(Istockphoto)

WEDNESDAY, Nov. 25, 2009 (Health.com) — Teens girls can skip Pap tests, according to new guidelines that say women should start cervical cancer screening at age 21. But some experts are concerned that rates of sexually transmitted diseases or unplanned pregnancies could increase without the Pap test to prompt a doctor’s visit.

As it stands, as many as 1 in 4 U.S. teenage girls has had an STD at some point in her life, often soon after she becomes sexually active, according to research published this week in Pediatrics.

“I am concerned that without the recommendation for young women to get Pap smears early on, they will lose important opportunities to seek advice and to learn about their health—particularly their sexual health—at a time in their lives when they need it most,” says Kimberly Spector, an adolescent health educator in Los Angeles. “Regardless of the tests performed during a gynecologist visit, the conversation regarding sexual health risks and preventative measures can be very informative and empowering for young patients.”

In the past, women were told to start Pap tests, which can detect abnormal cells in the cervix, three years after becoming sexually active or at age 21—whichever came first. However, these abnormal cells often go away on their own, particularly in young women. If they don’t, such cells grow so slowly that catching them at age 21 is still early enough to remove them before they become cancerous. And catching them sooner could lead to unnecessary tests and treatments that sometimes damage the cervix, increasing the risk for a premature birth later in life.

The new guidelines still recommend that girls who are under 21 see a gynecologist; they just don’t need Pap tests, according to the American College of Obstetricians and Gynecologists.

Next page: Will some teens misinterpret the guidelines?

The fear, however, is that some teens may misinterpret the new rules and miss out on important discussions about contraception and protection against STDs such as gonorrhea, bacterial vaginosis, chlamydia, and human papillomavirus (HPV).

“If women hear that they no longer need Pap tests annually or until they are 21, perhaps they wouldn’t seek any preventive health care, and whether this results in decreased screening and identification of chlamydia and other STDs remains to be determined, but it is concerning,” says Harold Wiesenfeld, MD, the director of the division of reproductive infectious diseases at the University of Pittsburgh School of Medicine.

Many STDs, including chlamydia and gonorrhea, have no symptoms. “Unless screened, young women will remain undiagnosed, untreated, and at risk for complications, including pelvic inflammatory disease, which results in infertility,” says Dr. Wiesenfeld, who is also an associate investigator at Magee-Womens Research Institute, in Pittsburgh. “[Still] the Pap test is not the 100% trigger to do chlamydia screening,” he says. “We need to do a better job about STD screening overall.”

Teens who are sexually active should use contraception and take steps (such as using condoms) to prevent STDs, even if they don’t need Pap tests, says Alina Salganicoff, PhD, the vice president and director of women’s health policy for the Henry J. Kaiser Family Foundation, an advocacy group based in Menlo Park, Calif.

“We are going to have to pay special attention to how we educate our adolescent patients about contraception and STD prevention,” she says.

However, most experts agree that Pap tests are indeed unnecessary for younger women and that the new guidelines will not put them at risk. Most also agree that the new guidelines are not an effort to limit care.

“I do not fear the consequences because these guidelines are well thought out and give us a great opportunity to focus on who is at risk for cervical cancer,” says Bobbie Gostout, MD, the chair of the department of obstetrics and gynecology at the Mayo Clinic, in Rochester, Minn.

“Cervical cancer screening is very important, but we are getting smarter at screening,” she says. “We are backing off from screening those that have less to gain from it.” The cervical guidelines, which recommend that sexually active teens still be counseled and tested for STDs (although a pelvic exam might not be necessary), “hit it right,” she says.

Teens who have received HPV vaccines, such as Gardasil, are protected against several HPV strains that are linked to many, but not all, cervical cancers and to genital warts. These types of vaccines may eventually reduce cervical cancer rates even further (rates have been dropping since the 1970s), although experts say the impact won’t be seen for 10 to 15 years. Therefore, girls and women given the HPV shot need to have Pap tests starting at age 21 and every two years after that, just like those who haven’t had the shot.

Next page: Experts recommend doctor’s visit before sexual activity

The Centers for Disease Control and Prevention, in Atlanta, added Gardasil to its routine childhood vaccine schedule. It recommends that Gardasil, which is administered in three doses, be given to all girls ages 11 and 12, and even for girls as young as 9, with catch-up doses for girls and women ages 13–26 who haven’t been vaccinated.

“We know that the HPV types targeted by the new vaccine are linked to cervical cancers that tend to occur five years earlier than cervical cancers caused by other HPV types,” Dr. Gostout says. “So once adolescents are well vaccinated against HPV, we should have even more confidence in eliminating Pap tests in younger women.”

“We are now rolling out the vaccine, and clearly the first group that will experience broader protection is young women,” agrees the Kaiser Family Foundation’s Salganicoff. “The HPV vaccine is a really important step that young women can take in terms of protecting themselves against HPV and subsequent cervical cancer.”

Ideally, teens should have an HPV shot and see a gynecologist for counseling about STDs before they become sexually active, experts say. HPV vaccines don’t protect women who have already been infected with the virus.

“Ideally, women need to establish a relationship with a reproductive health provider before they become sexually active,” Dr. Wiesenfeld says.

First, the Agency for Healthcare Research and Quality wants to change the requirements for mammography screening, now the American College of Obstetricians and Gynecologists has suggested women begin pap smears later in life and have them less often.

The new recommendations report a woman should begin cervical cancer screenings at age 21, regardless of sexual history. Furthermore, pap smears should only occur every two years between ages 21 and 29. They are again attempting to avoid false positives, spare us poor little women such mental trauma and unnecessary exams and treatments.

Obviously, I am not in favor of these changes. Just like the suggested mammography screening changes, they are playing the percentages. My question is how many deaths due to lack of screening are acceptable? How many mothers, sisters, aunts, daughters, grandmothers, nieces, granddaughters and friends are OK to loose? Just let us all know and we’ll leave you alone until then.

Okay, I give. I had promised that I wasn’t going to be just one more voice in the breast cancer screening debate. But when the US Preventive Screening Task Force (USPSTF) of the Department of Health and Human Services came out with revised Breast Cancer Screening and Pap Smear recommendations in one week, I could no longer sit idly by and say nothing.

Last week the USPSTF blew us all out of the water when they recommended that women no longer perform breast self examinations (BSE’s) and that annual screening mammography not begin until age 50. This is a huge departure from the previous guidelines promoted by the task force, The American Cancer Society and the American College of Obstetricians and Gynecologists which state that “women should perform breast self examinations monthly and that they should have clinical breast examinations by their physicians annually. Screening mammography should begin at age 40, be performed every 1-2 years and then be performed annually after age 50.”

Courtesy of BreastCancer.org

The Task Force concluded that BSE is not effective in reducing the incidences of breast cancer and that rather than doing BSE, women should just be “aware” of their breasts.” WTF??? How are you going to be aware of your breasts if you don’t know how they feel? Are women to rely solely on visible discoloration, dimpling or nipple retraction? What about non visible tumors, such as those that are close to the axilla (arm pits) that are typically only found on palpation? Many breast cancers in young women under 40 are found via BSE. Just before my 33rd birthday I found a cyst during a BSE. It actually bursted when I had a mammogram, but I found it initially myself. What if I hadn’t been doing BSE and it hadn’t been a benign cyst?

As far as the mammography recommendations go, the USPSTF states that for every 1900 women screened between the ages of 40 and 49, only one breast cancer is diagnosed. According to them, this small yield does not make the test worthwhile. However, the one breast cancer that will be detected out of 1339 women screened between the ages of 50 and 59, makes the test worthwhile. So what makes the life in the 50’s more valuable than the life in the 40?  Their argument is that you have to screen more women in the 40’s to find a cancer and the rates of false positives, “unnecessary” biopsies and  surgeries make the screening in this age population “not cost effective.” And with that statement, I think we have found the rationale.

Thankfully the American Cancer Society and The American College of Obstetricians and Gynecologists have flat out rejected these recommendations. Research studies have repeatedly demonstrated that breast self examination and annual screening mammograpy after age 40 saves lives. While the USPSTF may not be impressed at” just one life saved”, the families of those mothers, sisters, daughters, aunts, cousins, etc…are most grateful that their loved ones with breast cancer were diagnosed early and that many of them are alive and well today.

Later in the week news broke that Pap smear guidelines were also revised. The USPSTF now recommends that Pap Smears, the test used to detect cervical cancer, no longer be performed annually, but every 2 years and that the screening not be initiated until age 21. Previously the recommendation was that Pap Smears be initiated at age 18 or at age of first intercourse and then be performed annually but at least once every 3 years. Since cervical cancer is rare in women under age 25, the Task Force feels comfortable recommending that onset of screening not take place before age 21. Again their rationale stems from the fact that many women will have abnormal pap smears and be subject to potentially invasive screening and treatment and yet have no actual abnormality. In simple terms, It’s just not cost effective.

