The more Pap tests, the worse

The reason why this website is called Cancer Screening reflects the issue that intrigues me the most in the cervical cancer debate. As I said before, in many countries, including Portugal where I come from, screening for cervical cancer usually starts as early as women become sexually active. In England it doesn’t start until the age of 25.

Different factors should be considered when judging the quality of a screening programme, regardless the type of cancer it applies to. Budget, culture and private health services are just some of them, which partly explains why there isn’t a common cancer screening programme, for example, on a European level.

Portuguese GP
Dr Armando Brito de Sá

I spoke to one expert who is particularly concerned about such discrepancies. Dr. Armando Brito de Sá is Professor of General Practice and Family Medicine at the Medical School of Lisbon University.

He agrees with the screening programme adopted by the NHS. Both the age to start screening and the frequency (every three to five years) are recommended for the Portuguese primary care services, following the British model.

Some important bodies, such as the U.S Preventive Studies Task Force (USPSTF), still recommend screening once a woman becomes sexually active. But the Portuguese expert highlights the position taken two years ago by the American College of Obstetricians and Gynecologists (ACOG):

Screening before age 21 should be avoided because women less than 21 years old are at very low risk of cancer. Screening these women may lead to unnecessary and harmful evaluation and treatment.

According to Dr. Brito de Sá, “this is a surprising statement given that it comes from an organisation of specialists [and not of a wider range of health professionals], which is very good news”. In his opinion, such organisations tend to be more aggressive.

ACOG also states cytology should be made every two years – a frequency that “prevents cervical cancer just as well, has decreased costs, and avoids unnecessary interventions that could be harmful.”

There is no scientific evidence that supports doing a Papanicolaou test every year, the GP adds.

The more medical exams, the healthier: a wrong message

One of my questions was that although the Portuguese health service takes the NHS as an example, both systems can never be totally similar since the private sector plays an important role in the country.

According to Portuguese database Pordata, 1,485 gynaecologists/obstetricians and 5,160 GPs were active in the country in 2009.

"Pap" test

Dr. Armando Brito de Sá points out that, although most people are consumers of the national health service (SNS in Portuguese), there is an overuse of medical exams in the private sector – not only in Portugal but worldwide. “This happens because of this general and wrong idea that the more exams we do, the better health we have.”

In line with this, I know many people who ask their private gynaecologist to be screened every year – sometimes even twice a year. So I asked Dr. Brito de Sá whether patients understand that paying for an exam could be more harmful than attending a national programme that recommends less frequent smear tests.

“Patients are not idiots,” he answers. “When you tell them the facts, they understand and are capable of making their own decision”.

Overscreening is a direct breach of “Primum non nocere”, an ethic principle taught in medical schools which means “First, do no harm”

And the facts are clear in his words: “The problem caused by early, frequent screening is not only the very small number of lives it would save but mainly the thousands of young women that are unnecessarily overwhelmed with additional exams whenever they have an abnormal test.”


Making medical students aware of different evidence-based policies

While lecturing the future generation of doctors, one role of Dr. Armando Brito e Sá is to make them understand that governments do not always follow the latest, best scientific advice.

He points out the dangers of overprevention and overmedication – an idea that was highlighted in 2001 when the American Family Physician journal published these Screening Guidelines.

Numerous medical organizations have developed cancer screening guidelines. Faced with the broad, and sometimes conflicting, range of recommendations for cancer screening, family physicians must determine the most reasonable and up-to-date method of screening.

Finally, the Portuguese expert shows conviction in saying that government’s policies are just partly determined by scientific evidence. The implementation of the HPV vaccines in different national programmes was “inevitably political, because of the excessively heavy disease-awareness produced in the media by the vaccine manufacturers.”


To think about, even if not infected

“Until I had an abnormal smear test I never thought much about the screening programme.”

So far I have received many emails from readers of this project. Experts have shared their knowledge and research, whilst patients have shared their experience.

All patients who have contacted me have had some kind of personal experience related to cervical cancer, most being women with a history of abnormal smear tests. This shows, just like with other diseases, that unless it affects us or our beloved ones we are rather unlikely to engage in the debate. However, most of what these patients have told me should be of interest to the general public, especially young women. Here are some of those thoughts.

(Note: In order to protect the identity of the sources, I was asked to keep them anonymous.)

“Associating infection with sexual behaviour is unhelpful and stigmatising”, a woman told me. She had treatment for high grade cervical pre-cancer at the age of 33 and claims to have had two sexual partners with whom she has always used condoms. Her abnormal smear test came when she had been married for many years.

Do condoms protect against HPV? Credit: Wikicommons

Indeed, I wrote about the links between HPV infections and sexual behaviour, but it should be emphasised there is not one single way to prevent cervical cancer. Vaccines, smear tests, few sexual partners or use of condoms do not necessarily prevent the disease. To what extent would better health education and communication help tackle this problem?

In fact, “safe sex” is not enough, as many factors are associated with an HPV infection. Sexual intercourse is not the only way to transmit the virus; some of its strains can be transmitted through kissing. Most people will be infected in their lives, but in many cases our body’s immune system will be able to clear the virus without it causing problems.

Ironically, when it comes to vaccination this infection seems to be persistent, as most experts claim that a HPV vaccine doesn’t clear the virus if it has already been contracted. Again, HPV may not be as alarming as HIV, but shouldn’t there be more information about this virus?

Concerning HPV related cancers other than the cervix, let me share with you what a 31-year old Mexican man wrote me: “If I had taken the vaccine, I might have had my complete tongue by now”. He was 27 when diagnosed with tongue cancer. “In the biopsy we found HPV. The doctor asked me if I had had any homosexual intercourse, and the answer is no. I just have had one sexual partner, and that is my wife.”

