Pap Unneeded for Most After Hysterectomy

Cost of Routine Screening Can't Be Justified

From the WebMD Archives

July 21, 2003 -- Millions of women who have had hysterectomies are still subjected to annual Pap smear testing, even though most experts agree it makes little sense to screen for cervical cancer in women without cervixes.

The nation's top cancer prevention groups oppose the practice on the grounds that there is no medical justification for it. Now a new study shows there is no economic justification either.

Minor Risk, Major Cost

While some doctors still believe Pap smears are needed to detect vaginal cancers in women who have had hysterectomies, the University of Michigan study shows the cost of this practice is astronomical. Researchers estimated the expense of aggressive routine screening in these women can approach $13 million per year of life saved.

"The approximately 30% of women who have undergone hysterectomies for benign disease in the United States should be spared the burden and the costs of multiple visits, lost time, complications of unnecessary diagnostic testing, and discomfort of Pap smear examinations," researcher Michael D. Fetters, MD, MPH, MA, writes.

The study still recommends regular Paps for women who have had hysterectomies because of cervical cancer and for those women who have had HPV, which puts them at risk for cancers of the cervix, vagina, and vulva.

"In a woman who has been married for years and has only one sexual partner, it's appropriate to forgo Pap smears after hysterectomy," says researcher Richard Lieberman, MD in a news release. But if the woman's risk factors for lower genital tract cancer change, all bets are off and she'll need to be screened regularly."

Safely Stopping Pap Testing

The case against screening women who have undergone total hysterectomies for non-cancer-related causes was bolstered last year when the American Cancer Society (ACS) noted that these women could safely stop having Pap smears. The U.S. Preventive Services Task Force -- the nation's top preventive health policy group -- also reiterated its opposition to routine screening for these women in a strongly worded statement issued in January of this year.

"The argument that Pap smear screening is useful for detecting vaginal cancers among women who have had total hysterectomies really hasn't been borne out in the research," CDC cancer prevention specialist Mona Saraiya, MD, MPH, tells WebMD.


In a study published two years ago, Saraiya and CDC colleagues found that three-quarters of the surveyed women who had undergone hysterectomies continued to have Pap smears after their surgery. She tells WebMD the numbers may have dropped after the ACS revised its guidelines, but they are still very high.

One of the main arguments in favor of routine Pap testing in these women has been that it promotes an annual visit to a health-care provider. Once in the door, the thinking goes, doctors can advise women about other health interventions.

Ethically Challenged

But Saraiya and ACS spokesman Carmel J. Cohen, MD, agree that this reasoning borders on being ethically indefensible.

"The ethics of this are certainly arguable, and it makes no economic sense," says Cohen, professor of gynecology at New York's Mount Sinai School of Medicine.

"Pap testing is no longer a trifling part of health care. We do 50 million Pap smears a year in this country and 5 million are found to be abnormal. Estimates are that around 5,500 cervical cancers are identified each year through testing, so that is a lot of false positives."

Saraiya adds that limited public health dollars would definitely be better spent getting women who have not had hysterectomies to be screened.

"Sixty percent of cervical cancers occur among women who are never screened or are rarely screened," she says. "So that would be the place to put our resources if we want to save women from dying of this cancer."

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SOURCES: Michael D. Fetters, MD, MPH, MA, Department of Family Medicine, University of Michigan Health System, Ann Arbor, Mich. Carmel J. Cohen, MD, spokesman, American Cancer Society; professor of gynecology, Mount Sinai School of Medicine, New York. Mona Saraiya, MD, MPH, medical epidemiologist, division of cancer prevention and control, Centers for Disease Control and Prevention.
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