This makes me wonder, if  Pap smears are of little benefit for women under age 25 because they are at little risk for developing cervical cancer, why the big push to vaccinate 11 year old girls with Gardasil, The “Cervical Cancer” vaccine ? If the task force is not concerned about screening for Cervical Cancer before age 21 (since it is rare in women under age 25), why not wait until a girl is actually at risk for “developing” cervical cancer and give her the vaccine at say, 18? Gardasil is designed to prevent young women from contracting 4 strains of the Human Papilloma Virus, two of which are known to lead to cervical cancer and two which cause more than 90% of all cases of genital warts. If we are so concerned about each of our young women becoming “One less” woman stricken with cervical cancer, doesn’t it stand to reason that we should do all that we can to be sure that they are healthy, including routine Pap Smears? The USPSTF does not differentiate between those young women who are sexually active and those that are not, they  just issue the blanket statement that all women begin screening at age 21. Likewise, the recommendation for Gardasil is for all girls at age 11. But again, if cervical cancer is slow growing and highly treatable, is the vaccine really necessary? Why not just treat once disease is more likely detectable-that is what they are advocating for breast cancer, isn’t it? Seems to me that a “scare” tactic was utilized. Cancer scares people and fear sells.

More effective marketing would have been to market Gardasil as a prevention against genital warts. Each year women under the age of 25 account for the majority of new genital warts cases. Approximately 6.2 million new HPV infections occur every year in the United States and approximately 20 million individuals are currently infected. Some women are diagnosed via Pap smear and subsequent colposcopy or cone biopsy while other young women will actually present with lesions that can be excised and biopsied. Treatments for warts include cryotherapy, Tricloracetic Acid therapy, laser therapy and more invasive procedures such as Loop Electrosurgical Excision Procedures (L EEP). But with such readily available and effective treatments for genital warts available is there the same urgency to prevent genital warts as there is to prevent cervical cancer? Would consumers be willing to take the vaccine if marketed to prevent genital warts as opposed to cervical cancer? (Surveys show that less than 1/3 of young women in the appropriate age range for vaccination have actually received Gardasil to date.)  To push consumers towards vaccination, something stronger was needed and cervical cancer became the “buzz” used to promote (push) Gardasil.

But I digress. Has anyone else noted that these two new recommendations, both calling for reduction in screening for gynecologic cancers, came just before the US senate was about to debate the Democratic Health Care Reform Bill which includes a public (government sponsored) option? Look, if the public option is accepted and the Democratic Health Care Reform bill becomes law, women who are currently uninsured and very likely not receiving any sort of cancer screening, as well as women who choose the government sponsored health insurance plan instead of a private (more expensive) insurance plan (such as Cigna, Blue Cross & Blue Shield, Aetna, etc…) will cause an increase in utilization of health care screening services. A government subsidized plan with see an increase in claims and subsequent payout while private insurance companies may very well see a decrease in revenues. More utilization of services with less profit. Hmmm…

I won’t profess to know the collective mind of the USPSTF and since I was not present during the review of the recommendations nor privy to the discussions, I won’t state that these recommendations are a means of cost containment in the event that Congress does pass a health care reform bill that includes a public option. But the timing is suspect. It behooves all of us to watch vigilantly as the health care reform bills are debated. The recommendations by the USPSTF may be the very means by which the government and private insurances deny women access to preventive screening tests. I am worried that women won’t receive screening mammograms and Pap Smears more frequently than the USPSTF recommends-even if their health situations dictate more frequent screening. I worry that young girls will be forced to receive a vaccine for which we have no long term data (side effect profile) and no proven long term efficacy. I am worried that young girls may later be denied treatment for HPV related diseases if they didn’t take the vaccine, increasing their morbidity and mortality. I worry that we’ll see an increase in the incidence of more deadly cases of breast cancer. No one can predict the future, but I am concerned that if these guidelines are enforced “One Less” may very soon become “a whole lot more”.

Today’s roundup of news stories related to health disparities, health care, health issues, direct service, social justice, animal welfare, environmentalism… basically, all things Schweitzer:

• On Saturday, the U.S. Senate narrowly voted to start debating health care reform legislation (CBS News)
• If passed, will health care reform legislation “result in a potentially overwhelming demand for primary-care doctors”? (Miami Herald)
• According to the FBI, hate crimes linked to religion and sexual orientation are on the rise (Associated Press)
• Backlash against the new mammogram recommendations by the U.S. Preventive Services Task Force continues — but a nuanced conversation about expectations of mammography is also emerging (USA Today)
• Another controversial new women’s health recommendation: The American College of Obstetricians and Gynecologists is now suggesting that women wait until age 21 to begin cervical cancer screening (WebMD)

As if the recent release of changes in recommendations regarding breast cancer early detection were not enough, we now have hot on it’s heels a major change in recommendations for cervical cancer screening.  The irony of these two recommendations, though from differing groups and based on review of extensive data (which certainly in the case of breast cancer is open to debate) is that they suggest changes in long standing policy regarding early detection, which have clearly had an effect on reducing the incidence and mortality from these two cancers.  The cervical cancer recommendations have some thoughtful commentary regarding using these tests too early in a young woman’s life.  These concerns are valid.  However, it is also true, that among many populations and peer groups early sexual activity is a fact of life.  Having said that, the rate of HPV is rampant  and it seems, from a public health perspective a bit perplexing, that when we have initiatives to use a new vaccine to prevent HPV, we would at that same time be suggesting taking measures that makes diagnosing HPV less likely.   Not sure ACOG has thought that angle through enough. Proper testing is important and excessive testing is not helpful.  However, the individualization of recommendations we applaud from a medical perspective, but we know that this will lead to coverage issues for patients and doctors as health insurers will adjust their payment policies to reflect these new recommendations.  Below is potpourri of comments from ACOG and various news leads on this most public story . . . ben kazie md

Women should have their first cervical cancer screening at age 21 and can be rescreened less frequently than previously recommended, according to newly revised evidence-based guidelines issued today by The American College of Obstetricians and Gynecologists (ACOG) and published in the December issue of Obstetrics & Gynecology. Most women younger than 30 should undergo cervical screening once every two years instead of annually, and those age 30 and older can be rescreened once every three years.  Cervical cancer rates have fallen more than 50% in the past 30 years in the US due to the widespread use of the Pap test. The incidence of cervical cancer fell from 14.8 per 100,000 women in 1975 to 6.5 per 100,000 women in 2006. The American Cancer Society estimates that there will be 11,270 new cases of cervical cancer and 4,070 deaths from it in the US in 2009. The majority of deaths from cervical cancer in the US are among women who are screened infrequently or not at all. Cervical cancer is a slow growing cancer caused by certain strains of the human papillomavirus (HPV), an extremely common sexually transmitted disease among women and men. HPV also causes genital and anal warts, as well as oral and anal cancer…..

First Cervical Cancer Screening Delayed Until Age 21 Less Frequent Pap Tests Recommended – http://www.acog.org/from_home/publications/press_releases/nr11-20-09.cfm

New guidelines for cervical cancer screening say women should delay their first Pap test until age 21, and be screened less often than recommended in the past. The advice, from the American College of Obstetricians and Gynecologists, is meant to decrease unnecessary testing and potentially harmful treatment, particularly in teenagers and young women. The group’s previous guidelines had recommended yearly testing for young women, starting within three years of their first sexual intercourse, but no later than age 21. Arriving on the heels of hotly disputed guidelines calling for less use of mammography, the new recommendations might seem like part of a larger plan to slash cancer screening for women. But the timing was coincidental, said Dr. Cheryl B. Iglesia, the chairwoman of a panel in the obstetricians’ group that developed the Pap smear guidelines. The group updates its advice regularly based on new medical information, and Dr. Iglesia said the latest recommendations had been in the works for several years, “long before the Obama health plan came into existence.”  She called the timing crazy, uncanny and “an unfortunate perfect storm,” adding, “There’s no political agenda with regard to these recommendations.”…..

Guidelines Push Back Age for Cervical Cancer Tests – http://www.nytimes.com/2009/11/20/health/20pap.html?_r=4

The cervical cancer screening advice follows another panel’s controversial mammogram report, but experts say it’s a much different situation. Still, Paps are the only reason some women see a doctor. Only days after a federal panel scaled back on breast cancer screening recommendations for many women, another organization — the American College of Obstetricians and Gynecologists — has done the same for a screening credited with drastically reducing the rates of cervical cancer in the U.S. Women of all ages should undergo Pap smears less frequently than they do now, those new guidelines say. And young women are advised not to bother until age 21. The pullback follows the U.S. Preventive Services Task Force’s dismissal of routine breast cancer screenings for women younger than 50. That move triggered a storm of protest from medical groups and individual women, with some breast cancer specialists and Republicans accusing health officials of moving toward a rationing of care and services. On Wednesday, U.S. Health and Human Services Secretary Kathleen Sebelius emphasized that the task force guidelines amounted to advice, not policy, and that women should continue to consult with their physicians about mammograms based on their own histories and needs…..

Group recommends less-frequent Pap tests – http://www.latimes.com/news/nationworld/nation/la-sci-pap-smears20-2009nov20,0,5747799.story

Women can delay having their first Pap test for cervical cancer until they turn 21 and many can wait longer to go back for follow-up screenings, according to new guidelines released Friday by a major medical group. The American College of Obstetrics and Gynecologists (ACOG) recommended the change after concluding that more frequent testing did not catch significantly more cancers and often resulted in girls and young women experiencing unnecessary stress, anxiety and sometimes harmful treatments because of suspicious growths that would not cause problems. “We really felt that the downsides of more frequent screening outweighed any benefits,” said Alan G. Waxman, a professor of obstetrics and gynecology at the University of New Mexico who led the revision of the guidelines. “More testing is not always more intelligent testing.” The change comes amid sharp controversy over new recommendations from a federal task force that women wait until age 50 before they begin having routine mammograms and that women age 50 to 74 scale back to getting the exams routinely every two years…..

