Guidelines Push Back Age for Cervical Cancer Tests

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.”

Dr. Iglesia said the argument for changing Pap screening was more compelling than that for cutting back on mammography — which the obstetricians’ group has staunchly opposed — because there is more potential for harm from the overuse of Pap tests. The reason is that young women are especially prone to develop abnormalities in the cervix that appear to be precancerous, but that will go away if left alone. But when Pap tests find the growths, doctors often remove them, with procedures that can injure the cervix and lead to problems later when a woman becomes pregnant, including premature birth and an increased risk of needing a Caesarean.

Still, the new recommendations for Pap tests are likely to feed a political debate in Washington over health care overhaul proposals. The mammogram advice led some Republicans to predict that such recommendations would lead to rationing.

Senator Tom Coburn, a Republican from Oklahoma who is also a physician, said in an interview that he would continue to offer Pap smears to sexually active young women. Democratic proposals to involve the government more deeply in the nation’s health care system, he said, would lead the new mammography, Pap smear and other guidelines to be adopted without regard to patient differences, hurting many people.

“These are going to be set in stone,” Mr. Coburn said.

Senator Arlen Specter, a Pennsylvania Democrat and longtime advocate for cancer screening, said in an interview: “And this Pap smear guideline is yet another cut back in screening? That is curious.” Mr. Specter, who was treated for Hodgkin’s lymphoma in 2005 and 2008, said Congress was committed to increasing cancer screenings, not limiting them.

Representative Rosa DeLauro, Democrat of Connecticut, said that the new guidelines would have no effect on federal policy and that “Republicans are using these new recommendations as a distraction.”

“Making such arguments, especially at this critical point in the debate, merely clouds the very simple issue that our health reform bill would increase access to care for millions of women across the country,” she said.

There are 11,270 new cases of cervical cancer and 4,070 deaths per year in the United States. One to 2 cases occur per 1,000,000 girls ages 15 to 19 — a low incidence that convinces many doctors that it is safe to wait until 21 to screen.

The doctors’ group also felt it was safe to test women less often because cervical cancer grows slowly, so there is time to catch precancerous growths. Cervical cancer is caused by a sexually transmitted virus, human papillomavirus, or HPV, that is practically ubiquitous. Only some people who are exposed to it develop cancer; in most, the immune system fights off the virus. If cancer does develop, it can take 10 to 20 years after exposure to the virus.

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.

It is by no means clear that doctors or patients will follow the new guidelines. Medical groups, including the American Cancer Society, have been suggesting for years that women with repeated normal Pap tests could begin to have the test less frequently, but many have gone on to have them year after year anyway.

Debbie Saslow, director of breast and gynecologic cancer for the American Cancer Society, said professional groups were particularly concerned because many teenagers and young women were being tested and then needlessly subjected to invasive procedures.

In addition, Dr. Saslow said, doctors in this country have been performing 15 million Pap tests a year to look for cervical cancer in women who have no cervix, because they have had hysterectomies.

Dr. Carol L. Brown, a gynecologic oncologist and surgeon at Memorial Sloan-Kettering Cancer Center, said the new guidelines should probably not be applied to all women, because there are some girls who begin having sex at 12 or 13 and may be prone to develop cervical cancer at an early age.

“I’m concerned that whenever you send a message out to the public to do less, the most vulnerable people at highest risk might take the message and not get screened at all,” Dr. Brown said.

Dr. Kevin M. Holcomb, an associate professor of clinical obstetrics and gynecology at NewYork-Presbyterian/Weill Cornell hospital, said that when he heard the advice to delay Pap testing until 21, “My emotional response is ‘Wow, that seems dangerous,’ and yet I know the chances of an adolescent getting cervical cancer are really low.”

As with the new mammogram recommendations, women may not readily give up a yearly cancer test.

“For people who’ve been having the testing regularly every year, it’s a big emotional change to test less frequently and there’s this fear of ‘Oh my gosh, I might be missing something,’ ” said Ivy Guetta, 49, of Westport, Conn., who plans to continue with annual Pap tests. Ms. Guetta has three daughters, ages 17, 14 and 8, and at the moment, she would not encourage them to wait until they turn 21.

Jen Jemison, 24, a legal assistant from Babylon, N.Y., said she thought she began getting Pap smears when she was about 18, but said that if she had been aware that the procedure for treating precancerous lesions could lead to premature births, she would have waited until she turned 21.

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.”

Source: By Denise Grady, The New York Times

Why Sexism Kills

The Gist:
According to a report released on Nov. 9 by the World Health Organization, millions of women die each year from conditions that could be avoided — if they were men. Apart from hazards like female infanticide and maternal deaths, women are more likely to contract HIV, suffer from depression and domestic abuse, and lack access to basic health care that could help them survive. (See TIME’s pictures “Self-Injury and Despair in Japan.”)

Highlight Reel:
1. On the risks of unprotected sex: “Globally, HIV is the leading cause of death and disease in women of reproductive age. Some studies show that women are more likely than men to acquire HIV from an infected partner during unprotected heterosexual intercourse … Young women tend to have sex with older men who are more sexually experienced and more likely to be infected with HIV.”

2. On domestic abuse: “Studies from Australia, Canada, Israel, South Africa and the United States show that between 40% and 70% of female murders were carried out by intimate partners … In South-East Asia, burns are the third leading cause of death [for adolescent girls and women of reproductive age]. While many are the result of cooking accidents, some are homicides or suicides, often associated with violence by an intimate partner … Despite the size of the problem, many women do not report their experiences of violence and do not seek help. As a result, violence against women remains a hidden problem with great human and health-care costs.” (Read “Why Fires Are Deadlier for Women in India.”)

