity and, hence, become continuously exposed to sexually transmitted diseases.

in reply: Dr. Littell presents a valid concern in his letter when he questions the validity of cytologic screening in “all women 18 years and older,” but to classify the Pap smear as a test for sexually transmitted diseases is a dangerous simplification. The American College of Obstetricians and Gynecologists (ACOG) continues to recommend Pap smears for all sexually active women and for those who have reached 18 years of age, but does note that the screening can be performed less frequently in low-risk women.1 The ACOG committee opinion on Pap smear screening does report that, based on theoretic models, less frequent screening is cost effective; however, the committee also notes that a reduction in Pap smear screening in England was associated with an increased incidence in cervical cancer cases and deaths from cervical cancer.1

Research is mounting that human papillomavirus (HPV) infection is associated with 90 percent of cervical cancer, but let us not neglect the other 10 percent.2 Also, I don't assume that all of my patients report their risk factors with complete candor or even know their risk factors. There are no data on the risk of cervical dysplasia and cancer in female infants who are exposed to HPV at birth, nor do we know the number of young girls who are exposed as a result of incest and rape. Marriage and monogamy are not a guarantee that HPV is not present in our patients, for we must have intimate knowledge of the person and the partner's sexual history to be certain. Our patients may unwillingly fall victim to a treatable disease when a proven, simple screening test is available.

To label the Pap smear a screen for sexually transmitted disease is to stigmatize a valid screening test and may set the prevention of cervical cancer back 50 years. Until more data are available on the implications of perinatal transmission or a better screen for HPV is available, I stand by my opinion that physicians should continue to screen all their patients carefully and err on the side of screening.

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This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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