Cervical cancer screening can wait till 21, group says – http://www.washingtonpost.com/wp-dyn/content/article/2009/11/19/AR2009111904743.html

Women in the United States should start cervical cancer screening at age 21 and most do not need an annual Pap smear, according to new guidelines issued on Friday that aim to reduce the risk of unnecessary treatment. The guidelines from the American College of Obstetricians and Gynecologists or ACOG now say women younger than 30 should undergo cervical cancer screening once every two years instead of an annual exam. And those aged 30 and older can be screened once every three years. The recommendations are based on scientific evidence that suggests more frequent testing leads to overtreatment, which can harm a young woman’s chances of carrying a child full term. “Overtreatment of minor abnormal pap tests in young women and adolescents can lead to consequences such as preterm labor in some cases. It increases the risk,” said Dr. Thomas Herzog of Columbia University in New York, who is chairman of an ACOG subcommittee on gynecologic cancers. “Preterm delivery has become a huge problem in the United States that has potential serious consequences for the unborn fetus,” said Dr. Jennifer Milosavijevic, a specialist in obstetrics and gynecology at Henry Ford Health System in Detroit, who supports the guideline changes…..

New guidelines: Pap smears should start at age 21 – http://in.reuters.com/article/worldNews/idINIndia-44108820091120

The revised guidelines released today by the American College of Obstetricians and Gynecologists also recommend that women 30 and older get screened with a so-called Pap test once every three years, instead of every two to three years. The American Cancer Society’s gynecologic cancer director said the society agreed with the advice of the doctors’ organization that additional screenings may lead to unnecessary treatment. The ob-gyn organization is the second medical group this week to recommend less-frequent cancer screenings, citing scientific data. A U.S.-backed panel said Nov. 16 that most women in their 40s shouldn’t get annual mammograms to prevent breast cancer, setting off protests from women, physicians and health advocacy groups such as the cancer society. “The data is very good that a Pap test every two years is as good as a Pap test every year,” said Alan Waxman, the lead author of the new guidelines and a professor of obstetrics and gynecology at the University of New Mexico in Albuquerque, in a telephone interview. The additional tests are inconvenient and costly, and research shows “it doesn’t make a difference in terms of lives saved,” he said…..

Screening for Cervical Cancer Should Start at 21 – http://www.bloomberg.com/apps/news?pid=newsarchive&sid=aLDLltBDBErU

For the second time this week, a major U.S. medical panel has revised recommendations for a key test that millions of American women use to detect cancer. On Monday, it was mammograms. Today, it’s Pap tests. The American College of Obstetricians and Gynecologists says that women no longer need annual cervical cancer screenings. It also says women can now wait until they’re 21 to get their first Pap test, instead of getting one after they’ve become sexually active. “The tradition of doing a Pap test every year has not been supported by recent scientific evidence,” said Dr. Alan G. Waxman of the University of New Mexico, who headed the American College’s guideline revision…..

Annual Pap tests no longer needed, panel says – http://www.tampabay.com/news/health/annual-pap-tests-no-longer-needed-panel-says/1052944

Most women in their 20s can have a Pap smear every two years instead of annually, say new guidelines that conclude that’s enough to catch slow-growing cervical cancer. The change by the American College of Obstetricians and Gynecologists comes amid a completely separate debate over when regular mammograms to detect breast cancer should begin. The timing of the Pap guidelines is coincidence, said ACOG, which began reviewing its recommendations in late 2007 and published the update Friday in the journal Obstetrics & Gynecology.  The guidelines also say: -Routine Paps should start at age 21. Previously, ACOG had urged a first Pap either within three years of first sexual intercourse or at age 21. -Women 30 and older should wait three years between Paps once they’ve had three consecutive clear tests. Other national guidelines have long recommended the three-year interval; ACOG had previously backed a two- to three-year wait. -Women with HIV, other immune-weakening conditions or previous cervical abnormalities may need more frequent screening…..

Report: 20-somethings can go 2 years between Paps – http://www.washingtonpost.com/wp-dyn/content/article/2009/11/20/AR2009112000089.html

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]]> http://womenshealthnews.wordpress.com/2009/11/22/weekly-news-round-up-1122/ Sun, 22 Nov 2009 16:40:16 +0000 Rachel http://womenshealthnews.wordpress.com/2009/11/22/weekly-news-round-up-1122/

Assorted things of interest from the previous week.
It’s not nearly as controversial as the USPSTF’s breast cancer screening recommendations, but ACOG released a new practice bulletin on cervical cancer screening. The New York Times has coverage of the change, which is basically that women can wait until up to 21 years of age to start getting Pap tests, and then can get Paps every 2-3 years instead of every year once they’ve had a few normal tests. This is not entirely new – the USPSTF’s 2003 recommendations are very, very similar. (so, 6 years from now, we’ll be cool w/ the breast cancer recs?)

Some lots of Vick’s Sinex nasal spray are being recalled due to bacterial contamination.

The FDA has tips on holiday food safety.

Presented without comment: Highest Rates of Obesity, Diabetes in the South, Appalachia, and Some Tribal Lands [w/ the exception of a request to think about what that might mean in conjunction with the frequent framing of obesity as a moral failing of individuals]

SisterSong has posted a new issue of its Collective Voices newsletter [PDF]; this issue has a reproductive justice theme. You can follow SisterSong on Twitter.

The Kaiser Family Foundation issued a brief on how health reform might affect health disparities experienced by racial/ethnic minorities.

Nov 20 was the Transgender Day of Remembrance, set aside to memorialize those who were killed due to anti-transgender hatred or prejudice. Learn more here, and see the any of a number of blog posts observing the day.

The Voices Against Violence Zine is “A small zine-diy style, with work from people of color, indigenous folks, trans people & queer survivors of domestic violence, sexual violence and sexual assault. Included topics can be: healing from trauma, transformative words used as a healing mechanism, enabling healing, life after trauma, self-help guides/resources, self-healing, dancing as means to healing, healing through narration, forgiveness (do we need it?), & collective trauma.” It will be accepting submissions for the next issue through Nov 30. Learn more at Hermana, Resist.

The 60th Disability Blog Carnival has been posted at FWD/Forward.

The CDC updated their 2009 H1N1 Flu Information for People with Disabilities and Their Caregivers or Personal Assistants.

Renee at Womanist Musings talks about people making class assumptions about her based on her scooter use.

Good for them: the Ames Public Library in Iowa carries Sex, Etc. magazine, which is written by teens for teens to provide accurate sex education information. There was a petition to have it removed from the library. It’s going to stay. I have a librarian happy.

The release of two new suggestions for when women should be screened for cancer came this week in a fury of media coverage and confusion.

The United States Preventive Services Task Force released a statement early this week stating that women should not get mammograms until they are 50, instead of the previous recommendation of 40. They said that from the data they collected, women are more likely to develop breast cancer in their 50s than their 40s.

My mother has been getting her mammogram since I can remember. I would rather her get them than not. Tests can’t hurt, but cancer can. Especially if the cancer develops and spreads quickly. I would say based on your family history, your work environment (ex. work with chemicals that increase your risk of cancer), and discussions it with your doctor, you should get a mammogram done regardless if you are 40 or 50.

Another report released by the American College of Obstetricians and Gynecologists says that women should get pap smears every 3 years instead of every year. Before, it recommended that a woman have one every year, get her first one within 3 years of their first sexual intercourse or no later than 21.

The New York Times article says that the reason the number of pap smears should be reduced is because pap smears pick up pre-cancerous tumors and those tumors could either disappear on their own or eventually lead to cervical cancer which can take about 10 to 20 years to develop. The OB/GYNs believe that the tests cause more harm than good because doctors can remove the tumors when there is no need.

Again, I think that based on your family history and talking to your doctor, you should discuss whether getting a pap smear every year is the right plan for your health care.

Health care professionals are continually working on how to best screen for cancers and treat their patients when the tests come back. Screening procedures are still being tinkered with, so I wouldn’t be surprised if more screening announcements are made in the near future.

You know, this past week has been a very confusing week for women.

First you’re told that if you’re under 50 that you don’t need to do a mammogram because the risks far outweigh the rewards.

Then you had celebrities coming out swearing about the benefits of the screening.

What’s next?

Well, here are 21 questions that you need to take a look at and seriously think about their answers.

I have some empathy for those who are suspicious of recent recommendations pushing back screening ages for breast and cervical cancer.

Nothing, for example, can stop my pre-flight anxiety. And try as my boyfriend may, he will never convince me to go skydiving. It may be a “calculated risk,” as he says, but it just feels unnatural and, well, “risky.”

So I can sympathize with women who say, ‘that one person saved from breast cancer out of 2,000 others could have been me.’

Highly, highly unlikely. But however unluckily so, it could have been.

Humans tend to see things in 50-50 odds, in terms of this outcome or that. Either my plane lands safely or it doesn’t. My chute opens, or I pummel into the earth. It takes a lot more to think in terms of numbers, odds, risk.