3. How gender inequality affects treatment: “Because they are less likely to be part of the formal labor market, women lack access to job security and the benefits of social protection, including access to health care. Within the formal workforce, women often face challenges related to their lower status, suffer discrimination and sexual harassment, and have to balance the demands of paid work and work at home, giving rise to work-related fatigue, infections, mental ill-health and other problems.”

4. On the exploitation of female health care providers: “The backbone of the health system, women are nevertheless rarely represented in executive or management-level positions, tending to be concentrated in lower-paid jobs and exposed to greater occupational health risks.”

5. On addressing sexism in health care: “Lessons can be learned from bold national initiatives that have sought to address social inequality and exclusion in ways that promote gender equality and women’s health. For example, Chile’s multisectoral and integrated approach to social protection for the poor includes a universal program for early child development. Chile Crece Contigo (Chile Grows with You) includes access to child care, education and health services to help young children achieve their optimal physical, social and emotional development, while enforcing the right of working mothers to nurse their babies and also stimulating women’s employment.”

The Lowdown:
The WHO’s inaugural cradle-to-grave study on women’s health is far from comprehensive, but the U.N. agency can hardly be blamed for it. “The data and evidence that are available are too patchy and incomplete for this to be possible,” Margaret Chan, the WHO’s director, said in a statement accompanying the report’s release. As for the information that is available, far too much of it focuses solely on women’s reproductive and sexual health — “women are more than mothers,” the WHO notes, and they “should be engaged in research as active participants.” After all, who better to examine and understand female health issues than women themselves?

Source: By M.J. Stephey, Time

Ability to breast-feed may be influenced by hormones

Whether or not a mother can successfully breast-feed her infant may have to do with her concentrations of testosterone, according to a new study from researchers at the Norwegian University of Science and Technology. The study, published in the journal Acta Obstetricia and Gynecologica Scandinavica, followed 180 women from pregnancy through the first six months of their infants’ lives, and found that, even when controlling for factors such as age or smoking, women with higher levels of testosterone had significantly lower levels of breast-feeding success. What’s more, the team of researchers, led by Sven Carlsen, also conducted a review of 50 studies on the health impact of breast-feeding, and concluded that the benefits may be overemphasized, and that often, benefits attributed to breast-feeding may in fact be as a result of the mother’s healthy pregancy. As Carlsen told the BBC:

“These health differences are really not so significant in any event… When you look at the epidemiological studies and try to strip away the other factors, it is really hard to find any substantial benefits among children who were breastfed as babies.”

Most expectant mothers and mothers of newborns are well aware of the dominant medical mantra when it comes to breast-feeding: the World Health Organization and the American Academy of Pediatrics (AAP) both recommend exclusively breast-feeding infants for the first six months of life, and incorporating complementary foods and sources of nutrients while continuing to breast feed through the first year or two of life. Studies show that, for babies, being breast-fed can reduce the risk for diarrhea, ear infection, meningitis and possibly even diabetes and obesity. For mothers, the benefits are considerable as well: studies suggest that breast-feeding can reduce a mother’s risk for breast and ovarian cancer, and even potentially reduce the likelihood of developing osteoporosis.

Because of the prevailing recommendations on breast-feeding, however, too often when mothers struggle to breast-feed or ultimately are unsuccessful, they suffer a sense of guilt at not being able to provide the best possible nutrients for their infants. Yet, authors of this new study hope that their findings will remove some of the stigma from this issue. Carlsen and colleagues suggest that higher levels of testosterone may limit a mother’s development of milk glands, inhibiting her ability to breast feed. And while babies who are breast-fed may be healthier, Carlsen concedes, he argues that the correlation is misplaced. That is, he suggests that a baby’s overall health has more to do with its mother having a healthier pregnancy. The problems that cause women to have more difficult pregnancies, give birth to underweight babies or struggle with illness themselves may also impact their ability to breast-feed, he argues. And, one factor contributing to breast-feeding difficulties may simply be hormones, he says, telling the BBC:

“Basically a mother who finds she has difficulty shouldn’t feel guilty—it probably is just the way it is, and her baby will not suffer for being fed formula milk… A mother should do what makes her happy.”

Of course, Carlsen and his fellow researchers aren’t the first to make a case for reexamining the benefits of breast-feeding. In April 2009 Hanna Rosin wrote in her Atlantic article, “The Case Against Breast-Feeding,” that, “…overall, yes, breast is probably best. But not so much better that formula deserves the label of ‘public health menace,’ alongside smoking.” In response to her article, Dr. David J. Tayloe, Jr., president of the AAP, wrote a letter to the Atlantic refuting her argument that breast-feeding was only nominally preferable, and reiterating what continues to be the dominant medical perspective on the issue. Tayloe wrote:

“The evidence for the value of breastfeeding is scientific, it is strong, and it is continually being reaffirmed by new research work. The American Academy of Pediatrics encourages women to make an informed decision about feeding their infants based on scientifically established information from credible resources.”

Yet, regardless of the best medical advice, the fact remains that for some women, how they ultimately nourish their infant is not so simple as making an informed decision. Instead, it can be a harrowing process of determining the best course for their families based on a wide range of factors—including both physical and emotional.

Source: By Tiffany O’Callaghan, Time

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