His words reflect the need to clarify how HPV affects men. The fact that his doctor asked him about his sexuality may show that gay men are at increased risk of HPV-related cancers, however heterosexual men can develop these too. The number of sexual partners one has also does not necessarily determine how likely he or she will be infected with the virus. Many people become infected having had only one sexual partner – this partner might have had others though. But is it fair, or even useful, to let the rule of probabilities ruin the confidence between a married couple?

Prevention of cervical cancer in private healthcare can reach high costs. Credit: Grant Cochrane

A young woman from Portugal mentioned the financial costs associated with a HPV infection. In this project I’ve tried to discuss policies from different countries, therefore we should balance the weight of private healthcare services and insurance companies in other nations.

Upon being diagnosed with a HPV infection in her cervix, this 27-year-old Portuguese patient has paid more than €600 in the private sector for HPV testing, smear tests, other exams and dermatological treatment to her genital warts. She wonders whether the SNS (Portugal’s public healthcare system) would have prescribed her the same exams, how much of these costs would have been taken by the state, and how quickly she would have been treated otherwise. What is the situation like in your country?

When seeing these realities, one shouldn’t forget the UK has a National Health Service and an effective, public cancer screening programme. A British woman wrote me about her disappointment towards this programme, but she admitted not having had contact with health services of any other country.

The progress of science has allowed us to prevent and treat many diseases that people would have easily died of some years ago. It seems that the more we have, the more we expect; should we, journalists, make citizens wonder whether they are in the right to complain?

Cancer Research UK

Video: What cervical cancer is about

This video helps understand the main issues that this project aims to investigate. I spoke to Professor Jack Cuzick from Cancer Research UK, who highlighted the importance of changing cervical screening methods and the understanding of the human papilloma virus (HPV). I also heard the opinion of three women in the streets of London.

Video Transcript:

Débora Miranda: According to the World Health Organisation, over 12 million people are diagnosed with cancer every year. Two in five cancers are potentially preventable. The Human Papillomavirus or HPV causes cervical cancer, and is the second biggest cause of female cancer mortality. There are two main weapons against the disease. Screening for cervical cancer, which has been widespread in developed countries for many years, and newer techniques aimed at the virus that causes the disease.

Prof Jack Cuzick: There clearly is not very much understanding about the human papillomavirus. I think most people know that they should get screened and get an invitation. There has been a drop in acceptance of invitations in younger women. There is a lot of misunderstandings and fears about the virus because it is a sexually transmitted virus and it raises all sorts of issues about behaviour and partners behaviour which need to be handled with quite sensitively so doctors and people in general do need to understand more about this virus. It’s a very common virus. Like the common cold in most cases it leads to very minimal changes.

Voxpop 1: I’m not one of those organised people who makes a note of when the next smear test should be. I wait to get a letter from my GP or from the hospital.

Voxpop 2: When I got the letter I didn’t read it that well. I just sort of knew that I had to go. My friend had recently got a letter because she had just turned 25 as well, so we decided to book our appointments for the same day so we could both go to the doctor surgery together. That was quite nice to have the moral support. And even though I didn’t read the letter that much the nurse was really nice and she explained everything really well. The whole experience was much better because of that.

DM: Different countries implement different cancer screening programmes. It is important to understand the scientific evidence on which worldwide governments are based to make their decisions.

Voxpop 3: I grew up in another culture, where you get a yearly smear test if you’re on the pill. When I was in my early twenties I was taking the pill and so I would have the test every year and that was part of the culture. I grew up in the south of France and I think people are probably a bit more laid back about their sexuality or anything which involves your body It’s not seen as a taboo as maybe in an Anglo-Saxon culture.

Voxpop 1: I think it’s become better since there’s been so many high-profile cases. And I think Jade Goody’s case really brought to the general population the importance of testing and that it can happen to you at a very young age.

JC: The most important thing in screening programmes (and it’s been clearly demonstrated in cervix cancers) is high coverage. Screening can only work if people that can be screened do it. The coverage is very very important. The second most important thing is having an effective test and we’re seeing now that the HPV testing is more effective, more sensitive than cytology. So we do need to move to HPV testing as a method of screening.

DM: Cervical cancer raises controversial questions. Why does the age to start screening change from one country to another? Is there enough information about the vaccine? And what are the harms of screening?

JC: As with all screening there may be some harms. The main harm associated with cervical screening is, there is increasing evidence now that the treatment associated with lesions at a young age leads to increase miscarriage, early pregnancy rates because you basically have to loop out a piece of the cervix and that makes the cervix weaker.

DM: But before these questions are answered, follow the advice:

Voxpop 2: It wasn’t pleasant, I don’t think it would ever be pleasant to have that sort of thing but it was fine. It’s uncomfortable but it’s five minutes of your day compared to possibly the rest of your life if you catch something early. It’s a necessary evil but it’s really not that bad.

The key cervical cancer questions

These are some of the main questions I aim to investigate:

  • What is the incidence of false positives and unnecessary treatment for cervical cancer?
  • What is the difference between the Gardasil and the Cervarix vaccines?
  • Should men be vaccinated?
  • Are there any cervical screening programmes running in Africa?
  • Is it cost effective to run screening and vaccination programmes in tandem?
  • What is the scientific evidence that governments are based on to implement cancer prevention programmes?
  • What is the link between HPV and other types of cancer?

Feel free to add any questions.

Picture courtesy: Jan Christian, Creative Commons