That’s why public health experts do it for us. They’re trained to pit the risks of screening (radiation exposure and anxiety from false-positives for breast cancer, for example) against its benefits (how many lives does it really save?) and calculate sound advice.

It’s called evidence-based medicine, and it’s what doctors like to practice best.

But we don’t see the epidemiologists’ thought processes, their methodology, or their rationale, which could explain why there’s so much skepticism in the general public. As Paul Raeburn jokes in a recent Knight Science Journalism Tracker item, we can’t just consult our healthcare epidemiologist to tell us what to do and why.

But we can try to think like one. It’s as simple as searching the New York Times. These numbers are from a fantastic news analysis by reporter Kevin Sack:

According to their review, the U.S. Preventive Services Task Force found that one cancer death is prevented for about every 2,000 women ages 40 to 49 who are screened for 10 years.

For women ages 50 to 59, one death is prevented for every 1,300 women screened.

Looking very broadly at those numbers, your risk almost doubles when you hit 50. Starting to see their thought process?

The screen works even more efficiently for women ages 60 to 69, preventing one death for every 377 ladies. Based on those numbers, no one would deny screening at that age. That’s a huge difference from 1 in 2,000 — your risk is increased almost five times from when you were 40.

I don’t know the exact statistics, but it would also be worthwhile to factor in your risk of cancer from being exposed to radiation once a year from 40 to 49.

I surely wouldn’t be able to calculate that. As a rookie health reporter, I’m just beginning to understand risk. If I’m around it every day and am still no expert, I can imagine how challenging it must be for the lay reader.

And your doctor may not be able to offer much help, either, as Raeburn notes in his commentary. Physicians learned of the recommendations at the same time we readers did. And they are certainly not epidemiologists. Their last statistics course may have been during their undergraduate training.

So what can you do? Well, know your risks. Know that the new guidelines exempt women who have genetic risks for breast cancer. (And bear in mind that the new guidelines are only one set of recommendations. Other medical organizations, like the American Cancer Society, have not changed their policies yet.)

And do a bit of rationalizing on your own. If you’re not in the at-risk population, but you’re not comfortable relying on the numbers, then compromise. Get screened every three or five years during your 40s if that puts your concerns at ease. It may be statistically unnecessary, but at least you will have peace of mind.

Just like I do when I pray to the deity of statistics before takeoff.

Video here via DoublePlusUndead. (H/T ECM)

I suspect that they did it to save costs – it’s the UK version of the public option.

Many people in Columbus, Ohio are mourning today, saddened over the loss of Stefanie Spielman, wife of former OSU great and Buffalo Bills player, Chris Spielman. Only 42, she passed away at home surrounded by her family, including her four children. The Spielmans together helped raise millions for cancer research at The Ohio State University Medical Center’s James Cancer Hospital.

Just a couple weeks ago, I lost another friend, Jill Steuer, 57, to breast cancer, too. Jill was a nurse whose expertise in cardiac care was unsurpassed, and she made many significant contributions to improving patient care in central Ohio.

Another friend died in 2004, leaving behind four children and a husband, and several friends are currently dealing well with the disease since they caught it early.

This really makes me ask the question – what’s the deal with the new guidelines on breast cancer screening from the U.S. Preventive Services Task Force? After hearing for years that you should get an initial mammogram at age 40 and every year thereafter, this is fairly confusing. I thought this four-minute segment did a pretty good job explaining the issues at hand.

Great, but the American Cancer Society (ACS) and the American College of Obstetrics and Gynecology (ACOG) disagree with these new guidelines. It makes me wonder how much these women’s lives would have been different had these new guidelines been in place 10 or 20 years ago.

Then on top of this, ACOG issues new cervical cancer screening guidelines. These, however, aren’t much different than the ACS recommendations. Thank goodness.

It’s almost like each of us needs a Blackberry just to manage the complexity of scheduling the right appointments in the right location at the right time with the right doctor. Crazy.

You have to wonder, too, how healthcare reform will impact our choices, our insurance coverage, our ability to choose physicians, hospitals and other aspects of our care.

In the meantime, I’m deferring to my doctor, not a government panel, to help determine what’s for me given my family history and his knowledge of overall health. And trust me, I’m keeping the mammogram (see my post Newblets and the Boob X-Ray) yearly and other preventive checkups on the Blackberry for now and the foreseeable future.

Women’s health has been pulled in 500 different directions this week, and it doesn’t seem to be ending. One second the healthcare industry is telling women to get yearly mammograms after 40 years old, the next it’s after 50 years old. One second women are hearing to get pap smears yearly after the age of 18, the next they’re being told to wait until they’re 21 and to get the pap smear every two or three years. What’s next? Drinking heavily during pregnancy is good for the baby and calcium for bone strength is just a myth?

So, what do women do? Who do they believe? I tell you what, if you have had the same family physician and gynecologist for many years, ask them. In many cases, especially if you have a doctor who practices concierge medicine and has the time to take to discuss options with you, your doctor will know the best path for you to take.  

The American College of Obstetricians and Gynecologists made the release this week that stated women should wait until they’re 21 before their first pap smear, and then only have on three years after that until they reach their 30’s, when they should have one every two years. This is a huge step away from the yearly pap smears that start at age 18.

Many physicians are actually praising the new guidelines, saying that pap smears even before the age of 25 are unnecessary and cost patients more money than they need to spend. While a pap smear tests for many different conditions, it’s HPV that gets the most attention. Most physicians believe, and have the research to back them up, that women under the age of 25 still have a strong enough immune system to take care of any small HPV conditions on its own before it becomes cancerous. Only 0.1 percent of women are affected with cervical cancer before the age of 21.

According to ABCNews, the new guidelines were recommended based on the facts, and based on the concern for women’s mental health. Young women who are told, and scolded, for being affected by HPV in their early 20’s deal with fear, the embarrassment of the condition, and the depression that comes along with knowing cervical cancer is just around the corner. When, in reality, 90 percent of women who are affected by this condition in their early 20’s have a strong enough immune system to fight it before it turns into cancer, and all the worry and depression will have been for nothing.

Of course, there’s always two sides to every decision, and on the other side there are many physicians who are afraid that those women who only come into the office once a year for their ‘annual’ will only come in once every two years. This could create problems for any symptoms missed during those two years of not seeing a doctor for a routine check-up.

However, as the patient of a Signaure MD concierge physician, you have more time than any other common practice patients to give your doctor a call on their personal cell phone to discuss what options are best for you. With your concierge physician, you are completely assured that your doctor will know what’s best for you and your family, and will have an amplitude of available time to discuss your options with you. With Signature MD, your concierge physician has plenty of time to devote to each woman who is concerned with the ever changing field of women’s health.

If you are interested in learning more about concierge medicine and what Signarue MD can do for you, check us out at http://www.signaturemd.com.

So people are really freaking out about the new screening recommendations. Guess after years of being told to get routine pap smears and breast exams, we’re hard-wired to think that if we don’t get those tests, we’re basically asking for cancer.

I’m not surprised by these new recommendations and I don’t think the government or insurance companies are trying to screw me. When it comes to science, medicine in particular, things are rarely concrete: drugs are put on the market before long-term studies on their effects are done, new causes for diseases are suggested and then eliminated just as quickly, certain foods are deemed beneficial to health only to find out later they have no effect after all. My point is, doctors and researchers can only tell us what they know and what they know is bound to change with the more research they do.

I’m also not surprised, however, by the public’s reaction. Consider junk food. We know that junk food can cause obesity and all kinds of health problems but for the most part we still eat a lot of crap. Why? It’s really hard to change behavior, even when it is for our own benefit.

For more about the conflict between science and practice, read this NY Times story:  Medical Science and Practice in Conflict.

-Amber

This week, as we near the controversial health care debate to take place tomorrow in Congress, National Public Radio aired stories on two controversial studies that put forth new guidelines reducing screening recommendations for two forms of cancer frequently diagnosed in women.

They were just the two latest reports, in a series of stories aired over the past few months by the government-subsidized radio network, on new federal guidelines calling for decreased preventive and early-detection screening of several diseases that affect a wide range of the American population - the elderly, men, women, teens and newborns.

According to the most recent report on NPR, new guidelines from the American College of Obstetricians and Gynecologists call for women to get Pap smears every two years, between the ages of 21 and 29. Previous guidelines called for annual pap smears every year for three years after the start of sexual activity, or 21 years of age, followed by one every three years if all three previous exams were normal. Pap smears have been very effective in the early detection of cervical cancer, a growing problem for young women.

The ACOG’s new guidelines come just days after new screening guidelines for breast cancer were announced to much public fury, and the day before Congress begins debate on the health care reform bill.

“It’s just pure coincidence that these guidelines have been released now,” says Dr. David Soper, the Chairman of ACOG’s Gynecology Practice Bulletin Committee.

The new mammography guidelines established by the U.S. Preventive Services Task Force call for women, ages 50 and older, to have mammograms once every two years, as opposed to previous guidelines that recommend women 40 and older get annual mammograms.

The USPSTF, a group of experts convened by the Department of Health & Human Services, led by Kathleen Sebelius, is taking a lot of heat from women’s advocacy groups and physicians. But, in their coverage of the debate, NPR chose to talk first to a physician who said of the new guidelines, “It’s about time!”

“I was never convinced that mammography screening worked that well in younger women,” Dr. Susan Love said in support of the government-backed guidelines in an interview with NPR.

The American Cancer Society disagrees with the conclusions of the White House-convened USPSTF, and released a statement the same day the new government guidelines were released.

“The American Cancer Society continues to recommend annual screening using mammography and clinical breast examination for all women beginning at age 40. Our experts make this recommendation having reviewed virtually all the same data reviewed by the USPSTF, but also additional data that the USPSTF did not consider. When recommendations are based on judgments about the balance of risks and benefits, reasonable experts can look at the same data and reach different conclusions.”

– statement from Otis W. Brawley, M.D., chief medical officer, American Cancer Society

The American College of Surgeons followed with a press release supporting the American Cancer Society’s position on the new guidelines.

“The College is supporting the ACS guidelines despite the recommendations from the U.S. Preventive Services Task Force stating the women should have regular mammograms once every two years beginning at the age of 50. The College believes the ACS guidelines have resulted in an effective approach toward dealing with the possibility of breast cancer and that women should continue to follow them in consultation with their physicians.”

– American College of Surgeons

The National Medical Association was also quick to react to the government-backed guidelines of the USPSTF, issuing a press release to caution women about the potential harm.

“The NMA is concerned about the USPSTF recommendations that women have routine mammography screenings beginning at age 50 instead of 40. The new recommendations could have serious implications for African American women since studies have shown that African American women develop breast cancer at an earlier age, are often diagnosed at a later stage of the disease, and develop more aggressive types of breast cancer. The USPSTF recommendations could result in even higher death rates for this disease and further exacerbate the challenges for the uninsured and the under insured.”

– National Medical Association

Women are not the only ones to have their health and wellbeing subjected to new screening guidelines. In the Nov. 11^th issue, the Journal of the American Medical Association noted a disparity between recommendations of the USPSTF and those of the Centers for Disease Control and Prevention for screening for the hepatitis B virus.

According to the JAMA report, “More than 500 million persons worldwide are infected with hepatitis B or C virus, estimates the World Health Organization, and more than 5 million US residents have such infections, according to the U.S. Centers for Disease Control and Prevention (CDC). Yet these infections often go undetected and untreated because patients and physicians may be unaware of who is at risk or may fail to pursue testing.

“Although prevention efforts have helped dramatically reduce the incidence of hepatitis B and C viral infections in the general U.S. population, demographic shifts are leading to growing numbers of chronically infected patients who may develop severe complications such as cirrhosis and hepatic cell carcinoma.”

Despite these alarming facts, the USPSTF still “recommended against routine screening for HCV infection in asymptomatic adults who do not have risk factors and found insufficient evidence to recommend for or against routine screening in those at risk. The task force also recommended against routine screening of asymptomatic individuals for HBV.”

The list of USPSTF-recommended cutbacks in preventive and early-detection screening goes on:

• Favors ending screenings for all forms of cancer if and when an older patient is more likely to die of another condition than of cancer
• Supports reductions in screening for prostate cancer
• Suggests there is insufficient evidence available to support guidelines calling for regular skin cancer screening.
• Finds insufficient evidence to support screening for newborn jaundice, despite the fact that 60 percent of babies are born with jaundice – a condition that can lead to brain damage.

A Single Agenda for Legislating and “Researching”

The perfectly-aligned agendas of the Obama Administration and Sebelius’ department (which oversees the work of the USPSTF) are causing increased concern among Americans that these new and more restrictive guidelines – put forth by a government agency leading up to the most critical health care reform debate in our nation’s history – are veiled attempts by our federal government to pave the way for rationing of health care through a phased conditioning of expectations.

The unity of purpose among Democrats in Washington – defying all obligations to the American people – is tough to deny.

DISCLAIMER: I love many NRP programs – Car Talk, A Prairie Home Companion and Wait, Wait, Don’t Tell Me, in particular. And I enjoy their human interest stories from around the world, which is I why I contribute financially to NPR. However…

I was out a few nights ago and a friend asked me my thoughts on vaccinating her daughters for HPV – Human Papillomavirus. We’ve all seen the ads but what is it? Why is it taking center stage now? And in the grand scheme of sexually transmitted infections (STI) how dangerous is it?  

I didn’t have an opinion – although my gut was telling something so I thought I’d take a look. I’m writing this as I’m doing my research… so I’m taking you on my “thought” journey to look at the data and see what I think. This is how I’m thinking about the numbers – but if you find a different way let me know.

HPV is actually better known as the virus that causes warts – yep those icky things on your hand and feet. There are around 100 HPV strains that have been categorized.

There are about 40 known strains of HPV that infect the genital region. Of these 9 of these are considered high-risk – causing anything from low-grade cervical changes to cancers in women. Low-risk strains (the American Cancer Society lists 2) may cause genital warts, respiratory pappillomas (very rare – and involves the transmission from a mother to a new born) or low-grade changes in the cervix.

So… what about the other 29 strains?

The Centers for Disease Control state that 50% of sexually active adults (men and women) will get HPV at some point in their life.

According to the American Cancer Society “70% of HPV infections appear to go away within a year and 90% within 2 years.” The CDC adds that “in 90% of the cases, the body’s immune system clears the HPV infection naturally.” Most people don’t even know that they’ve had it.

So for a huge number of the infected there is no cause for alarm – our body takes care of itself and off we go.

Forgive me while I do a little math… let’s start with 200 people, 100 men and 100 women. Okay out of each group 50 will get some strain of HPV – whether it is a high-risk or a low-risk strain 90% of them will clear it up in two years. That leaves 1 woman and 1 man left to worry about right (I know – it could be 2 women or 2 men – but this is a thought experiment)?

So what about that 10% – which is a huge number if you’re looking at the total population of the US – what happens to them? Remember they can have either high-risk or low-risk HPV infections.

Now I’m going to limit this to cancer – the other types of problems HPV creates can be dealt with fairly easily – but cancer kills.

To figure out the risk to our 10% I plugged in the American Cancer Society’s estimates of the number of HPV related cancers in 2008 and the US population curtsey of the US Census Bureau and got the table below.

So… this gets a little funky – I made the US Population numbers to equal 10% of the population. So the risk to the 10% is the percent below. Not the risk to the general population.

  *estimation of US births in 2008

Our two people – have less than a .08% chance of getting a HPV related cancer to their problematic HPV strain – less if you are male and a little more if you are female. And there isn’t a vaccine for men – so if you are looking at the 30 million remember that the vaccine could only help 15 million of them.

Which means that the Jill on the street has a .008% chance of getting a HPV related cancer and yes genital warts can be an embarrassment but they aren’t cancer. I think most lottery odds are better. On the site Dr. Math it is reported that a person has a 1:80,089,128 chance in matching all 5 numbers plus the power ball if playing Powerball Lotto. I didn’t look at his formula but thought we’d roll with it – it makes my point.

Now let’s play another game because even 15 million problematic HPV infections in women seems a like a lot. But remember there are 40 strains of HPV that infect the genital region – of which 9 are high-risk.  

Gardasil, one of the two vaccinations for HPV on the market, was designed to prevent the following:

• 2 types of high-risk HPV known to cause cervical cancer that are responsible for 70% of all HPV related cervical cancers.
• 2 types of low-risk HPV known to cause genital warts that are responsible for 90% of all genital warts.

Cevarix will protect against the same high-risk HPV but not the low-risk.

So, if our young woman gets cancer from HPV – she has a 41% chance of having a cancer that isn’t cervical. She also has a 30% chance, if she has cervical cancer, that it isn’t one of the two strains included in the vaccinations.

These odds become more astronomical by the minute….     

The American Cancer Society in their guidelines state:  

• girls ages 11 to 12
  The vaccine should be given to girls ages 11 to 12 and as early as age 9.

• girls ages 13 to 18
  Girls ages 13 to 18 who have not yet started the vaccine series or who have started but have not completed the series should be vaccinated.

• young women ages 19 to 26
  Some authorities recommend vaccination of women ages 19 to 26, but the American Cancer Society experts believed that there was not enough evidence of benefit to recommend vaccinating all women in this age group. We do recommend that women ages 19 to 26 talk to their doctors or nurses about whether to get the vaccine based on their risk of previous HPV exposure and potential benefit from the vaccine.

I’m not against vaccinations – I think they are great! In fact just got a booster shot at the doctor the other day for tetanus. No Small Pox almost no Polio – these were great things that saved lives and dealt with viruses that were killing us. But we are being asked to “protect our girls” from an almost nonexistent cancer. A cancer that appears in a sliver of the population and the biggest risk is from cervical cancer which currently has a survival rate of 92% with early detection and 71% for detection at all stages.

Yes – HPV is very infectious but statistically it’s not killer.

So why? Why the huge ad campaign? Why make us feel that something is terribly wrong when the number don’t really support it?

Viruses evolve with their hosts – that said HPV has been around for a very long time – infecting us for millions of years.

The odds are that it will continue to be an occasional problem and general nuisance. A lot of viruses are in a push-me-pull-you state with their hosts. They come. They go. And Leave immunity in their wake.

Which makes me wonder if there is any indication of reinfection with HPV? You know like the common cold – you get it and then get it again and we never seem to get much better at fighting it. But the raw data – just the numbers that we’ve looked at suggest that infection happens – is cleared – and then you have your own immunity. 

Is it the right thing to do? Why are so many women talking about this and wondering what they should do? Well… remember the ads?

Let’s look at the issue another way.  

If we become convinced, as a society, that the guidelines should be adhered to there are an estimated 4.5 million children born every year in the US. Imagine half of them are girls…2.25 million. That means that if we go by the America Cancer Society guidelines and vaccinate every young woman, right now, between the ages of 11 and 18 that is an estimated18 million young women.

Gardasil goes for $120 a dose and three doses are required for immunity so that is $360 per woman.

18 million young women multiplied by $360 per treatment is $6.5 billion…with an additional $900 million possible every year thereafter.

If they succeed in making us believe… what? That we are doing a disservice to our young women not to vaccinate them – this may be a “nice to have” but I just can’t classify it as a “need to have”.  

Oh, and on the American Cancer Society website they have a section that interests me in their FAQs. “Did the American Cancer Society play a role in the development of the HPV vaccines?”

The answer… Yes. One of the four teams received funding from the ACS in the mid 1990s – the grant could be anything from a little to a lot…  

And you wonder why you’ve seen all the ads. I don’t. This is economics driving healthcare – and I have to admit I’m rather sad about it.

But there is a flip side… I was talking to another friend who has decided to immunize her daughter. She did it because she and another mother she knows had been one of the 10% – the ones with some sort of problem with their vaginal wall cells caused by HPV. The treatment was painful and my friend felt that since her insurance was paying for it she would rather not take the risk of there being a genetic predisposition.

Another woman said that she would have done it – her daughters are older now – just because it was one less thing to worry about.

Yet another said that since there are very few “wins” when preventing cancers of any kind that it was just nice to know you were doing something.

So where are we?

A drug company is going to make billions off our sense of responsibility? This will be a choice each of us will have to make. The risks are low yet it seems this is a bizarrely difficult decision to make.

What about you?  

 ~ Tess

Earlier this week we questioned the government’s motivations behind their new recommendations for breast cancer screening.  The recommendations made by the United States Preventative Services Task Force (USPSTF) significantly reduced the screening recommended, including the use of mammograms.  While the science behind the recommendations is open for discussion, the timing of the announcement was curious.  Are cost savings that would occur from the changes and the government’s desire to manage the healthcare system related?

Now, the American College of Obstetricians and Gynecologists recommends reducing screening for Cervical Cancer tests.  The uproar was immediate.  Is this another indication of additional meddling in the name of Healthcare reform?  Quite possibly not since the College was actually against the USPSTF’s of breast cancer recommendations.  However, this huge outcry shows a lack of trust Americans have in their government, especially when it comes to such personal issues as healthcare.  Given the government’s many mishaps of the past, the reaction is justified.

The main problem with American healthcare is high cost and most Americans agree this issue needs to be addressed.  However, turning our healthcare system over to being government managed will not lower cast.  In fact if history is a good judge, it will increase the costs.  Add to that the inevitable meddling that will occur when bureaucrats take over the decision making and you have a formula for disaster.

At the beginning of the week, the United States Preventative Task Force issued a set of new guidelines for use of mammography. And the storm hit — OMG, the government will be rationing health care; OMG! the gubmint wants women to die!

“I do believe that women will die” if they’re followed, she said.

Not once in the ensuing storm of criticism, did anyone bother to look at the statement that these new guidelines are NOT for ALL women, and will actually promote doctors to spend some time with their patients and give them some individualized time deciding on the most effective course of prevention for the individual patient. Furthermore, not a single one of the idiots trotted out to oppose the new guidelines (Kathleen Sebelius, Debbie Wasserman, for example) have bothered to recognize that even low doses of radiation from yearly mammography can lead to breast cancer — yes, radiation (which remains in the body) is one of the KNOWN causes of breast cancer. And finally, not once have I heard anyone in the media note that these new guidelines put the US in line with European nations that also use a screening process and which have no higher incidence of breast cancer with less screening.

Today, another group, American College of Obstetricians and Gynecologists, has issued new guidelines for Pap Smears. Again, the guidelines call for less screenings.

The new guidelines say women 30 and older who have three consecutive Pap tests that were normal, and who have no history of seriously abnormal findings, can stretch the interval between screenings to three years.

In addition, women who have a total hysterectomy (which removes the uterus and cervix) for a noncancerous condition, and who had no severe abnormalities on previous Pap tests, can quit having the tests entirely.

The guidelines also say that women can stop having Pap tests between 65 and 70 if they have three or more negative tests in a row and no abnormal test results in the last 10 years.

The changes do not apply to women with certain health problems that could make them more prone to aggressive cervical cancer, including H.I.V. infection or having an organ transplant or other condition that would lead to a suppressed immune system.

These are some pretty specific ifs contained in the new guidelines, just as there were specific ifs in the new guidelines for mammography.

Nevertheless, the idiots with serious reading comprehension problems and a basic understanding of cervical cancer are coming out of the woodwork, including for this NY Times article.

On the other hand, Ms. Jemison said that now that she is over 21, “I would still go every year” for the Pap test.

“One of my cousins had cervical cancer, so that’s in my head too,” she said. “I’d rather get it checked out regularly than have to worry about that.”

There is no evidence that cervical cancer is inherited. However, there can be a familial connection of a suppressed immune system, which, under the new guidelines, means you should continue to get yearly pap smears.

I’m left wondering why the media insists on promoting stupid, which will not further discussion of the cause and effect of over-testing, for both mammograms and pap smears.

(Getty Images)

FRIDAY, Nov. 20, 2009 (Health.com) — Young women should have their first Pap test no sooner than age 21, regardless of when they become sexually active, say new guidelines from the American College of Obstetricians and Gynecologists (ACOG). Earlier screening for cervical cancer may lead to unnecessary and possibly harmful treatments for an increasingly rare cancer, according to ACOG, the leading U.S. professional organization for obstetricians and gynecologists.

After age 21, women should have a Pap test every two years, instead of every year. At age 30, if a woman has no history of cervical cancer and has had three normal Pap tests in a row, she can be screened every three years, rather than every two to three years. (Women with certain risk factors, such as those who are HIV positive or who have a suppressed immune system, may need to be screened more often.)

However, annual pelvic exams—which are necessary for performing a Pap test—won’t necessarily be going away. ACOG says it may still be appropriate for women to visit their doctor annually for a pelvic exam, even if a Pap test isn’t performed. And sexually active adolescents shouldn’t wait until age 21 to see a gynecologist for the first time. (Such visits don’t necessarily have to include a pelvic exam.)

The guidelines were published this week in the journal Obstetrics & Gynecology.

ACOG had previously recommended that women receive their first Pap test three years after having sex for the first time, or no later than age 21, with annual checkups after that.

Why the change? Rates of cervical cancer, which is caused by the sexually transmitted human papillomavirus (HPV), have declined by 50% since the 1970s. Cervical cancer is now extremely rare, especially among women under the age of 30, the group most affected by the new guidelines. On average, just 14 cases occur nationwide in women between the ages of 15 and 19 each year, according to data from the Centers for Disease Control and Prevention. Among women ages 20 to 24, an average of 123 cases occur.

“The risk of invasive cancer is so exceedingly rare in this age group that to start screening at age 21 will still pick up the overwhelming majority of cases,” says Alan Waxman, MD, a professor of ob-gyn at the University of New Mexico School of Medicine, in Albuquerque, who led the preparation of the document spelling out the recommendations. “The incidence of cervical cancer in 15- to 19-year-olds has been reported at 1 to 2 per million girls. That’s a lot of unnecessary pelvic exams and unnecessary potential treatments that can be avoided.”

The cervical cancer rate will probably drop even further due to newer vaccines like Gardasil, which are now approved for HPV prevention in girls and women ages 9 to 26. However, ACOG says the vaccines won’t affect cervical cancer rates for 15 to 20 years, so they did not play a role in the new cervical cancer screening guidelines. Such vaccines don’t protect against all types of HPV that can cause cancer, so Pap tests are still necessary.

About half of all people are infected with HPV at some point in their lifetime, although the infection often goes away on its own. (Only in some cases does the virus damage cervical cells, causing abnormalities that can be picked up on a Pap test.)

Studies that ACOG consulted also show that screening older women every two to three years is nearly as effective as screening annually. And for women who’ve had healthy Pap tests for years, screening could probably be stopped around ages 65 to 70.

Next page: Guidelines not a major overhaul

Mark Einstein, MD, an associate professor of gynecologic oncology at Montefiore Medical Center, in the Bronx, N.Y., and a spokesman for the Society of Gynecologic Oncology, says the new guidelines are a “data-driven fine-tuning,” not a major overhaul.

“It’s important for patients to realize that the science behind the guidelines is strong,” Dr. Einstein adds.

ACOG’s revisions reflect a trend toward a more conservative approach to managing the cervical abnormalities that sometimes lead to cancer.

Cervical lesions are common, especially among adolescents. About 1 in 5 Pap tests in that age group will turn up an abnormality, but the vast majority of low-grade cervical lesions—up to 90%—will get better on their own within three years. Among older women, the rates are lower, but low-grade lesions still rarely progress to the precancerous stage.

Moreover, a series of studies in recent years suggests that women who have cervical lesions surgically removed or burned away with a laser may be at a higher risk of giving birth to a premature or underweight baby. As a result, ACOG and other organizations now recommend monitoring the condition rather than immediately treating it when some types of lesions are found.

Scaling back the schedule for Pap tests will minimize unnecessary and potentially harmful procedures, the guidelines say. Although they also cite the expense of screening and the anxiety and “emotional impact” caused by abnormal Pap tests, “the risk of treatment was the driving factor” behind the changes, says Dr. Waxman.

ACOG’s recommendations come less than a week after the U.S. Preventive Services Task Force (USPSTF), an independent panel of experts that advises the federal government on preventive care, released new guidelines for breast cancer screening. The USPSTF recommended that women begin mammograms at age 50, not 40, and decrease the frequency thereafter.

Both the mammography and Pap test guidelines are part of a broader, evidence-based shift toward less screening, says Karen Soren, MD, the director of adolescent health services at Columbia University Medical Center, in New York City.

“We always used to feel that the more screens you get, the better. And I think there’s a new philosophy,” says Dr. Soren, who has studied Pap tests in adolescents. “The whole medical community in general is saying, ‘Perhaps we’re overscreening.’ And that relates to mammography as well.”

By changing its guidelines, ACOG is breaking ranks with the other main authorities on cervical cancer. The American Cancer Society (ACS) and the USPSTF both recommend that women get their first Pap test within three years of having sex, or at age 21.

The ACS recommends that women ages 21 to 30 should be tested every one or two years, depending on whether a conventional or liquid-based Pap test is used. Women over 30 with three consecutive normal Pap tests can be screened every two to three years, again depending on which tests are used. (The ACOG guidelines do not distinguish between the different types of testing.)

The USPSTF’s mammogram guidelines, which deviated from those of the ACS, caused an uproar and have sowed confusion among women, but experts agree that the ACOG recommendations aren’t likely to have the same effect.

In fact, the ACOG committee that assembled the guidelines believes it will help eliminate confusion and simplify care. “Now age 21 is there as a landmark point in a young woman’s lifetime: ‘Gee, I’m 21, now it’s time to get my Pap test,’” says Dr. Waxman.

The hope, he says, is that the ACS and the USPSTF will head in the same direction with their own recommendations. “It’s very frustrating when you have three major professional organizations saying three different things,” Dr. Waxman says.

Setting a woman’s first Pap test at age 21 is clearer than pegging it to sexual activity, says Dr. Soren. “The recommendations have been changing and evolving, and people have been slow to catch on,” she says. “Patients have been asking for different things. I think the fact that there are concrete guidelines now is actually better.”

Fred Wyand, a spokesman for the American Social Health Association, a nonprofit organization that raises awareness about HPV and cervical cancer prevention, downplayed the potential for confusion among the public or health-care providers. The debate over the schedule for Pap tests is “not new,” says Wyand. “The guidelines are new, but the discussion that preceded it dates back years. So I don’t think anybody’s going to be caught off guard.”

Experts stress that annual pelvic exams may still be appropriate even though Pap tests will be performed less frequently. And, most importantly, women who have received the HPV vaccine need to stick to the same screening schedule as everyone else.

“It is number one on our list to make sure that patients know that vaccination doesn’t replace screening,” says Dr. Einstein. “We’re not ready to be making separate guidelines for vaccinated and non-vaccinated patients, and we won’t be ready to do so for some time.”

A few days ago I wrote this screed of disdain about David Brooks data-less, thoughtless complaint about the vapid sex lives of Kids These Days™.*  I have more than once commented on the evil consequences of marrying sexual queasiness to bad science, social or otherwise — and it struck me that  it is important to remember that Brooks’s queasiness about sex has a broader context and worse consequences.

The thought came to me as I was reading my pre-pub copy (what used to be called a galley) of Rebecca Skloot’s marvelous new book The Immortal Life of HEnrietta LAcks.  Rebecca has written a work that  is proximately the story of HeLa —  the most ubiquitous (some would say ferocious) human cell line used in modern biology — and the woman from whom those cells were derived, without her knowledge or permission.  It’s more than that, of course — an inquiry into race and its twisted history in America, family, medical practice and medical ethics, the autonomy — or lack therof — with which we all inhabit our own bodies, and much more besides.  I’ll blog about it properly closer to pub date, but put this one on your list.

Within all that, the factoid that got me thinking was Rebecca’s discussion of the particular type of cancer that killed Henrietta Lacks so swiftly and cruelly: cervical cancer, the sequel to her multiple infections with HPV-18, one of the most malign of the 100+ strains of Human Papilloma Virus.

HPV infection was and is an epidemic.  In 2008, the Centers for Disease Control reported that

HPV is the most common sexually transmitted infection in the U.S., with about 20 million people currently infected. Women have an 80 percent chance of getting HPV by the time they are 50. HPV is most common in young people who are in their late teens and early 20s.

That is:  about 7 percent, give or take, of the American population — closer to ten percent of the adult population**–are infected with a virus whose consequences range from nothing to death in predictable proportions.  The same CDC report tells us that each year 11,000 women are diagnosed with cervical cancer, and that 3,600 will die of it.

For those of you keeping score, the number of women who will die this year of the disease that killed Henrietta Lacks is about 80% of the total US military deaths in Iraq since 2003 — 4363, according to the latest AP count.  It is greater than the number of combat deaths in that period:  3,476.

There is this difference of course:  death is a necessary component of battle.  War is the imposition of national will by violence, in one short hand definition, and within that context, people will die.

By contrast, no one — or rather, within a generation, very close to no one — need die of HPV infection.  The HPV vaccine, approved by the FDA in 2006, protects against four of the strains of HPV, including those that cause genital warts and cancer.  It is effective, according to the CDC, and safe:

As of June 30, 2008 VAERS has received a total of 9,749 reports of potential adverse events following HPV vaccination. Ninety-four percent (94%) of these reports were about non-serious adverse events.

Six percent (6%) of adverse events reported for the HPV vaccine were considered serious, which is about half of the average number of serious reports for other vaccines. In comparison, the overall average in VAERS for any serious adverse event following vaccination ranges from 10% to 15%; therefore, the percentage of serious reports for Gardasil® is less than the overall average for other vaccines.

The CDC goes on to caution that the number of adverse events actually caused by the virus vaccine is almost certainly lower than that number, due to the post hoc ergo propter hoc problem.

The virus vaccine is recommended for girls aged 11-12.  Why?  Because this is before the age of likely infection, given that HPV is a sexually transmitted pathogen.

We all know where this goes.  The notion of protecting girls from a deadly disease transmitted in the context — oh get the fainting couch ready — of the sexual lives of their older selves is terrifying, at least to some.

So much so that  those terrified of especially female sexual appetite and expression (see for an allegedly respectable example, Chunky Reese Averse Ross Douthat) would rather kill people than acquiesce in the possibility that human beings might on occasion make the beast with two backs.

Recall:  Texas secessionist Governor Rick Perry wasn’t always 100% crazy.  Back when the loon quotient was down to no more than 95% or so, he actually, in a moment of clarity in 2007, signed an order that all require all sixth grade girls in Texas to receive the HPV vaccine.  The response?  As you’d expect.  Texas legislators “rushed to file bills that would override the governor’s order, which they said revokes parental rights and could encourage young girls to be promiscuous.”

To his credit Perry stood up for modern public health:

Providing the HPV vaccine doesn’t promote sexual promiscuity any more than the Hepatitis B vaccine promotes drug use,” Perry said Monday. “If the medical community developed a vaccine for lung cancer, would the same critics oppose it, claiming it would encourage smoking?”

Soon, though — damn soon — in fact, he lost.  Though he complained — accurately, that the legislators who had voted in favor of the bill overturning his executive order would rather tell women that  ”We could have prevented this disease for your daughters and your granddaughters, but we just didn’t have the gumption to address all the misguided and misleading political rhetoric,” he lacked the votes to prevent his veto from being overturned, and allowed the bill, unsigned, to become law.

Perry, it should be noted, still defends this decision.  I have no time for just about everything Perry stands for  – but on this one, he has it right.

So let’s recap:  we face a disease that kills more women in this country each year than have died in battle in the last six in our war in Iraq….

…that will be allowed to persist in the lives of our daughters because to some people it is more important to pretend that human beings don’t have sex with more than one person in their lives than it is to prevent wholly avoidable suffering.

So, finally, to return to why I find David Brooks’s maundering about the sex lives of New Yorkers so pernicious is not just because of the gaping crater of intellectual shoddiness at its heart:  it that he offer a well-spoken version of the attitude that declares, whatever may actually happen in real human experience, women shouldn’t have the temerity to uncross their legs.  Remember the corollary of that belief as well:  if they do, then, by gum, disease, distress and death are merely the appropriate consequences for such sin.

Last note:  when ever I hear the term “value voters” I throw up in my mouth.  The single central value of just about any ethical system, including those advanced by the sages of traditional religion, is that it is wrong to use other people as objects, rather than subjects, individuals of intrinsic value.  Requiring others to die to avoid unpleasant contradiction with one’s own value system is not a virtue.  It is, in the only true sense of the word, the very definition of a sin.

A pox upon them.

I mean that literally.

Oh — and one more thing.  If anyone wants to draw the obvious connection to the current health care debates (Joe Stupak, are you listening?  Senators?) then I think that is an entirely appropriate link.  The entire anti-health care movement is in the end a decision to allow innocents to die in large numbers in order to achieve other ends; it sacrifices individuals in the service of either or both abstract “values” and the financial interests of various elites.  Mere sin hardly covers the case; evil is more like it.

*I later found out that Brooks’ silliness was deeper than I thought, for I chanced across the original article in New York magazine in which the editors described the process by which they accumulated the sex diaries that so confounded the gentle Mr. Brooks.  These were, which I’m sure will surprise no one, wholly selected for maximum effect.  Producing social commentary on the basis of sought-and-found soft porn purveyd to prop up an at-risk publishing model is something only the credulous or the contemptuous-of-their-readers would attempt.  Consider this an exercise for the readers to decide which it might be.

**and yes, I know that plenty of under-18s will have HPV infections.  This is numerical shorthand here — an attempt to express scale.  It is not, as I hope the language makes obvious, a precise claim.

Update: minor but crucial edits above (for “virus” read “vaccine” twice) thanks to the eagle eye of  Lovable Liberal.

Images:  Albrecht Dürer, “The Revelation of St John: 4. The Four Riders of the Apocalypse” 1497-1498

Berthe Morisot, “The Balcony” 1872

(CFD.net.au – Contract for Difference, Share, Forex, ETFs, Commodities Traders) – Blood products and vaccines developer CSL Ltd has warnedforeign exchange rates may shrink its profit and that its ability to frank dividends dwindles as its offshore business grows.

At the company’s annual general meeting on Wednesday, CSL said first quarter 2010 trading was in line with expectations and that its swine flu vaccine would give a strong boost to the annual result.

But with 80 per cent of the group’s sales now deriving from offshore, the strengthening Australian dollar could hurt its profit – and its ability to frank dividends.

For 2009/10 net profit was expected to be between $1.16 billion and $1.26 billion at 2008/09 exchange rates, CSL chairwoman Elizabeth Alexander told the meeting.

“However, if currency rates on October 9, 2009, were to apply for the balance of the fiscal year, the net profit after tax range referred to earlier would be in the order of $970 million to $1.070 billion,” Ms Alexander told shareholders.

The Australian dollar has climbed in recent weeks and hit a fresh 14-month high of $US0.9137 during local trade on Wednesday.

The biopharmaceutical company also said that as the business grows successfully offshore its ability to provide fully franked dividends declined.

“We do not … expect to be able to frank the interim dividend for the 2009/10 fiscal year,” Ms Alexander said.

A decision on franking the final dividend will be taken after the completion of the 2009/10 final accounts.

The Melbourne-based company distributes vaccines and pharmaceuticals to 27 countries.

Following the rollout of the human papillomavirus (cervical cancer) vaccine program in Australia, CSL’s sales of Gardasil were expected to decline substantially as the catch-up program drew to a close, CSL said.

But the novel H1N1 influenza vaccine, also known as swine flu vaccine, is expected to provide a strong contribution to revenue in 2009/10.

CSL also said it would donate three million doses of the swine flu vaccine to theWorld Health Organisation (WHO) for use in developing countries in the South Pacific and South East Asia.

In August, CSL reported a 63.3 per cent jump in annual profit to $1.15 billion and declared a final dividend of 40 cents per share, unfranked, taking the total for the year to 70 cents.

Source: Exchange rates may shrink profit: CSL

The family of a woman who died in 2004 after a misdiagnosis of cervical cancer was persistent in their efforts to get justice for her in their medical malpractice lawsuit.  The case was originally dismissed for lack of substantial evidence, but they refused to give up.  They recently presented new evidence of fraud on behalf of the negligent doctor and won another day in court.

Parminder Kaur Bhatia was a patient of Dr. Anuradha Kollipara for several years, dating from 2000 through 2004.  The final time Bhatia was treated by Dr. Kollipara in April 2004, she was complaining of fatigue and an irregular menstrual cycle.  Her husband and daughter were present and they claim that at no time was Bhatia advised to have a Pap smear, a test designed to detect cervical cancer.

She was later diagnosed with the condition, but by then it was too late.    She died a few months later at the age of 46.

The original lawsuit was dismissed mainly because medical charts submitted by Dr. Kollipara showed that on several occasions she had recommended that the patient schedule a Pap smear.  Based on this evidence, the original judge overseeing the case felt that the doctor was not at fault for Bhatia’s death.

Bhatia’s family refused to give up, however, and hired a forensic document examiner to take a closer look at the medical records in question.  Shockingly, it was discovered that a different pen had been used on three of the six reports where the Pap smear recommendations were referenced, indicating that the physician had tried to alter the documents to make it appear that she had, in fact, suggested the patient be tested.

Because of the persistence of Bhatia’s family, the evidence was enough for a judge to grant them a new trial.

If you have tried in the past to file a medical malpractice lawsuit but have been unsuccessful, it may benefit you to discuss your situation with a skilled medical attorney to determine if you still have a chance to seek justice for yourself or your loved one.

Lesbians can catch cervical cancer.

If you have trouble understanding that sentence then you may find that, throughout your life, simple stuff generally confuses you. Don’t be alarmed to find out that most people probably think you are a twat. The likely cause of this is that you probably are.

You see, if even a layperson struggled to understand the above statement, I would be shocked. It’s not exactly a revelation is it? (PS Did you know that women and straight men can get AIDS too?). So to face such ignorance from a qualified professional took some beating.

Today I went to a Family Planning Clinic (Why? You might ask… lesbians can’t have kids can they?), to discuss why once a month I turn into Regan at the drop of a hat and cry at episodes of Jeremy Kyle. I meet with a nurse who is friendly enough.

She asks what I use for contraception and I politely explain that I don’t really need any – ‘I’m gay.’ ‘Brilliant,’ she replies, more than a little flustered.

On we go with the questions… ‘Are you pregnant?’

‘Err… no. Not unless my girlfriend has a big giant invisible cock.’ I didn’t say that though. I just shook my head.

‘Have you ever had a cervical smear?’

‘Yes,’ I reply, thinking that they were compulsory and remembering the dozens of letters I’ve had from my GP urging me to make sure I have regular smear tests.

‘Have you really? Why on earth would they do that? I mean, you don’t need one do you? How funny.’

At this point, my cervix probably blushed, it’s hard to tell, but my face certainly did. ‘I was sure that every woman over a certain age has to have a smear test.’

‘Really?’ Yes, that’s what the NURSE actually said to me.

‘I don’t think sexuality has anything to do with getting cancer.’

‘I suppose not,’ she pondered.

Now, forgive me for condemning this woman. She was pretty nice other than this and didn’t intentionally mean to make me feel hugely uncomfortable in what was a pretty personal and private meeting anyway. But I could not go so far as to say that her comments or attitude were harmless. Far from it – she directly implied that as a lesbian, I do not require regular, if any, cervical smear tests and therefore that I am not at risk from cervical cancer.

It doesn’t take a genius to figure out that this is bullshit in its rawest form. It’s staggering that a health professional, whose job it is to inform vulnerable women about sexual issues, could be so discriminatory and ignorant at the same time.

Sadly, this isn’t an isolated case. Diva magazine did a feature on this very thing not that long ago.

According to this, statistics show that a woman’s risk of cervical cancer is cut by 84% if she has a smear test every five years, and 91% if she has a smear every three years. It’s estimated that NHS cervical screening saves more than 1000 lives each year.

A British Medical Journal editorial published in 2003 said: “An unfortunate perception exists among healthcare providers and women who have sex with women that they don’t need regular cervical smears… sexual intercourse with men is a powerful risk factor for cervical cancer. However, it’s important to counter the erroneous assumption that women who have sex with women aren’t at risk of catching human papillomavirus. Around one in five women who’ve never had heterosexual intercourse have human papillomavirus which is associated with developing high-grade cervical intraepithelial neoplasia” – in other words abnormal cervical tissue development.

So please, don’t ever be fooled into thinking that because you sleep with women and not men that you can’t develop cervical cancer.

It is more than just a myth. It’s a lie that puts lives at risk.

70% of cervical cancer cases are caused by Human papillomavirus and a new vaccine has been recently developed for Types 6, 11, 16, and 18. In Australia (2006) approval was given to add this vaccination to the Australian vaccination program. In a recent study published in PNAS of a mouse model of HPV-associated cancer, the estrogen receptor alpha (ERalpha) was also required for cancer development and the blocking with estrogen receptor antagonists were effective in treating and/or preventing cervical cancer in these mice.

Prevention and treatment of cervical cancer in mice using estrogen receptor antagonists. Chung SH, Lambert PF. Proc Natl Acad Sci U S A. 2009 Nov 9. [Epub ahead of print] PMID: 19901334

“These data are consistent with the observation in women that long-term use of oral contraceptives or multiple pregnancies significantly increases the risk for cervical cancer in HPV-positive women. In the present study, we examined whether drugs that interfere with the function of ERalpha are effective in treating and/or preventing cervical cancer in mice. We provide evidence that a complete ER antagonist, ICI 182,780 (ICI), as well as a selective ER modulator, raloxifene, efficiently clear cancer and its precursor lesions in both the cervix and the vagina.”

(More? UNSW Embryology – Womens Health Issues | Medline Plus)